The Journal of the Arkansas Medical Society Med Journal June 2019 Final | Page 13

AFMC: A CLOSER LOOK AT QUALIT Y
advanced again after at least 24 hours
of symptom-free activity.
RETURN-TO-SCHOOL PROTOCOLS
Returning to school should be a
collaborative effort between health
care and school-based professionals,
gradually increasing the duration
and intensity of academic activities
as tolerated (Moderate, Level B). The
goal is to increase participation with-
out worsening symptoms. This may
require abbreviated class schedules,
lessened homework loads or a tem-
porary hold on testing, depending on
the child. Return-to-school protocols
should be customized for each child,
based on severity of symptoms
(Moderate, Level B) with the recog-
nition that each child has a different
recovery trajectory. Some children
may require additional educational
supports, such as an Individualized
Education Plan (IEP) or 504 plan. If a
child has prolonged symptoms that
interfere with classwork performance,
need for an IEP should be assessed by
the school (High, Level B).
Ongoing monitoring of academic
performance to collaboratively
determine needs for additional or
ongoing educational supports is
crucial (High, Level B). There is a
balance between prompt return to
school and the necessary cognitive
recovery that must take place.
Cognitive impairment can occur in
the setting of mTBI, and treatments
should be directed to its presumed
etiology (High, Level B). A formal
neuropsychological assessment
can help determine etiologies
and recommend specific helpful
interventions (High, Level C). These
assessments, particularly as they
relate to academics, should be
shared with the child’s school, with a
parental release of information.
TREATING PAIN
Acute headache is an extremely
common symptom after mTBI.
Emergency department profession-
als should consider head computed
tomography (CT) in children with
severe or worsening headache,
particularly when associated with
other risk factors, including age
younger than 2 years, vomiting, loss
of consciousness, severe mechanism
of injury, amnesia, nonfrontal scalp
hematoma, GCS score of less than
15 and/or clinical suspicion of skull
fracture 6 (High, Level B). Children
with headache and acutely wors-
ening neurologic symptoms should
have emergent neuroimaging (High,
Level B). Hypertonic 3 percent saline
should not be administered for
treatment of acute headache in mTBI
outside of research settings (Moder-
ate, Level R). Caregivers and health
care providers should offer non-opi-
oid analgesics (acetaminophen or
non-steroidal anti-inflammatories)
for acute mTBI-associated headache
(Moderate, Level B). Counsel the fam-
ily on the risk of analgesic overuse
and rebound headaches.
Chronic headaches after mTBI
tend to be multifactorial, requiring
multidisciplinary approach (High,
Level B). This may include psychol-
ogy, physical therapy, and additional
physician specialists such as physical
medicine and rehabilitation, neu-
rology, sports medicine, and pain or
sleep medicine. Analgesic overuse
is often a significant contributory
factor. Additional factors may include
vestibulo-oculomotor dysfunction,
which may respond to rehabilitation
(Moderate, Level C). Sleep disorders
can also contribute to headaches
and to overall recovery. Education on
proper sleep hygiene should be pro-
vided to families (Moderate, Level B).
Pediatric mTBI is a challenging and
dynamic diagnosis to manage and
treat. Careful progression to play and
academics is vital for recovery but can
be complicated by post-traumatic
symptoms. If a child is not recovering
as expected, referral to a specialist
who manages mTBI is recommended.
Arkansas Children’s Hospital offers a
weekly concussion clinic. For appoint-
ments call 501-803-2599.
More detailed guideline and
family education materials at:
www.cdc.gov/HEADSUP. s
Dr. Hobart-Porter is medical director,
Spinal Cord Disorders Program and
Concussion Clinic, UAMS and Arkansas
Children’s Hospital.
REFERENCES
1. Mannix R, O’Brien M, Meehan III W, (2013).
The epidemiology of outpatient visits for mi-
nor head injury: 2005 to 2009. Neurosurgery,
73 (1), 129-134.
2. Lumba-Brown A, Yeates K, Sarmiento K, et.
al., (2018). CDC Guideline on the Diagnosis
and Management of Mild Traumatic Brain
Injury Among Children. Jour Amer Med Assoc
Pediatrics, 172 (11), e182853.
3. Carroll L, Cassidy J, Holm L, et. al., (2004).
WHO Collaborating Centre Task Force on Mild
Traumatic Brain Injury. Methodological issues
and research recommendations for mTBI.
Jour of Rehab Med, 43 (supplement), 113-125.
4. Silverberg N, Iverson G, (2013). Is rest after
concussion”the best medicine?” recommen-
dations for activity resumption following
concussion in athletes, civilians, and military
service members. Jour of Head Trauma Rehab,
28 (4), 250-259.
5. Moser R, Schatz P, Glenn M, et .al., (2015).
Examining prescribed rest as treatment for
adolescents who are slow to recover from
concussion. Brain Injury, 29 (1), 58-63.
6. Boran B, Boran P, Barut N, et. al., (2006)
Evaluation of mild head injury in a pediatric
population. Ped. Neurosurgery, 42 (4), 203-207
AFMC WORKS COLLABORATIVELY WITH PROVIDERS,
COMMUNITY GROUPS AND OTHER STAKEHOLDERS TO
PROMOTE THE QUALITY OF CARE IN ARKANSAS THROUGH
EDUCATION AND EVALUATION. FOR MORE INFORMATION
ABOUT AFMC QUALITY IMPROVEMENT PROJECTS,
CALL 1-877-375-5700 OR VISIT AFMC.ORG.
JUNE 2019
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