CME CREDIT NOW AVAILABLE-1.0 AMA PRA Category 1 Credit FOR EACH ISSUE (2 ARTICLES)!!!!!!

By Micheal Greenwald

mgreenw@emory.edu

Research continues on a number of fronts regarding head injury evaluation and management.  Below are highlights from 2 of these articles and a summary of a recently published set of guidelines from the CDC.  The articles were exceptionally large studies that pertain to important factors in deciding when to use CT in evaluation of head injury in children. The CDC guidelines explain levels of evidence for a variety of issues regarding diagnosis, prognosis management and treatment of concussion.

Vomiting as a predictor of intracranial injury¹

This large sampling (19, 920) of pediatric head injury patients in Australia and New Zealand (2011-14) looked at association of clinically important TBI (ciTBI) and vomiting.  This study supports previous research showing that vomiting is common following head injury, especially under 2 years of age; however, vomiting is rarely an independent predictor of ciTBI.

Patients with skull fractures, altered mental status, and headaches more likely to have ciTBI with vomiting (OR 80.1; 95% CI 43.4–148.0; OR 2.4; 95% CI 1.0–5.5; and OR 2.3; 95% CI 1.3–4.1, respectively).

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Take Home Points:Head injured patients with vomiting as their only apparent symptom may be observed prior to and usually instead of imaging. Immediate neuro-imaging should be considered in acute head injury featuring vomiting + headache or altered mental status and particularly if evidence of skull fracture is present. 

Radiation Risk²: Evaluation of leukemia & brain tumor risk following exposure to low-dose ionizing radiation from CT scans in childhood.

This retrospective cohort of 168,394 children who received one or more CT scans in a Dutch hospital demonstrated an increased risk of malignant and non-malignant brain tumors during following decades. Cumulative brain dose was on average 38.5 mGy and was statistically significantly associated with risk for malignant and nonmalignant brain tumors combined

Take Home Point:CT neuro imaging is associated with a small but statistically significant increased risk of later developing brain tumors and therefore should be used selectively when other options are not viable and the benefit of immediate information outweighs the risk of possible brain tumor later in life,

CDC Pediatric Mild Traumatic Brain Injury Guidelines³  – September 2018

These guidelines were the product of a collaboration (Pediatric Mild Traumatic Brain Injury Guideline Workgroup)  between the CDC, National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee. The workgroup drafted recommendations based on the evidence obtained and assessed within a systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published January 1990 – July 2015.  Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment. Below is a truncated summary of these recommendations based on levels of evidence.

1. Almost always should be followed:

Health care professionals should not routinely obtain head computed tomography (CT) for diagnostic purposes in children with mTBI

Health care professionals should use validated clinical decision rules (e.g. PECARN decision rules) to identify children with mTBI at low risk for ICI in whom head CT is not indicated, as well as children who may be at higher risk for clinically important ICI and thus may warrant head CT.

For children diagnosed as having mTBI, health care professionals should discuss the risks of pediatric head CT in the context of risk factors for ICI with the patient and his/her family

In providing education and reassurance to the family, the health care professional should include the following information:

• Warning signs of more serious injury
• Description of injury and expected course of symptoms and recovery
• Instructions on how to monitor post-concussive symptoms
• Prevention of further injury
• Management of cognitive and physical activity/rest
• Instructions regarding return to play/recreation and school
• Clear clinician follow-up instructions

1. Usually should be followed:

Health care professionals in the ED should clinically observe and consider obtaining a head CT in children seen with severe headache, especially when associated with other risk factors and worsening headache after mTBI, to evaluate for ICI requiring further management in accord with validated clinical decision-making rules

Children undergoing observation periods for headache with acutely worsening symptoms should undergo emergent neuro-imaging

Health care professionals and caregivers should offer non-opioid analgesia (i.e., ibuprofen or acetaminophen) to children with painful headache after acute mTBI but also provide counseling to the family regarding the risks of analgesic overuse, including rebound headache

Health care professionals should not routinely use skull radiographs, MRI or single-photon emission CT (SPECT) in the acute evaluation of suspected or diagnosed mTBI

Health care professionals should use an age-appropriate, validated symptom rating scale as a component of the diagnostic evaluation in children seen with acute mTBI

The Standardized Assessment of Concussion should not be exclusively used to diagnose mTBI in children aged 6 to 18 years

Health care professionals should counsel patients and families that most (70%-80%) children with mTBI do not show significant difficulties that last more than 1 to 3 months after injury

Health care professionals should counsel patients and families that, although some factors predict an increased or decreased risk for prolonged symptoms, each child’s recovery from mTBI is unique and will follow its own trajectory

