Mild traumatic brain injury (MTBI) is a frequent occurrence in children. Current practice in treating such injuries varies in terms of evaluative studies, length of observation, need for inpatient hospitalization, sports restrictions, and follow-up. A multidisciplinary panel of experts from a level I pediatric trauma center was convened to develop and implement a clinical pathway to improve the quality and consistency of care provided to children after MTBI. The clinical pathway, based on current literature and expert consensus, provides a management guideline for the management of MTBI in the emergency department through discharge. The algorithm provides reasonable management options based on the child's clinical presentation, history, and age.
Exemplary care of children and their families after MTBI includes appropriate patient/family education. Standardized discharge instructions for MTBI were developed to provide comprehensive information in a succinct and easy-to-read format. The instructions for home management focus on expected symptoms and guidance for when to seek further medical attention. They also incorporate injury prevention, return to sports guidelines, and resources for additional information.
Mild traumatic brain injury (MTBI) in children is common and may leave children with long-term consequences if unrecognized. Variations in diagnosis, treatment, anticipatory guidance, and follow-up are evident in current practice. This potentially puts children at increased risk for delayed or undiagnosed learning and behavioral disabilities, as well as raising the danger and consequences of reinjury.
A multidisciplinary panel of experts from a level I pediatric trauma center was convened to examine current management and to develop a clinical pathway for children with MTBI. The group consisted of health care professionals involved in the clinical management of children with MTBI from the resuscitative through rehabilitative phases of care to represent the full spectrum of patient care issues. The team's efforts, coordinated by the institution's trauma clinical nurse specialist, included representation from trauma surgery, emergency medicine, physiatry, critical care medicine, speech language pathology, trauma social work, and emergency, critical care and surgical nursing. In addition, all of the materials were reviewed by the entire emergency medicine staff and the Trauma Committee. Institutional systems guidance and expertise was achieved through Trauma and Rehabilitation management participation.
The group's objectives included the integration and expansion of currently accepted management guidelines to address children of all ages seen in the emergency department (ED) or requiring hospital admission for MTBI. Given the lack of evidence about the predictive ability of specific symptoms, the group made a deliberate decision to err on the conservative side of evaluation and treatment options. A goal unique from previously published reports was to advance the scope of the practice guideline to incorporate education, injury prevention as well as the role of rehabilitation services in the management of MTBI.
Recommendations were made after a thorough review of the literature and discussion over the course of approximately 1 year. Clinical algorithms and supportive educational materials were developed for the evaluation of patients in the ED as well as for patients admitted to the inpatient units. What follows is a detailed discussion of the group's findings and recommendations.