How to assess and treat sports-related head trauma in children

A wide array of injuries to the head and spine can be sustained in kids' sports. There is a tendency to demonize certain sports (such as American football and rugby) due to the relatively high rates of concussion and spinal injury. However, many other under-supervised youth activities such as biking, skateboarding, and horseplay are also associated with high rates of serious injury.

An acute head injury can be an immediate threat to an athlete from an expanding hematoma, vascular injury, or severe brain swelling. Any suspicion of a serious injury demands an immediate evaluation by medical professionals.

Less serious injuries (e.g., concussion or mild traumatic brain injury) are a risk to the athlete until they have fully resolved. For example, there is a risk of a rare—but deadly—complication known as second impact syndrome which is caused by further head injuries during the healing phase. However, it is more common that the athlete is simply ill-equipped to fully protect themselves in competitive and high-risk scenarios. Their balance, reaction time, judgment, timing, and coordination may be grossly or subtly impaired, leaving them more vulnerable to a serious injury.

There are four steps to perform after a head injury if the athlete is unconscious:

1. Summon emergency medical services (EMS). When they arrive, assist with positioning the player on a spine board for swift evacuation to a medical center.
2. Assess pulse, airway, and breathing. But, do not try to reposition or remove safety equipment.
3. Check and note the player’s response to pain.
4. Check pupils for size and reactivity.

If needed, cut away a face cage to provide respiratory support. Do not use smelling salts or try to aggressively wake the athlete up. In the event of cardiopulmonary arrest, initiate cardiopulmonary resuscitation (CPR).

If an athlete was knocked unconscious but is now awake, remove them from the game. At the very least, they have sustained a substantial concussion.

Assess them for neck pain and neurological complaints. Also assess cognition, balance, coordination, and motor function.

If the athlete is experiencing neck pain, neurological complaints, paralysis, weakness, or if the athlete is not fully alert and oriented, initiate spinal precautions and call for emergency medical services to transfer the patient to a medical center. In a patient that you are preparing to evacuate to a medical center, assess airway and breathing and perform a cursory neurological exam—but do not attempt to move them.

An athlete who has fully awakened from unconsciousness and is experiencing no signs and symptoms still needs to be removed from the athletic competition. They have a concussion and will not be able to return to competition until they are fully recovered. They should undergo a medical evaluation, but need not be emergently evacuated if they are medically and neurologically stable.

If an athlete experienced a head trauma but was not knocked unconscious and appears well, assess for neurological signs and symptoms. If the patient has any signs or symptoms of neurological dysfunction such as headache, dizziness, nausea, difficulty processing, fuzziness of thought, imbalance, lack of coordination, or photophobia, they have a concussion and should not return to play. Persistent signs or symptoms should be evaluated at a medical facility.

To return to play at a sporting event (or practice after head trauma), an athlete must be free of all signs and symptoms and must be able to participate in vigorous exercise without any neurological signs or symptoms. Preferably, they should undergo a graded series of increasingly vigorous exercises and mock competitions before returning to a fully competitive situation.

Many authors recommend a formalized sideline concussion evaluation like the Concussion Vital Signs Sideline Assessment. These assessments look for subtle symptoms, cognitive difficulties, balance difficulties, and more. An athlete should be able to pass the assessment before returning to play and should be watched carefully for signs of developing difficulties.

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