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TBI, especially in children and adolescents. From 2010 to 2016, an
estimated 283,000 children annually sought ED care related to sports or
recreational TBI. This may be due, in part, to increased identification and
codifying of concussion as well as local and state policies regarding sports
injuries. The state of Washington was the first to pass a concussion in sports
law in 2009, and by 2013 all 50 states including the District of Columbia
had enacted legislation regarding concussions in sports for youth and/or
high school athletes. This legislation focuses on education,
recommendations for removing athletes from play, and permission to return
to play. Many states require return to play permission be obtained by a
healthcare professional, which may influence the number of TBI-related
visits. Please refer to Chapter 41 Injury: Head , for a detailed discussion
regarding pathophysiology and signs and symptoms.
Clinical Considerations
Clinical Recognition. The features of concussion are nonspecific and some
may be indicative of ciTBI. The most common symptoms include
headache, dizziness, gait abnormalities, confusion, disorientation, difficulty
concentrating, nausea, vomiting, loss of consciousness, amnesia both
retrograde and anterograde, light and noise sensitivity, visual changes, sleep
disturbances, emotional lability, and irritability. The physical examination
in patients with concussions is typically normal. The evaluation should
include a comprehensive neurologic examination including mental status,
gait, and visio-cerebellar function 1 . Any focal neurologic findings during
the physical examination should alert the clinician to the potential for ciTBI
and prompt the need for neuroimaging.
Multiple concussion assessment tools have been utilized in children and
adolescents. The list includes, and is not limited to, the Sport Concussion
Assessment Tool Version 5 (SCAT 5), Child-SCAT5, Balance Error Scoring
System (BESS), Standardized Assessment of Concussion, individual
sideline assessment tools, and the Centers for Disease Control (CDC) and
Prevention’s Acute Concussion Evaluation (ACE) tools. Many of these

tools have not been validated in children, and the lack of standardized
assessment tools creates challenges for providers. Most of these instruments
are in depth, detailed and time consuming. Their use in the ED has not been