The Journal of the Arkansas Medical Society Med Journal May 2019 Final 2 - Page 12

EDITORIAL PANEL: Chad T. Rodgers, MD, FAAP | Elena M. Davis, MD, MPH | William L. Mason, MD | Michael Moody, MD | J. Gary Wheeler, MD, MPS New Guidelines on Pediatric Traumatic Brain Injury LAURA J. HOBART-PORTER, DO, FAAPMR P ediatric mild traumatic brain injury (mTBI) is complex and presents numerous challenges to physicians across multiple specialties. Children with mTBI made more than 2 million outpatient and nearly 3 million emergency department (ED) visits between 2005 to 2009. 1 Most recover in one to three months, but many patients have persistent and functionally impairing symptoms that require intervention. In November 2018, the Centers for Disease Control and Prevention (CDC) presented a consensus guideline on the management of mTBI in children ages 18 and under, based on a systemic review of articles published between 1990–2015 and a period of public commentary in 2017. 2 This guideline recommended clinical use of mild traumatic brain injury in place of concussion. Mild TBI is defined as “an acute brain injury from mechanical energy to the head from external physical forces including: (1) one or more of the following: confusion or disorientation, loss of consciousness for 30 minutes or less, post-traumatic amnesia for less than 24 hours, and/ or other transient neurological abnormalities such as focal signs, symptoms, or seizure; (2) Glasgow Coma Scale (GCS) score of 13-15 after 30 minutes post-injury or later upon presentation for healthcare.” 3 This definition includes children with intracranial injury (ICI), which can be skull fracture or intracranial bleed. These children may recover more slowly than those with an uncomplicated mTBI. CDC’S RECOMMENDATIONS Forty-six recommendations were rated according to CDC committee level of confidence and strength of recommendation. Levels of confidence include High, Moderate, Low and Very Low. Strength of recommendations include Level A (should always be followed), Level B (usually should be followed), Level C (may sometimes be followed), Level U (insufficient evidence to make a recommendation) and Level R (should not be done outside of 252 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY a research setting). A summary of committee consensus on diagnostics and TBI prognostic factors is presented here. IMAGING RECOMMENDATIONS Imaging is an oft-debated area of mTBI. Head computed tomography (CT) should not be used routinely for diagnostic purposes (Moderate level of confidence, Level B strength of recommendation). Rather, it is recommended that existing decision rules guide use of CT, such as the Pediatric Emergency Care Applied Research Network (PECARN). 4 Up to 8 percent of children seen in the ED will have ICI. 5 It is necessary to weigh risk factors that indicate possible need for CT imaging, including: age younger than 2 years, vomiting, loss of consciousness, severe mechanism of injury, severe or worsening headache, amnesia, nonfrontal scalp hematoma, GCS score of less than 15, and/or clinical suspicion of skull fracture. Use of other cranial imaging options is appropriate only in specific circumstances. MRI should not be VOLUME 115