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February 23, 2024
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Written by Amanda Mathews
In this systematic review, authors identified clinical practice guideline (CPG) recommendations with moderate to high quality evidence that can be used by the ED practitioner to help in the care of pediatric patients with mild traumatic brain injury (mTBI).
How to treat and protect the pediatric brain
This was a systematic review of CPG recommendations for children with acute mild TBI. Mild TBI was defined as GCS ≥ 13 at 30 minutes post injury with one of more of the following symptoms: < 30 min loss of consciousness, <24 hours post-traumatic amnesia, impaired mental state at time of injury, and/or transient neurologic deficit. Out of 6 CPGs deemed to be high quality, the authors identified 34 recommendations with moderate to high quality evidence that should be implemented in clinical practice.
The following recommendations had moderate to strong evidence:
- ED providers should observe and consider head CT in children seen with severe headache, especially when associated with other risk factors and worsening headache after mTBI in accordance with validated clinical decision making rules.
- Children undergoing observation for headache with acutely worsening symptoms should undergo emergent neuroimaging.
- Skull radiographs should not be used in the diagnosis of pediatric mTBI or screening for intracranial injury
- ED providers should inform the family on the following: warning signs of more serious injury, description of the 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, instruction regarding return to play/recreation and school and clear clinician follow up instructions.
The study team found that the areas of repeat imaging, neurosurgical consultation, and hospital admission did not have guidelines backed by moderate to high quality evidence and would benefit from further research.
How will this change my practice?
This study validates my practice of using clinical decision making rules (such as PECARN Head CT) to help guide CT imaging of pediatric mTBI. It is a good reminder of the importance of education for patients and families when discharging patients with mTBI so you can prevent further injury and promote long term healing from their head injury. Check out the full list of recommendations yourself!
Source
Clinical Practice Guideline Recommendations in Pediatric Mild Traumatic Brain Injury: A Systematic Review. Ann Emerg Med. 2023 Dec 22:S0196-0644(23)01381-1. doi: 10.1016/j.annemergmed.2023.11.012. Epub ahead of print.
