New guidelines from the CDC have established practice-changing recommendations in the diagnosis and treatment of pediatric mild traumatic brain injury (TBI).1 This information is especially important to frontline providers, as statistics suggest an increasing number of children are presenting to the ED with concussions. Investigators noted that in 2013, 642,000 children presented to the ED for TBI-related injuries, a sharp increase from 2007 (461,000 visits).2

The guidelines include 19 sets of recommendations pertaining to the diagnosis, prognosis, and management of pediatric mild TBI. The guidelines identify best practices based on current evidence and are intended to help standardize and improve the way these cases are managed, both while patients are in the doctor’s office or ED and after they have been discharged. “These [recommendations] represent the only evidence-based guidelines on the management of pediatric mild TBI in the U.S. They [apply to] all pediatric ages and mechanisms of injury,” says Angela Lumba-Brown, MD, lead author of the new guidelines. Lumba-Brown is a clinical assistant professor of emergency medicine and pediatrics at Stanford University School of Medicine and co-director of the Stanford Concussion and Brain Performance Center. “This is key because the majority of head injuries in children are not attributable exclusively to organized sports. They [are caused by] motor vehicle collisions, bike accidents, [and] falls from play equipment.”

The recommendations, which are generalizable to injuries sustained from all these potential causes, were co-authored by a multidisciplinary team of experts from fields ranging from emergency medicine and neurosurgery to neuropsychology and imaging specialists, Lumba-Brown says. “Most importantly, they represent a review of evidence to provide support for management and counseling strategies that are based in fact,” she adds.

Refrain From Routine Imaging

Lumba-Brown says emergency providers should pay close attention to the recommendation about refraining from routinely imaging children to diagnose mild TBI. Rather, TBI should be a clinical diagnosis supported by adjuncts such as age-appropriate, post-concussive symptom scales, she explains. “Similarly, blood tests are not needed to make this diagnosis and should be reserved for research purposes at this time,” Lumba-Brown offers.

The guidelines also emphasize the importance of providing families with appropriate guidance on the care of mild TBI. “Counseling families regarding a child’s diagnosis of mild TBI and likely prognosis for recovery begins in the ED,” Lumba-Brown says. “Often, children may not be able to see their regular doctor for days following injury. The ED clinician is then critical to give support and information to these families.”

In an editorial published in the Annals of Emergency Medicine, Lumba-Brown and colleagues adapted key aspects of the larger guidelines specifically for emergency providers, in part because they view the counseling piece as such a crucial aspect of providing effective care.3

“Whether it be what to watch for in a 2-month-old with fever or how to move forward with an asthma action plan in a 10-year-old ... or what to watch for in a 7-year-old with mild TBI, counseling our pediatric patients and their families is key,” Lumba-Brown stresses. “Effective counseling is best and most succinctly delivered when we fully understand the information we are trying to get across.”

In children diagnosed with mild TBI, the guideline authors recommend a gradual return to activities after no more than two to three days of rest in most cases. “[This] includes physical and cognitive activity such as school re-integration and participation during play,” Lumba-Brown explains. “However, an ED physician cannot clear a child to return to sports or activities such as mountain biking or jumping on a trampoline that pose significant risk for repeat head injury at any point following the [original] injury.”

Use EMR

What steps can ED leaders take to ensure clinicians adhere to the new guidelines? Lumba-Brown recommends that they review what aspects of their electronic medical record (EMR) can be used to function as reminders and to easily incorporate important aspects of the clinical visit into documentation.

“It is not aspects of counseling a family that strain a physician’s time, but rather their extensive and often cumbersome requirements for documentation that require time and energy that could be better spent,” Lumba-Brown observes. “By streamlining an approach to any type of guideline with EMR integration, including updated discharge instructions, we can focus on our patients.”

(Editor’s Note: In accordance with the new guidelines, the CDC offers provider tools and other resources to assist clinicians in implementing the guidelines and effectively caring for young patients with mild TBI. Also available are resources for patients and families affected by mild TBI. These resources can be accessed online at: https://bit.ly/2MQ0rOQ.)

REFERENCES

  1. Lumba-Brown A, Yeates KO, Sarmiento K, et al. Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatr 2018; Sep 4:e182853. doi: 10.1001/jamapediatrics.2018.2853. [Epub ahead of print].
  2. Taylor CA, Bell JM, Breiding MJ, Xu L. Traumatic brain injury-related emergency department visits, hospitalizations, and deaths - United States, 2007 and 2013. MMWR Surveill Summ 2017;66:1-16.
  3. Lumba-Brown A, Wright DW, Sarmiento K, Houry D. Emergency department implementation of the Centers for Disease Control and Prevention pediatric mild traumatic brain injury guideline recommendations. Ann Emerg Med 2018;72:581-585.

SOURCE

  • Angela Lumba-Brown, MD, Clinical Assistant Professor, Emergency Medicine and Pediatrics; Co-director, Stanford Concussion and Brain Performance Center, Stanford University School of Medicine, Palo Alto, CA. Email: alumba@stanford.edu.