Guidelines - Adolescent Concussion/mTBI

Guideline Summary

English

Scope and Purpose of Guideline

 

Objective: To provide clinical recommendations for healthcare professionals related to the diagnosis, prognosis, and management/treatment of pediatric mild traumatic brain injury (mTBI).

Target population: 

  • Children (≤18 years of age) with mTBI.

Health Condition: mTBI is defined as an acute brain injury resulting 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; and

  2. Glasgow Coma Scale score of 13-15 after 30 minutes post-injury or later upon presentation for healthcare.

Reporting of Recommendations

 

Level of Confidence:

  • High: High-quality randomized controlled trials

  • Moderate: Randomized controlled trials with significant limitations

  • Low: Other controlled studies

  • Very Low: No measures of the effectiveness or statistical precision

Strength of Recommendation:

  • A: The recommendation almost always should be followed

  • B: The recommendation usually should be followed

  • C: The recommendation may sometimes be followed

  • U: There in insufficient evidence to make a recommendation

  • R: The intervention generally should not be done outside of a research setting (applicable only to recommendations related to interventions)

Strength

Confidence

Diagnostic Recommendations

 

Moderate

B

Moderate

B

Moderate

B

Moderate

B

Moderate

B

High

B

High

B

Moderate

B

Moderate

B

Moderate

C

High

R

Moderate

B

Moderate

B

Moderate

B

Moderate

B

Moderate

B

High

C

Moderate

B

Moderate

B

Moderate

C

Moderate

C

High

B

Moderate

B

High

A

Moderate

B

Moderate

B

High

B

Moderate

B

Moderate

C

Moderate

B

Moderate

B

High

B

High

B

Moderate

B

Moderate

B

High

B

High

B

Moderate

B

Moderate

R

High

B

Moderate

C

Moderate

B

Moderate

C

Moderate

B

High

B

High

C

​Risk Factors for Intracranial Injury and Computed Tomography

  • Routinely obtaining head computed tomography (CT) should not be used for diagnostic purposes in children with mTBI

  • Use validated clinical decision rules (such as the Pediatric Emergency Care Applied Research Network (PECARN) decision rules) to identify children with mTBI at low risk for intracranial injury (ICI) in whom head CT is not indicated, as well as with children who may be at higher risk for clinically important ICI and thus warrant head CT

  • Risk factors that increase the risk for serious injury include:

    • Age younger than 2 years

    • Vomiting

    • Loss of consciousness

    • Severe mechanism of injury

    • Severe or worsening headache

    • Amnesia

    • Non-frontal scalp hematoma

    • Glasgow Coma Scale score less than 15

    • Clinical suspicion for skull fracture

  • For children diagnosed as having mTBI, discuss the risk factors for ICI with the patient and his/her family

​Brain Magnetic Resonance Imaging

  • Magnetic resonance imaging (MRI) should not be used in the acute evaluation of suspected or diagnosed mTBI

Single-Photon Emission CT

  • Single photon emission CT (SPECT) should not be used in the acute evaluation of suspected or diagnosed mTBI

Skull Radiograph

  • Single photon emission CT (SPECT) should not be used in the acute evaluation of suspected or diagnosed mTBI

  • Skull radiographs should not be used in the screening for ICI

Neuropsychological Tools, Including Symptom Scales, Computerized Cognitive Testing, and Standardized Assessment of Concussion

  • Use validated, age-appropriate computerized cognitive testing in the acute period of injury as a component of the diagnosis of mTBI

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

Serum Markers

  • Biomarkers outside of a research setting should not be used for the diagnosis of children with mTBI

Strength

Confidence

Prognostic Recommendations

General Counseling of Prognosis

  • 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

  • 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

Prognosis Related to the Premorbid Conditions

  • 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

  • Counsel children and families completing pre-participation athletic examinations, and children with mTBI along with 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 preinjury symptoms (i.e., similar to those commonly referred to as “post-concussive”; e.g., headache, dizziness, sleep difficulties, cognitive difficulties involving memory, concentration, and thinking)

    • Family and social stressors

 

Assessment of Cumulative Risk Factors and Prognosis

  • Screen for known risk factors for persistent symptoms in children with mTBI

    • Older children/adolescents

    • Hispanic race/ethnicity (compared with white race/ethnicity)

    • Lower socioeconomic status

    • More severe presentation of mTBI, including those associated with ICI

    • Reporting of more acute post-concussive symptoms​

  • Use validated prediction rules to provide prognostic counseling to children with mTBI evaluated in emergency department settings

Assessment Tools and Prognosis

  • Use a combination of tools to assess recovery in children with mTBI

  • Use validated cognitive testing (including measures of reaction time) to assess recovery in children with mTBI

Interventions for mTBI with Poor Prognosis

  • Closely monitor children with mTBI who are determined to be at high risk for persistent symptoms based on their premorbid history, demographics, and/or injury characteristics

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

Strength

Confidence

Management/Treatment Recommendations

Patient/Family Education and Reassurance

  • In providing education and reassurance to the family, 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

    • return to play/recreation and school as tolerated, avoid prolonged physical and cognitive rest

Cognitive/Physical Rest and Aerobic Treatment

  • Counsel children to observe more restrictive physical and cognitive activity during the first several days after mTBI

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

  • Offer an active rehabilitation program of progressive reintroduction of noncontact aerobic activity that does not exacerbate symptoms, with close monitoring of symptom expression (number and severity) after the patient has successfully resumed a gradual schedule of activity

  • Counsel patients to return to full activity when they return to premorbid performance if they have remained symptom free at rest and with increasing levels of physical exertion

Psychosocial/Emotional Support

  • 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

Return to School

  • 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

  • Customize return-to-school protocols based on the severity of post-concussive 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 students 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-concussive 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 preinjury levels

  • For students who demonstrate prolonged symptoms and academic difficulties despite an active treatment approach, refer the child for a formal evaluation by a specialist in pediatric mTBI

Post-traumatic Headache Management/Treatment

  • In the ED, 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 neuroimaging

  • Offer non-opioid analgesia (ie, 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

  • Administering 3% hypertonic saline to children with mTBI for treatment of acute headache should not be used outside of a research setting at this time

  • Chronic headache after mTBI is likely to be multifactorial; therefore, refer children with chronic headache after mTBI for multidisciplinary evaluation and treatment, with consideration of analgesic overuse as a contributory factor

Vestibulo-Oculomotor Dysfunction Management/Treatment

  • Refer children with subjective or objective evidence of persistent vestibule-oculomotor dysfunction after mTBI to a program of vestibular rehabilitation

Sleep Management/Treatment

  • Provide guidance on proper sleep hygiene methods to facilitate recovery from pediatric mTBI

  • If sleep problems emerge or continue despite appropriate sleep hygiene measures, refer children with mTBI to a sleep disorder specialist for further assessment

 

Cognitive Impairment Management/Treatment

  • Determine the etiology of cognitive dysfunction within the context of other mTBI symptoms

  • Recommend treatment for cognitive dysfunction that reflects its presumed etiology

  • Refer children with persisting problems related to cognitive function for a formal neuropsychological evaluation to assist in determining the etiology and recommending targeted treatment

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CCGI is funded by provincial associations and regulatory boards, and national associations including the Canadian Chiropractic Association

and Canadian Chiropractic Protective Association. CCGI maintains editorial independence from funders.

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