Emergency Department Assessment and Management of Pediatric Acute Mild Traumatic Brain Injury and Concussion (Trauma CME) -
Publication Date: June 2021 (Volume 18, Number 06)
CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. CME expires 06/01/2024.
Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional approval.
Madeline Joseph, MD, FACEP, FAAP
Professor of Emergency Medicine and Pediatrics, Associate Dean for Inclusion and Equity, Emergency Medicine Department, University of Florida College of Medicine-Jacksonville, Jacksonville, FL
Audrey Paul, MD, PhD
Assistant Professor; Pediatric Emergency Medicine; NYU Long Island School of Medicine, New York, NY
Susan B. Kirelik, MD, FAAP
Pediatric Emergency Physician, Rocky Mountain Hospital for Children; Medical Director, Rocky Mountain Pediatric OrthoONE Center for Concussion, Denver, Colorado
Todd W. Lyons, MD, MPH
Assistant Professor of Pediatrics and Emergency Medicine, Harvard Medical School, Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA
Mild traumatic brain injury (mTBI) and concussion, a subtype of mTBI, commonly present to the emergency department (ED)and may present with symptoms identical to those associated with more severe TBI. The development and use of clinical decision rules, increased awareness of the risk of radiation associated with head computed tomography, and the potential for patient observation has allowed emergency clinicians to make well-informed decisions regarding the need for imaging for patients who present with mTBI. For patients who present to the ED with concussion, appropriate diagnosis, management, and education are critical for optimal recovery. This issue reviews the most recent literature on concussion and mTBI and provides recommendations for the evaluation, diagnosis, and treatment of mTBI and concussion in the acute setting.
An 18-month-old boy who tripped and fell down 7 steps at home is brought in by his parents…
The toddler was crying a lot at the time of the fall, but he did not lose consciousness. He had 1 episode of vomiting on the way to the hospital.
The toddler has a small frontal hematoma without step-off, laceration, or abrasion. His vital signs are: heart rate, 120 beats/min; blood pressure, 90/57 mm Hg; respiratory rate, 25 breaths/min, and normal pulse oximetry. His Glasgow Coma Scale (GCS) score is 15. He has no neurologic deficits on examination, and he is warming up to the ED staff and smiling. No other injuries were noted. Upon discussion with the parents, you find that he has no history of bleeding disorder or other past medical problems.
What are your next steps in evaluating this patient? Do they include observation or imaging? How should you involve the parents in decision-making?
A 12-year-old girl who sustained a head injury while playing hockey is brought in by EMS...
According to the coach who is with her, the girl ran into another player. She did not lose consciousness or vomit. She initially appeared dazed and seemed “wobbly” on the ice. While sitting on the bench, she began complaining of a headache and worsening dizziness.
The girl is alert and oriented, with no signs of head trauma. Her vital signs are: heart rate, 85 beats/min; blood pressure, 108/70 mm Hg; respiratory rate, 16 breaths/min; and normal pulse oximetry. Her GCS score is 15. Upon examination, she is pale-appearing and complains of nausea, headache, and dizziness. She has no palpable hematoma, no cervical spine tenderness, and no neurologic deficits.
What are your next steps in evaluating this patient? What testing, if any, would you perform in the ED? If you decide to discharge this patient, what instructions should you give to her parents?
A 16-year-old girl is brought to the ED by her parents because her pediatrician referred her for persistent headaches…
The girl was fine until 3 weeks ago when she was playing lacrosse and was hit in the head with a lacrosse ball. She had a mild headache that night and then played in a tournament the next day, during which she sustained a second minor head injury upon colliding with another player. She followed up with her pediatrician that week due to persistent fatigue and headaches. She was told to rest, avoid sports, and take ibuprofen as needed. She now presents with fatigue and daily headaches that do not respond to NSAIDs. She mentions that she has no headaches in the morning, but that they gradually worsen throughout the school day.
On examination, she is alert and oriented. She is complaining of a 6/10 headache. Her vital signs are: heart rate, 74 beats/min; blood pressure, 110/75 mm Hg; respiratory rate, 18 breaths/min, and normal pulse oximetry. She has no deficits on neurologic examination.
What additional information should you obtain in her history? Does this patient need neuroimaging?
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