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 NUMBER 11 MAY 2019 • 253