By Jonathan Springston, Editor, Relias-AHC Media
The CDC recently released a report detailing management of traumatic brain injury in children, highlighting care gaps, presenting potential solutions to reduce the gaps, and offering policy strategies to address the short- and long-term consequences of traumatic brain injury.
The agency reports that in 2013, there were 640,000 traumatic brain injury-related ED visits, 18,000 related hospitalizations, and 1,500 deaths among children 14 years of age and younger. This age group leads all others in ED visits for traumatic brain injuries. These events can lead to short-term symptoms, such as reports of dizziness or headaches, and lead to long-term problems with cognitive development.
Frustratingly, there are variations in not only how clinicians diagnose traumatic brain injury but also in formal guidelines for long-term management of children who sustain this injury, along with gaps in available treatment services. Among many recommendations, the CDC report calls for more formal training in this area for healthcare providers and higher spending on health clinics and telemedicine to address this issue (especially in sparsely populated areas where all healthcare resources are lacking).
When it comes to diagnosing young patients, is there a misunderstanding about precisely when a concussion/head injury diagnosis in these patients is appropriate? Or does it boil down to terminology? In a recently published study, investigators from Rutgers New Jersey Medical School suggested concussions are “grossly” underdiagnosed in EDs, but there was no clear explanation for this phenomenon nor what that means for patients who may have sustained a concussion and don’t receive the diagnosis explicitly and immediately.
The March issue of ED Management notes that this Rutgers study was confined to a single center and conducted over 18 months. Out of 627 children who were evaluated for a head injury during the study period, 233 demonstrated criteria compatible with a diagnosis of concussion, but investigators found that just 87 of these patients were diagnosed with concussion. Investigators found that children were more likely to be diagnosed with concussions if they arrived after a motor vehicle collision, and that they were less likely to be diagnosed if they came in after a sports-related injury or they received a CT scan.
“I started off doing a retrospective chart review looking to see if we were compliant with guidelines regarding head imaging of children in the ED,” Katie Myers, MD, the lead investigator and a third-year resident, told ED Management. “As I started looking back through charts, I was reading these stories about these kids coming in with head injuries, and I realized there were a lot of kids that I felt met the criteria for concussion where I wasn’t seeing concussion anywhere in the chart.”
Still, Myers was careful to note that the facility exhibited a 95% compliance rate with guidelines concerning when children presenting with head injuries require a CT scan, indicating providers are performing their work with the right amount of care and concern. But why is the underdiagnosis rate so high? Myers attributed it to variations in terminology (e.g., “head injury” vs. “concussion” vs. “minor traumatic brain injury”).
“We need to better understand how management and intervention across a child’s lifespan relate to everyday improvements for children and their families,” the CDC report concluded. “Overall, there is a critical need to reduce variability and inconsistency in care delivered at the time of injury, and over the long-term after mild and more severe pediatric [traumatic brain injuries]. Standardization of care is critically needed; however, a better evidence base is required to inform management practices.”
For more, check out the March issue of ED Management. And for much more on pediatric health and neurology, be sure to read the latest issues of Pediatric Emergency Medicine Reports and Neurology Alert.