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
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