Health care professionals should assess the premorbid history of children either before injury as a part of pre-participation athletic examinations or as soon as possible after injury in children with mTBI to assist in determining prognosis

Health care professionals should counsel children and families completing pre-participation athletic examinations and children with mTBI, as well as their families, that recovery from mTBI might be delayed in those with the following:

• Premorbid histories of mTBI
• Lower cognitive ability (for children with an intracranial lesion)
• Neurological or psychiatric disorder
• Learning difficulties
• Increased pre-injury symptoms (i.e., similar to those commonly referred to as “post-concussive”)
• Family and social stressors

When assessing for prognosis in children with mTBI providers should

• screen for known risk factors for persistent symptoms
• use a combination of tools to assess recovery
• use validated symptom scales to assess recovery

For children with mTBI whose symptoms do not resolve as expected with standard care (i.e., within 4-6 weeks), health care professionals should provide or refer for appropriate assessments and/or interventions.

Providers should counsel patients to observe more restrictive physical and cognitive activity during the first several days after mTBI .

Following these first several days, providers should counsel patients and families to resume a gradual schedule of activity that does not exacerbate symptoms, with close monitoring of symptom expression (number and severity)

To assist children returning to school after mTBI, medical and school-based teams should counsel the student and family regarding the process of gradually increasing the duration and intensity of academic activities as tolerated, with the goal of increasing participation without significantly exacerbating symptoms.

Return-to-school protocols should be customized based on the severity of post-concussion symptoms in children with mTBI as determined jointly by medical and school-based teams.

For any student with prolonged symptoms that interfere with academic performance, school-based teams should assess the educational needs of that student and determine the student’s need for additional educational supports, including those described under pertinent federal statutes (e.g., Individuals With Disabilities Education Act §504)

Post-concussion symptoms and academic progress in school should be monitored collaboratively by the student, family, health care professional(s), and school teams, who jointly determine what modifications or accommodations are needed to maintain an academic workload without significantly exacerbating symptoms

The provision of educational supports should be monitored and adjusted on an ongoing basis by the school-based team until the student’s academic performance has returned to pre-injury levels.

Health care professionals should provide guidance on proper sleep hygiene methods to facilitate recovery from pediatric mTBI. Health care professionals should recommend treatment for cognitive dysfunction that reflects its presumed etiology

1. Recommendation may be followed

Health care professionals may use validated, age-appropriate computerized cognitive testing in the acute period of injury as a component of the diagnosis of mTBI

Health care professionals may use validated prediction rules, which combine information about multiple risk factors for persistent symptoms, to provide prognostic counseling to children with mTBI evaluated in ED settings

Health care professionals may assess the extent and types of social support (i.e., emotional, informational, instrumental, and appraisal) available to children with mTBI and emphasize social support as a key element in the education of caregivers and educators

Take Home Points:

These guidelines support current standard of care/institutional recommendations with regard to diagnosis, prognosis, and management/treatment of pediatric mTBI. Interestingly they do not address vomiting as a predictor of ciTBI nor the question of whether ondansetron may be safely used to control vomiting after an acute head injury. They also do not endorse concerns from 1 study about the possible deleterious effects of excessive rest after injury.  For the primary care provider these guidelines may provide new clarity regarding evaluation and management of post concussive symptoms.

References

1. Meredith L. Borland, Stuart R. Dalziel, Natalie Phillips, Sarah Dalton, Mark D. Lyttle, Silvia Bressan, Ed Oakley, Stephen J.C. Hearps, Amit Kochar, Jeremy Furyk, John A. Cheek, Jocelyn Neutze, Franz E. Babl, on behalf of the Paediatric Research in Emergency Department International Collaborative group Vomiting With Head Trauma and Risk of Traumatic Brain Injury Pediatrics March 2018

2. Johanna M Meulepas Cécile M Ronckers Anne M J B Smets Rutger A J NievelsteinPatrycja Gradowska Choonsik Lee Andreas Jahnen Marcel van StratenMarie-Claire Y de Wit Bernard Zonnenberg JNCI:Radiation Exposure From Pediatric CT Scans and Subsequent Cancer Risk in the Netherland Journal of the National Cancer Institute, 18 July 2018

3. Lumba-Brown A, Yeates KO, Sarmiento K et al. CDC Pediatric Mild Traumatic Brain Injury Guidelines.JAMA Pediatr. Published online September 4, 2018. doi:10.1001/jamapediatrics.2018.2853

4.https://www.cdc.gov/traumaticbraininjury/PediatricmTBIGuideline.html

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