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 NUMBER 12 JUNE 2019 • 277