The Journal of the Arkansas Medical Society Med Journal May 2019 Final 2 | Page 13

AFMC: A CLOSER LOOK AT QUALIT Y
used routinely in acute evaluation of
mTBI, due to the need for sedation,
study length and the exam’s
expense (Moderate, Level B). This
is an evolving area, however, with
successful use of rapid sequence MRI
in non-sedated patients. 6
Single-photon emission CT
(SPECT) should not be used in the
acute evaluation of mTBI, because
of the need for sedation, contrast
and higher expense (Moderate,
Level B). Skull radiographs are not
appropriate with mTBI, as some
fractures and intracranial bleeds
will not be visible with this modality
(High, Level B).
OTHER ASSESSMENT TOOLS
Additional assessment tools
are available, including symptom
scales, computerized assessments
and serum biomarkers. It is
recommended that an age-
appropriate, validated symptom
rating scale be used as part of the
diagnostic evaluation for pediatric
acute mTBI (Moderate, Level
B). There are several symptom
scales available, but no single
tool is strongly predictive of
outcome. Use of a standardized
tool to routinely track recovery is
recommended (Moderate, Level
B). Reaction time and balance
testing may also be used to assess
recovery (Moderate, Level C).
Age-appropriate computerized
cognitive testing may be used in
acute settings as part of diagnostic
evaluation (Moderate, Level C).
Several studies indicate that a
computerized neurocognitive
test battery can distinguish high
school athletes with and without
mTBI in the first four days after
injury, although these studies only
evaluated one product. 7
Serum markers should not be
used outside a research setting
to diagnose children with mTBI
(High, Level R). EDITOR’S NOTE: Dr. Hobart-Porter
will discuss mTBI management and
treatment guidelines in the June “A
Closer Look at Quality” column.
FAMILIES NEED REASSURANCE
Education and counseling can
provide reassurance and prevent
complications. Patients and families
should be advised that most (70-
80%) of pediatric mTBI patients
will not show significant related
problems beyond one to three
months from injury, and each child
will follow his or her own path
to recovery (Moderate, Level B).
Currently, there is no identified single
factor that can predict symptom
resolution or outcome. 8 However,
premorbid history should be
obtained as this can guide providers
in determining prognosis (Moderate,
Level B). Specifically, children may
have a delayed recovery if they have
one or more of these comorbidities:
premorbid TBI, lower cognitive ability,
neurological or psychiatric disorder,
learning disorder or problems,
preinjury symptoms (headache) or
family or social stressors. Certain
risk factors can raise the likelihood
of persistent post-mTBI symptoms
(High, Level C), including: age (older
children/adolescents), ethnicity/
race (Hispanic), lower socioeconomic
status or more severe initial
presentation. Headaches tend to be
more common in females with mTBI. 9
Children who have not responded
to standard treatment within four
to six weeks should be referred for
appropriate assessments and/or
interventions (Moderate, Level B). s REFERENCES
Dr. Hobart-Porter is medical director,
Spinal Cord Disorders Program and
Concussion Clinic, UAMS and Arkansas
Children’s Hospital.
1. Mannix, R, O’Brien, M, Meehan III, W
(2013) The epidemiology of outpatient
visits for minor head injury: 2005 -
2009. Neurosurgery, 73(1), 129-134.
2. Lumba-Brown, A, Yeates, K, Sarmiento, K,
et.al., (2018) Centers for Disease Control
and Prevention Guideline on the Diagnosis
and Management of Mild Traumatic Brain
Injury Among Children. Jour of the Amer
Medical 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 mild traumatic brain injury. Jour of
Rehab Med, 43 (supplement), 113-125.
4. Kuppermann, N, Holmes, J, Dayan, P (2009)
Pediatric Emergency Care Applied Research
Network (PECARN) Identification of children
at very low risk of clinically-important brain
injuries after head trauma: a prospective
cohort study. Lancet, 374 (9696), 1160-1170.
5. Boran, B, Boran, P, Barut, N, et.al.,
(2006) Evaluation of mild head
injury in a pediatric population. Ped.
Neurosurgery, 42 (4), 203-207.
6. Young, J, Duhaime, A, Caruso, P, et.al.,
(2016) Comparison of non-sedated brain
MRI and CT for the detection of acute
traumatic injury in children 6 years of age
or less. Emerg. Radiology, 23 (4), 325-331.
7. Schatz, P, Pardini, J, Lovell, M, et.al., (2006)
Sensitivity and specificity of the ImPACT
Test Battery for concussion in athletes. Arch.
of Clin Neuropsychology, 21 (1), 91-99.
8. Zemek, Farion, K, Sampson, M, et.al.,
(2013) Prognosticators of persistent
symptoms following pediatric concussion:
a systematic review. Jour of the Amer
Med Assoc Pediatrics, 167 (3), 259-265.
9. Blume, H, Vavilala, M, Jaffe, K, et.al.,
(2012) Headache after pediatric
traumatic brain injury: a cohort
study. Pediatrics, 129 (1), e31-e39.
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.
MAY 2019
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