Mild Traumatic Brain Injury and Concussion: Management of Pediatric Patients -
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Emergency Department Assessment and Management of Pediatric Acute Mild Traumatic Brain Injury and Concussion (Trauma CME)

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About This Issue

Mild traumatic brain injury (mTBI) is one of the most common neurologic diagnoses and accounts for the majority of TBIs that present to the emergency department (ED). Concussion is often considered to be a subtype of mTBI, with sports-related concussion as a subset of concussion. 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 evaluation, diagnosis, and treatment in the acute setting. Clinical decision rules and their utility in clinical practice are also discussed. You will learn:

Definitions for mTBI and concussion

Common symptoms of concussion

The differential diagnosis of mTBI and strategies for ruling out those diagnoses

Tools for sideline assessment and evaluation for concussion, including the SCAT5©, child SCAT5©, Post–Concussion Symptom Scale, modified Balance Error Scoring System, tandem gait evaluation, Standardized Assessment of Concussion, and King Devick Test

Clinical decision rules to risk-stratify patients with mild head injury, including CATCH (Canadian Assessment of Tomography for Childhood Head Injury), CHALICE (Children’s Head Injury Algorithm for the Prediction of Important Clinical Events), and PECARN (Pediatric Emergency Care Applied Research Network)

Important aspects of the physical examination of the patient with suspected mTBI

Tools for assessing level of consciousness, including the Glasgow Coma Scale/Pediatric Glasgow Coma Scale

Components of a comprehensive concussion evaluation in the ED, including a thorough neurologic examination and symptom, cognitive, balance, and vestibular-ocular assessment

Treatment options for posttraumatic headache and/or nausea

Recommendations for headache management (if the patient complains of headache); return to activity, school, and sports; sleep hygiene; and appropriate follow-up

Criteria for observation, discharge, and admission

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
    1. Defining Mild Traumatic Brain Injury and Concussion
      1. Concussion
      2. Sports-Related Concussion
  4. Critical Appraisal of the Literature
  5. Etiology and Pathophysiology
  6. Differential Diagnosis
  7. Prehospital and Sideline Care of mTBI and Sports-Related Concussion
    1. Evaluation for Concussion
      1. The SCAT5©
      2. The Post–Concussion Symptom Scale
      3. The Balance Error Scoring System/Modified Balance Error Scoring System and Tandem Gait Evaluation
      4. The Standardized Assessment of Concussion
      5. The King Devick Test
      6. Comprehensive Concussion Examination
  8. Emergency Department Evaluation
    1. Historical Questions for Assessment of Structural Injury
      1. Clinical Decision Rules
      2. Vomiting
      3. Mechanism of Injury
      4. History of Seizure
      5. Headache
      6. Loss of Consciousness
      7. Past Medical History
    2. Physical Examination Components/Findings for Structural Abnormalities
      1. Glasgow Coma Scale Score at Presentation
      2. Scalp Hematoma
      3. Skull Fracture
  9. Diagnostic Studies
  10. Concussion in the Emergency Department
    1. Symptom Evaluation
      1. Cognitive Assessment
      2. Balance Assessment
      3. Vestibular-Ocular Assessment
      4. Cervicogenic Evaluation
  11. Treatment
  12. Special Circumstances
    1. Nonaccidental Trauma
    2. Patients at Risk for Post–Concussion Syndrome
  13. Controversies and Cutting Edge
    1. Biomarkers
    2. D-Dimer
    3. Brain Magnetic Resonance Imaging
  14. Disposition
    1. Mild Traumatic Brain Injury Recovery Recommendations
      1. Post–Concussion Syndrome Risk Factors
      2. Headache Recommendations
      3. Activity Recommendations
      4. School Recommendations
      5. Sports Recommendations
      6. Sleep Hygiene and Concussion
      7. Follow-up
    2. Observation
    3. Discharge
    4. Admission
  15. Summary
  16. Time- and Cost-Effective Strategies
  17. Key Points
  18. Risk Management Pitfalls in The Assessment and Treatment of Mild TBI and Sports-Related Concussion in Children
  19. Case Conclusions
  20. Clinical Pathway for Computed Tomography for Children With a Glasgow Coma Scale Score of 14-15 After Head Trauma
  21. Tables, Figures and Appendix
    1. Table 1. Symptoms of Concussion
    2. Table 2. Differential Diagnosis for Mild Traumatic Brain Injury
    3. Table 3. Clinical Decision Rules for Risk Stratification of Children With Minor Head Injury
    4. Table 4. Concussion Evaluation in the Emergency Department
    5. Table 5. Common Posttraumatic Headaches
    6. Table 6. Medications Used for Treatment of Posttraumatic Headache and/or Nausea
    7. Table 7. Graduated Return-to-School Activities
    8. Figure 1. Sideline Concussion Assessment Tool (SCAT) Red Flags
    9. Appendix 1. Resources for Assessment of Concussion
  22. References

Abstract

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.

Case Presentations

CASE 1
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?
CASE 2
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?
CASE 3
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?

