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More Children Visiting Emergency Room With Sports-Related Head Injuries, But Admissions Remain Steady, Study Says

Increase in percentage of admissions for milder injuries suggests more cautious, wait-and-see approach to mild TBI

The number of emergency department (ED) visits for sports-related traumatic brain injuries (TBIs) has risen over the past ten years, but the percentage of admissions has remained unchanged at about 10%, reports a new study.[1]

The study also reported a trend towards admitting children with less severe TBI, which experts speculate may be the result of a greater emphasis on in-patient observation to watch for signs of a serious brain injury and less reliance on the routine use of CT and MRI scans and parents to observe their children for such signs at home.    Emergency Department sign

Findings

Researchers at Cincinnati Children's Hospital reviewed data on children from birth to age 19 who presented for sports-related TBI to a large, pediatric level 1 trauma center between January 1, 2002 and December 31, 2011. They found that:

  • Sports participation was responsible for about 15% of all TBIs (a figure comparatively lower than the 20% reported in 1996 [2] and the 30% reported in a 2010 study;[3] 
  • Sports participation was responsible for 9.6% of admissions of children due to TBI;
  • No difference in age or gender was observed between those children seen in the ED and discharged from the hospital (outpatient) and those admitted to the hospital (inpatient), although football accounted, as would be expected, for a larger percentage of TBI among boys, and soccer-related TBI rates were higher for girls;
  • Children admitted to the hospital were more likely to have brain bleeds, skull fractures, and brain contusions than those seen in the ED and discharged;
  • The percentage of those patients diagnosed with concussion was similar in the ED and hospital admission groups, accounting for 46.9% and 49.7% of the totals, respectively;
  • For children seen in the ED and discharged, the sports most commonly associated with TBI were:
    • Football (29.1%);
    • Soccer (16.5%); and
    • Basketball (15.4%)
  • For admitted patients, the most common sports were:
    • Football (24.7%)
    • Skateboarding/roller blading (16.1%); and
    • Baseball/softball (12.9%).
  • Skateboarding/roller blading, sledding, and skiing had the highest admission rates per patients seen in the ED for TBI.
  • More patients were being admitted with less severe injuries, but the length of stay for those admitted remained low (<2 days) and was trending downward.

Reasons for total increase unclear

The reasons for the near doubling of ED visits for sports-related TBI over the 10-year study period, with a large, accounted-for spike in the number of sports-related TBI beginning in 2009, were not clear, wrote lead author, Holly R. Hanson, MD. in the journal Pediatrics.

Among the possible explanations, Hanson and her colleagues said, were an increase in recognition of sports-related TBI, more coaches educating athletes and parents, and/or more media attention to the topic. Because the study period ended before two of the three states in the region using Cinncinati Children's Hospital as their "home" hospital (Ohio and Kentucky) enacted so-called "Lystedt" laws, and only seven months after the youth sports concussion safety law became effective in the third (Indiana), the changes required under those laws in terms of concussion education, management and return-to-play were not likely to have affected the study results.

More cautious approach to TBI seen

While the researchers were not be able to explain definitively why the average severity of TBI for those patients seen in the ED who were later admitted to the hospital was down, Hanson and her colleagues speculated that the decrease may have been related to two possible factors:

  • greater reliance on in-patient observation to watch for signs of deteriorating mental status suggestive of a more serious head injury and less routine use of imaging (i.e. MRI and/or CT); and/or
  • an improved ability of ED physicians to recognize TBI, so that it took a less severe injury to trigger an admission for observation in a hospital setting, instead of sending the patient home to be observed for signs of deteriorating mental status by parents or guardians at home.   

Such a more cautious approach by ED physicians to the management of TBI and less routine use of imaging, which is usually normal in cases of mild TBI, such as concussion, is consistent with the approach recommended by many experts, including William P. Meehan, III, MD, Director of the Sports Concussion Clinic at Boston Children's Hospital.  "As an emergency room doctor, if I was so concerned about a patient that I wanted their parents to check on them every hour or two, I would keep them in the hospital, I wouldn't send them home." 

"Ideally if you're that worried about a bleed," says Meehan, "you can either get some kind of imaging and find out is there blood in the brain, or you observe them, and you watch them get better and then you don't need it.  Concussion, all that waking them up every hour or two is going do is make them worse [because] you want them to sleep so they get better. So the real reason to [admit a child with TBI] is if you're not sure it's concussion, you're worried there's something else going on, and for me if I'm that worried about it, I don't send them home."

Higher rates of admission for TBI seen in non-organized sports

That common, competitive sports such as soccer, basketball, and football had the highest number of sports-related TBI in the ED, and accounted for more than twice as many TBIs as non-organized sports did not surprise the researchers and was consistent with a recent study. [3]

Their finding, however, that non-organized sports, such as sledding, skiing and skateboarding had the greatest percentage of ED visits for TBI requiring admission, was somewhat puzzling. "This discrepancy may be secondary to [greater] education about ... TBI among players in organized sports or because of lesser regulation in sports equipment among participants in nonorganized sports." In other words, children in sports such as skateboarding and skiing, where helmet use is not mandatory, may be more likely to suffer a severe TBI when they are injured than those in helmeted sports, such as football.  They called for further studies to confirm such suspicion.


1. Hanson HR, Pomerantz WJ, Gittelman M. ED Utilization Trends in Sports-Related Traumatic Brain Injury.  Pediatrics 2013;132(4). doi: 10.1542/peds.2013-1704 (epub September 30, 2013). 

2. Sosin DM, Sniezek JE, Thurman DJ. Incidence of mild and moderate brain injury in the United States, 1991. Brain Inj. 1996;10(1):47-54

3. Meehan WP III, Mannix R. Pediatric concussions in United States emergency departments in the years 2002 to 2006. J Pediatr. 2010;157(6):889-893.

Posted September 3, 2013

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