Mild traumatic brain injury (mTBI) in children is a rapidly growing public health concern that impacts the emergency physician’s daily practice. The number of emergency department visits for mTBI has been on the rise over the past decade. In 2007, there were 461,000 emergency department visits for TBI among children 14 years and younger; in 2013, that number was up to 642,000.1,2
Explore This IssueACEP Now: Vol 37 – No 12 – December 2018
Although the terms “concussion,” “minor head injury,” and “mTBI” often are used interchangeably, they have different connotations and could lead to misinterpretation if not used correctly. Therefore, the Centers for Disease Control and Prevention (CDC) guideline recommends the clinical use of the single term “mild traumatic brain injury.” The recently published CDC pediatric mTBI guideline identifies the best practices based on the current evidence for health care professionals in various settings, including the emergency department.3-4 The guideline was developed through a rigorous process guided by the American Academy of Neurology and 2010 National Academy of Sciences methodologies. An extensive review of scientific literature, spanning 25 years of research, formed the basis of the guideline. Importantly, research pertaining to the assessment and management of mTBI in children is rapidly evolving and advancing, and guidelines should be revised periodically to reflect new evidence.
The CDC pediatric mTBI guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment. The vast majority of these recommendations are very useful for emergency physicians as they are the frontline providers to care for most children with mTBI in the emergency department.
The CDC pediatric mTBI guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence.
Recommendations and Tools
Routine neuroimaging in the acute care setting is not recommended for mTBI in children. CT imaging should be considered when there is a suspicion of more severe forms of TBI supported by validated clinical decision instruments that evaluate a variety of risk factors (eg, Pediatric Emergency Care Applied Research Network [PECARN] head CT rules).5 The CDC has developed guideline implementation tools, such as postconcussion symptom rating scales for emergency physicians to document their patients’ presenting symptoms. These tools assist emergency physicians in making the accurate diagnosis of concussion and contribute to prognostic counseling of children and their families. In addition, based on best evidence, the guideline identifies premorbid history and other risk factors for prolonged recovery that can be easily assessed in the acute care setting. These include older children/adolescents, Hispanic ethnicity, lower socioeconomic status, severe presentation of mTBI including intracranial hemorrhage, and higher levels of postconcussive symptoms. The guideline also emphasizes the unique recovery trajectory for individual patients.