CDC guidelines on treatment of paediatric mild TBI

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New evidence-based guidelines, developed by the Centres for Disease Control and Prevention (CDC) with input from the American College of Emergency Physicians (ACEP) and others put forward recommendations for a broad range of health care providers responsible for detection and management of paediatric mild traumatic brain injury, most of which are concussions.

The CDC recommendations span diagnosis, prognosis, management and treatment in a variety of clinical settings.

From 2005-2009, there were almost 3m emergency visits for paediatric mild traumatic brain injury, according to the CDC. “The experts in emergency departments are often the first care providers to evaluate a child’s head injury,” said Dr Angela Lumba-Brown, paediatric emergency physician, lead author and clinical assistant professor of emergency medicine at Stanford University. “These guidelines standardise a framework for recognising, treating and managing a child’s recovery from mild traumatic brain injury – encouraging appropriate use of diagnostic imaging, safe prescribing, and making sure each child, family or caretaker is equipped with the information they need for a quick and safe recovery.”

Key recommendations include that mild traumatic brain injury does not require imaging in an acute care setting. Computed tomography (CT) imaging should be considered when there is suspicion of more severe forms of injury, the authors wrote.

The CDC suggests that clinicians screen for risk factors because recovery will vary by individual characteristics. Non-opioid analgesics should be prescribed by the emergency department along with counselling about risks of overuse. The child and family should be educated before discharge about the warning signs for more serious injury and the expected course of recovery. And, the new recommendations call for providers to describe healthy sleep habits and other strategies to help facilitate recovery.

The CDC is offering new tools that can help health care providers with implementation of the guidelines, including a checklist for diagnosis and management; patient discharge instructions; recovery tips for parents to support their child; and a letter to schools to be filled in by healthcare providers.

Introduction
From 2005 to 2009, children made more than 2 million outpatient visits and almost 3 million emergency department (ED) visits for mild traumatic brain injury.1 The actual number of mild traumatic brain injury cases is difficult to assess because patients may seek treatment in a variety of medical or school settings, or not at all. However, there is evidence that these numbers are increasing; in 2007, there were 461,000 ED visits for traumatic brain injury among children aged 14 years and younger; by 2013, that number had increased to 642,000.2, 3
The detection, evaluation, and management of pediatric patients with mild traumatic brain injury is complicated by the lack of standardization and evidenced-based guidance. The short- and potential long-term effects of mild traumatic brain injury can have significant consequences that affect a child’s ability to function physically, cognitively, and psychologically.4, 5, 6 Although most pediatric patients no longer experience symptoms within 1 to 3 months, a subset of patients may have protracted symptoms.7 The ED clinician plays a critical role by recognizing patients with mild traumatic brain injury, conducting and documenting an appropriate focused examination, providing symptom management, guiding preventive measures, and providing sound discharge instructions.

Authors
Angela Lumba-Brown, David W Wright, Kelly Sarmiento, Debra Houry

American College of Emergency Physicians material
Annals of Emergency Medicine editorial abstract


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