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With the start of another school year, school nurses and nurses working in primary care and pediatric settings likely will see an influx of young patients with head injuries.

In the United States, between 1.6 million and 3.8 million sports- and recreation-related traumatic brain injuries occur each year. Most of these injuries result in mild traumatic brain injury, also known as concussion. These injuries typically are not treated in a hospital or ED. School nurses often are the first to assess children who sustain head injuries.

Concussion is caused by a bump, blow, or jolt to the head that results in mild-to-severe disruption in brain function. Children and young adults up to age 24 and adults 75 or older are at highest risk for concussion.

Current understanding of the pathophysiology of concussion is shifting from anatomic damage to an emphasis on the dysfunction of neurons resulting from a complex cascade of chemical, metabolic, and physiologic events. Symptoms can be as varied as each patient. Consequently, concussion diagnosis entails a detailed process.

Sheila A. Alexander, RN, PhD, assistant professor in acute/tertiary care at the University of Pittsburgh School of Nursing, says loss of consciousness is not always associated with concussion. She points out only about 10% of patients who sustain concussions lose consciousness. In addition, a "normal" brain scan cannot rule out concussion. "Scans are done to rule out signs of serious concussion such as bleeding or tissue damage," Alexander says.

"When I'm assessing for concussion, I first try to determine if there was a loss of consciousness, and, if so, how long it lasted," says Roberta Bavin, RN, MN, CPNP. Bavin is a nurse practitioner in the school-based heath centers (SBHCs) of the Clovis Unified School District in Clovis, Calif. She also is chair of the SBHC special interest group of the National Association of Pediatric Nurse Practitioners. "Longer periods of unconsciousness correlate with severity. I also want to know about the mechanism of the injury. Was it contact-induced? Where and how was the child hit? Did a knee hit a head? Was the child pushed into an inanimate object? Where did it hit the head?"

A detailed description of the events that lead to an injury helps nurses assess for symptoms. There also are "red flags" that signal a patient should be transported immediately to an ED (preferably a Level 1 trauma center). Nurses should alert parents or caregivers to watch for any of the red flags in the "Concussion Red Flags" box accompanying this article and call 911 if these conditions occur at home.

Concussion symptoms may be physical, cognitive, emotional, or sleep-related. Both mild and emergency symptoms are shown in this article's box "Symptoms That May Indicate Concussion." Short-term memory often is impaired following the incident causing the injury, so a series of questions that evaluate for recent memory is useful. Nurses working with young athletes can use the Maddock's Questions Battery to assess for sports-related head trauma. If an athlete gives an incorrect response to any of the questions below, he or she should be removed from the athletic field and further evaluated at an ED or nearby medical facility:

• Where are we playing?

• Which team are we playing?

• What quarter or inning is it?

• Which side scored last?

• Which team did we play last week?

• Did we win last week?

The concussion healing period varies widely. Rest is a key factor in the healing process, and patients must not return to high-risk activities until symptoms disappear. Parents, teachers, nurses, coaches, and athletic trainers can help monitor childrens' recoveries; however, only healthcare providers can determine when it is safe for patients who sustain mild or more serious concussions to return to normal activities.

"It is a long-held myth that children recover more quickly from concussions than adults," Alexander says. "Current research shows concussion that occurs while the brain is still developing can lead to persistent neurocognitive deficits. It is also believed there is no more harm in repeated concussions than in a single episode, when, in fact, a repeat injury prior to complete healing from the initial concussion can lead to much larger anatomical or behavioral impairment than two isolated concussions."

Bavin stresses teenagers may withhold medical information in the interest of being allowed to begin or resume athletic pursuits. She recalls her work with a teen who recently had visited her for sports clearance. He checked off nothing unusual in the cardiology section of his health questionnaire, yet she detected a noticeable abnormality on auscultation. When she lifted his shirt, she found a scar from a previous cardiothoracic surgery. "You can expect to get only 75% of the information you need provided voluntarily by teens on sports participation questionnaires," she cautions.

The Centers for Disease Control and Prevention developed a resource kit on concussion prevention, diagnoses, and treatment. The Heads Up kit contains acute concussion evaluation forms, a sample care plan, and updated information on concussion for healthcare practitioners. It may be downloaded at www.cdc.gov/ncipc/tbi/Physicians_Tool_Kit.htm.

Joanna Shields is a freelance writer.