2025 – PAGE 217 – 218 – EMERGENCY MEDICINE & TOXICOLOGY
POST-CONCUSSION TREATMENT (2013 AAN GUIDELINES)
“Concussion” is a clinical diagnosis and may include symptoms such as confusion, amnesia, loss of consciousness, balance/coordination abnormalities, sound/light sensitivity, headache, fogginess, etc. Remove any athlete suspected of a concussion immediately from play. The player needs to be evaluated by a licensed healthcare provider trained in concussion diagnosis and management, and should not return to play until all concussion symptoms have resolved. There is NO set timeline for recovery or return to play. There is weak evidence that a step-by-step plan of return to activity might be helpful. Any activity that makes symptoms worse or puts the athlete at risk for another concussion should NOT be a part of the management plan while any concussion symptoms are still present.
- IMAGING: Obtain if there’s loss of consciousness (LOC), post-traumatic amnesia, persistently altered mentation, focal neurological deficits, evidence of skull fracture, or signs of clinical deterioration.
- PEARLS: Football, rugby, soccer, and basketball players are at highest risk. No specific type of helmet has been proven to be better than another. Symptom checklists, the Standardized Assessment of Concussion (SAC), neuropsychological testing, and the Balance Error Scoring System may be helpful tools in diagnosing and managing concussions but should not be used alone for making a diagnosis. High school and younger athletes should be treated more conservatively than adults.
ENDOTRACHEAL TUBES AND VENTILATION
- PEDIATRIC ENDOTRACHEALTUBE SIZE (AKA ET TUBE or ETT SIZE): In general, keep (Age/4) + 4 in mind. It’s doubtful that you will be asked about cuffed ET tubes, but if so, CUFFED size = (Age/4) + 3.5 Babies’ ETT size is based on weight. 2.5 mm if < 1.5 kg, 3.0 mm if < 2.5 kg and 3.5 mm if > 2.5 kg.
- VENTILATION: Tidal Volume (AKA TV) = 7 cc/kg
- MEDICATIONS: Naloxone(for acute opioid exposures), Atropine (for bradycardia), Valium, Epinephrine, and Lidocaine may be given via the ETT.
- MNEMONIC: The word “NAVEL” should help you remember the medications that can be given through the ETT. If that doesn’t work, imagine an ETT that goes so deep that it almost pokes out of an intubated baby’s NAVEL!
- CRASHING PATIENT: If you are presented with a rapidly deteriorating intubated patient, consider EXTUBATION followed by bag and valve mask ventilation as the next step. If the patient’s condition is deteriorating more gradually, evaluate for displacement of the ETT, obstruction of the ETT, pneumothorax, and equipment failure.
- MNEMONIC: DOPE = Displacement, Obstruction, Pneumothorax, and Equipment failure. For rapidly deteriorating patients, extubation and bag and valve mask ventilation address D, O, and E.
IMPAIRED PERFUSION/HYPOVOLEMIA
Since poor capillary refill is an early finding in shock, pulse oximetry is unreliable in cases of impaired perfusion or Hypovolemia. Hypotension is the LATE finding. Try to get IV access for 90 sec or three tries, but then MOVE ON to an intraosseous line (IO).
CARDIOPULMONARY RESUSCITATION (CPR)
Cardiopulmonary Resuscitation (CPR) is a low-yield topic because guidelines are always changing.
- SINGLE RESCUER CPR FOR BABIES: Provide compressions and breaths at a ratio of 30:2 to minimize transition times. Also, COMPRESSIONS are more important than breaths.
- DOUBLE RESCUER CPR FOR BABIES: Provide compressions and breaths at a ratio of 15:2 (15 compressions for every two breaths).
- ADOLESCENTS: 30:2 regardless of the number of rescuers.
- PEARL: Guidelines are always changing, but the key is to remember that it’s becoming more and more important to focus on high-quality chest compressions to get the blood flowing rather than focusing on breaths.