Clinical Pathway for Computed Tomography for Children With a Glasgow Coma Scale Score of 14-15 After Head Trauma

Clinical Pathway for Computed Tomography for Children With a Glasgow Coma Scale Score of 14-15 After Head Trauma

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Tables, Figures and Appendi

Table 1. Symptoms of Concussion

Table 2. Differential Diagnosis for Mild Traumatic Brain Injury
Table 3. Clinical Decision Rules for Risk Stratification of Children With Minor Head Injury
Table 4. Concussion Evaluation in the Emergency Department
Table 5. Common Posttraumatic Headaches

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

2. * Lumba-Brown A, Yeates KO, Sarmiento K, et al. Diagnosis and management of mild traumatic brain injury in children: a systematic review. JAMA Pediatr. 2018;172(11):e182847. (Systematic literature review and clinical guideline) DOI: 10.1001/jamapediatrics.2018.2847

3. National Center for Injury Prevention and Control. Report to congress on mild traumatic brain injury in the United States: steps to prevent a serious public health problem. Accessed May 15, 2021. (Literature review and recommendations from the CDC mTBI group)

8. * Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170. (Prospective cohort; 42,412 children) DOI: 10.1016/S0140-6736(09)61558-0

9. * Halstead ME, Walter KD, Moffatt K, et al. Sport-related concussion in children and adolescents. Pediatrics. 2018;142(6). (Guideline) DOI: 10.1542/peds.2018-3074

21. * Committee on Sports-Related Concussions in Youth, Board on Children, Youth, and Families, Institute of Medicine, National Research Council. Sports-related concussions in youth: improving the science, changing the culture. Washington DC: National Academies Press (US). 2014. (Consensus study report) DOI: 10.17226/18377

37. * Osmond MH, Klassen TP, Wells GA, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ. 2010;182(4):341-348. (Prospective cohort; 3866 children) DOI: 10.1503/cmaj.091421

38. * Dunning J, Daly JP, Lomas JP, et al. Derivation of the children’s head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child. 2006;91(11):885-891. (Prospective cohort; 22,772 children) DOI: 10.1136/adc.2005.083980

39. * Lyttle MD, Crowe L, Oakley E, et al. Comparing CATCH, CHALICE and PECARN clinical decision rules for paediatric head injuries. Emerg Med J. 2012;29(10):785-794. (Review) DOI: 10.1136/emermed-2011-200225

40. * Easter JS, Bakes K, Dhaliwal J, et al. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Ann Emerg Med. 2014;64(2):145-152, 152.e141-145. (Prospective cohort; 1009 children) DOI: 10.1016/j.annemergmed.2014.01.030

45. * Nigrovic LE, Lee LK, Hoyle J, et al. Prevalence of clinically important traumatic brain injuries in children with minor blunt head trauma and isolated severe injury mechanisms. Arch Pediatr Adolesc Med. 2012;166(4):356-361. (Secondary analysis of a prospective observational cohort study; 42,412 patients) DOI: 10.1001/archpediatrics.2011.1156

54. * Palchak MJ, Holmes JF, Vance CW, et al. A decision rule for identifying children at low risk for brain injuries after blunt head trauma. Ann Emerg Med. 2003;42(4):492-506. (Prospective cohort; 22,772 children) DOI: 10.1067/s0196-0644(03)00425-6

57. * Dayan PS, Holmes JF, Schutzman S, et al. Risk of traumatic brain injuries in children younger than 24 months with isolated scalp hematomas. Ann Emerg Med. 2014;64(2):153-162. (Secondary analysis of a prospective multicenter cohort study; 10,659 children) DOI: 10.1016/j.annemergmed.2014.02.003

92. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Accessed May 15, 2021. (Clinical descriptions and diagnostic guidelines)

Subscribe to get the full list of 104 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: mild traumatic brain injury, mTBI, clinically important traumatic brain injury, clinically important TBI, ciTBI, concussion, sports-related concussion, sport-related concussion, symptoms of concussion, clinical decision rules, Pediatric Emergency Care Applied Research Network, PECARN, Canadian Assessment of Tomography for Childhood Head Injury, CATCH, Children’s Head Injury Algorithm for the Prediction of Important Clinical Events, CHALICE, Glasgow Coma Scale, GCS, Pediatric Glasgow Coma Scale, pGCS, Sideline Concussion Assessment Tool, SCAT, SCAT5, Maddocks questions, Balance Error Scoring System, BESS, mBESS, tandem gait evaluation, Standardized Assessment of Concussion, Post–Concussion Symptom Scale, Vestibular Ocular Motor Screening, VOMS, King Devick Test, cognitive assessment, balance assessment, vestibular-ocular assessment, computed tomography, magnetic resonance imaging, neuroimaging, post–concussion syndrome, posttraumatic headache, second-impact syndrome, SIS, ImPACT, sideline assessment, sideline care, evaluation for concussion, nonaccidental trauma, return-to-sports recommendations, return-to-school recommendations

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Publication Information
Authors

Madeline Joseph, MD, FACEP, FAAP; Audrey Paul, MD, PhD

Peer Reviewed By

Susan B. Kirelik, MD, FAAP; Todd W. Lyons, MD, MPH

Publication Date

June 2, 2021

CME Expiration Date

June 2, 2024

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.
Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits.

Pub Med ID: 34008934

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CME Information

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