Medical Decision Making

Clinical decision making has been geared toward reducing the mortality associated with TBI. The greatest improvements in mortality occur when deterioration is prevented in those with minor head injury.

Neuroimaging has been used to identify patients at risk for deterioration following TBI, but clinicians working with pediatric populations must balance the utility of neuroimaging with the risks associated with radiation and sedation (children may require sedation to obtain a computed tomography [CT] scan). Studies suggest that the theoretic risk for fatal brain tumors increases as age at time of intracranial imaging decreases, and even though complications of sedation are rare, many children experience prolonged recovery and delayed side effects.⁷ Studies have found that approximately 6% of children with minor head injury have abnormal findings on CT and, more important, that less than 1% require neurosurgical intervention.⁸ When compared with the adult population, pediatric patients are more likely to be seen in the ED following very mild injury, thus further lowering the pretest probability of significant intracranial injury.

Given this tendency, many studies have sought to identify criteria that would guide the use of neuroimaging in pediatric populations. A recent study by the Pediatric Emergency Care Applied Research Network (PECARN) assessed 42,000 pediatric patients to develop a decision rule.⁹ For children 2 years or younger, they found that patients with abnormal mental status, non–frontal scalp hematoma, loss of consciousness, a severe mechanism of injury, and a palpable skull fracture and those who were not “acting normally” per parent could be accurately predicted to have significant intracranial injury. For patients older than 2 years, they found abnormal mental status, loss of consciousness, significant vomiting, severe mechanism of injury, clinical signs of basilar skull fracture, and severe headache predicted significant intracranial injury (Fig. 24.1). Use of these clinical guidelines would significantly reduce unnecessary intracranial imaging.

Fig. 24.1 Suggested computed tomography (CT) algorithm for children younger than 2 years (A) and for those aged 2 years and older (B) with Glasgow Coma Scale (GCS) scores of 14 to 15 after head trauma.

(From Kuppermann N, Holmes JF, Dayan PS, et al. Lancet 2009;374:1160-70.) ciTBI, clinically important traumatic brain injury; LOC, loss of consciousness.

Observation is an alternative to neuroimaging in patients with mild injury. A retrospective Canadian study of approximately 17,000 pediatric patients older than 8 years found that delayed deterioration (>6 hours) occurred in no patients with a normal GCS score.¹⁰ Pediatric patients are often evaluated several hours after their injury; continued observation within the department or at home would be an acceptable alternative to emergency imaging in low-risk patients.

For patients with mTBI or concussion, emergency department (ED) clinicians in general have not focused on the morbidity associated with this injury and may not recognize their ability to improve patient outcomes. It has been shown that accurate assessment of the severity of the injury and consequent outpatient guidance and management may decrease recovery time, reduce the risk for secondary complications, and improve outcomes. mTBI or concussion can also be challenging to diagnose. Patients with polytrauma or other significant injury may not be screened for the subtle findings associated with concussion, which can result from any blow to the head or an indirect force through the neck or to the body. The immediate symptoms of concussion are the result of trauma-induced alterations in neurologic function and include amnesia (retrograde or anterograde), altered consciousness (loss of consciousness, dazed, stunned, confused), migrainelike symptoms (headache, nausea, photophobia or phonophobia, visual changes, dizziness or balance problems), cognitive symptoms (difficulty concentrating or remembering), and changes in personality. These immediate symptoms are typically short-lived and are associated with a normal findings on physical examination and neuroimaging. Clinicians in the ED are in a unique position to diagnose mTBI and initiate proper management to minimize the adverse outcomes of concussion.

Treatment

With severe or moderate injury, initial pediatric management is similar to adult management. The primary focus is to protect the airway, maintain hemodynamic stability, and identify patients with more significant intracranial injury. Patients with severe TBI require early consultation with a pediatric neurosurgeon or transport to a pediatric trauma center (or both). Early surgical intervention and initiation of intracranial pressure monitoring have been shown to improve long-term outcomes.

Admission and Discharge

The majority of patients with mTBI or concussion are reassured and discharged home. For these patients, appropriate diagnosis, patient education, and outpatient management may decrease recovery time, reduce the risk for secondary complications, and improve outcomes.¹¹ Pediatric patients with normal neuroimaging findings but persistently abnormal GCS scores, severe vomiting, or unremitting headache should be admitted to the hospital for observation and hydration.

Determining concussion severity and recovery is critical because returning patients to physical activities too soon following concussion can lead to disabling and even life-threatening outcomes such as second impact syndrome, which is the sudden onset of cerebral edema after a second (even minor) concussion. Historically, however, evaluation and management of victims of concussion have been inconsistent. To add to the confusion, more than 25 concussion grading systems exist, each with their own ranking of concussion severity and management recommendations. Unfortunately, these clinical grading systems are not validated and have not allowed clinicians, patients, or families to recognize the spectrum of postconcussive symptoms.

The Centers for Disease Control and Prevention has recently changed its recommendations for acute concussion management from the use of grading scales to use of the Acute Concussion Evaluation (ACE) (see ACE and ACE-Care Plan, available at www.cdc.gov). The ACE is a paper evaluation form that was designed to provide a diagnostic framework for clinicians in the outpatient setting to define concussion and characterize the patient’s symptoms.¹² Rather than focus on grading assessments of concussion severity, the ACE provides a standardized tool to aid in identifying mTBI in primary care settings. Unlike grading systems that provide set return-to-play decisions (e.g., those with grade 1 concussion may return to play in 15 minutes), the ACE offers an ACE-Care Plan, a set of best-practice discharge instructions that strongly recommend rest and endorse the “Stepwise Return to Play” (Box 24.1). The ACE-Care Plan also offers extensive information regarding return to school and work to minimize overexertion and improve recovery. The ACE and ACE-Care Plan represent a transition from passive management to active evaluation of concussion and intervention to decrease secondary injury.

Most patients with mTBI will recover within the first 7 to 10 days. In others, postconcussive syndrome will develop, a constellation of neurocognitive symptoms (including headaches, fatigue, sleep problems, changes in personality, photophobia, hyperacusis, dizziness, and deficits in short-term memory and problem solving) that may persist for days to weeks. Athletes who suffer multiple concussions are more likely to be plagued with postconcussive symptoms. School performance may be affected in these children, and some may need specific accommodation plans. Patients at high risk for complications related to mTBI (e.g., athletes, those with previous concussions or personal history of migraines) should be evaluated by a concussion specialist.¹³

Occasionally, patients with postconcussive syndrome return to the ED for subsequent problems. In patients with waxing and waning postconcussive symptoms or migraine headache, emergency imaging is not necessary except to exclude alternative diagnoses. Postconcussive symptoms respond well to standard migraine treatment (nonsteroidal antiinflammatory drugs, intravenous fluids, antiemetics). These patients should be referred to a concussion specialist for follow-up.