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 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 (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