Dear Drs. Meyer and Oster,
Thank you for your interest in our paper(1) and for your concern for
the proper management of children suffering from acute brain injury.
As you know, a concussion is a complex pathophysiologic process
resulting from a rapid rotational acceleration of the brain caused by
trauma.(2-4) It is a form of traumatic brain injury. The Glasgow Coma
Scale, on the other hand, was developed as a means of communicating the
neurological status of patients that have sustained a head injury. Its
value reflects a head-injured patient's vocalization, motor movements, and
eye movements, either spontaneously or in response to various stimuli.(5-
6) It is frequently used in the acute setting to transfer information from
one group of caregivers to another. It is not, however, reflective of a
specific diagnosis. A patient with a Glasgow Coma Scale score of 14, for
example, may be suffering from a concussion, or may have a subdural
hematoma, or an epidural hematoma, or cerebral edema, or a cerebral
contusion, or some combination of these injuries. As our objectives were
to determine the number of hospital admissions due to concussion, and to
determine the imaging and medications used for assessing and managing
concussions, we could not achieve our stated objectives by assessing
patients identified solely by their Glasgow Coma Scale scores.
Furthermore, as the Pediatric Health Information System is an
administrative database, such clinical data was not available to us.
We agree with your recommendation to discourage "the almost
indiscriminate" use of computed tomography of the brain. We believe, as
you suggest and as suggested by the paper by Nigrovic et al that we
referenced, a period of observation in place of computed tomography may be
a safe alternative for some patients. In fact, we suspect that a shorter
time period than the 24-48 hours you recommend may suffice. Our data
suggests that such an observation period would likely decrease the cost of
an emergency department visit when compared to the cost of a visit with
computed tomography.
Once again, we thank you for your interest in our work and for
offering your thoughts in response.
Yours Sincerely,
William P. Meehan III Cary Thurm Brian M. Pate Jason G. Newland Matt
Hall Jeffrey D. Colvin
References 1.)Colvin JD, Thurm C, Pate BM, Newland JG, Hall M, Meehan
WP, 3rd. Diagnosis and acute management of patients with concussion at
children's hospitals. Arch Dis Child published 13 July 2013,
10.1136/archdischild- 2012-303588. 2.)McCrory P, Meeuwisse W, Aubry M, et
al. Consensus statement on concussion in sport--the 4th International
Conference on Concussion in Sport held in Zurich, November 2012. Clin J
Sport Med. Mar 2013;23(2):89- 117. 3.) Meehan WP, 3rd, Bachur RG. Sport-
related concussion. Pediatrics. Jan 2009;123(1):114-123. 4.) Ommaya AK,
Gennarelli TA. Cerebral concussion and traumatic unconsciousness.
Correlation of experimental and clinical observations of blunt head
injuries. Brain. Dec 1974;97(4):633-654. 5.) Teasdale G, Jennett B.
Assessment and prognosis of coma after head injury. Acta Neurochirurgica.
1976;34(1-4):45-55. 6.) Teasdale G, Jennett B. Assessment of coma and
impaired consciousness. A practical scale. Lancet. Jul 13 1974;2(7872):81-
84
Conflict of Interest:
None declared
Dear Drs. Meyer and Oster,
Thank you for your interest in our paper(1) and for your concern for the proper management of children suffering from acute brain injury.
As you know, a concussion is a complex pathophysiologic process resulting from a rapid rotational acceleration of the brain caused by trauma.(2-4) It is a form of traumatic brain injury. The Glasgow Coma Scale, on the other hand, was developed as a means of communicating the neurological status of patients that have sustained a head injury. Its value reflects a head-injured patient's vocalization, motor movements, and eye movements, either spontaneously or in response to various stimuli.(5- 6) It is frequently used in the acute setting to transfer information from one group of caregivers to another. It is not, however, reflective of a specific diagnosis. A patient with a Glasgow Coma Scale score of 14, for example, may be suffering from a concussion, or may have a subdural hematoma, or an epidural hematoma, or cerebral edema, or a cerebral contusion, or some combination of these injuries. As our objectives were to determine the number of hospital admissions due to concussion, and to determine the imaging and medications used for assessing and managing concussions, we could not achieve our stated objectives by assessing patients identified solely by their Glasgow Coma Scale scores. Furthermore, as the Pediatric Health Information System is an administrative database, such clinical data was not available to us.
We agree with your recommendation to discourage "the almost indiscriminate" use of computed tomography of the brain. We believe, as you suggest and as suggested by the paper by Nigrovic et al that we referenced, a period of observation in place of computed tomography may be a safe alternative for some patients. In fact, we suspect that a shorter time period than the 24-48 hours you recommend may suffice. Our data suggests that such an observation period would likely decrease the cost of an emergency department visit when compared to the cost of a visit with computed tomography.
Once again, we thank you for your interest in our work and for offering your thoughts in response.
Yours Sincerely,
William P. Meehan III Cary Thurm Brian M. Pate Jason G. Newland Matt Hall Jeffrey D. Colvin
References 1.)Colvin JD, Thurm C, Pate BM, Newland JG, Hall M, Meehan WP, 3rd. Diagnosis and acute management of patients with concussion at children's hospitals. Arch Dis Child published 13 July 2013, 10.1136/archdischild- 2012-303588. 2.)McCrory P, Meeuwisse W, Aubry M, et al. Consensus statement on concussion in sport--the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Clin J Sport Med. Mar 2013;23(2):89- 117. 3.) Meehan WP, 3rd, Bachur RG. Sport- related concussion. Pediatrics. Jan 2009;123(1):114-123. 4.) Ommaya AK, Gennarelli TA. Cerebral concussion and traumatic unconsciousness. Correlation of experimental and clinical observations of blunt head injuries. Brain. Dec 1974;97(4):633-654. 5.) Teasdale G, Jennett B. Assessment and prognosis of coma after head injury. Acta Neurochirurgica. 1976;34(1-4):45-55. 6.) Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. Jul 13 1974;2(7872):81- 84
Conflict of Interest:
None declared