Head Trauma Guidelines Often Abandoned for Young Patients in the ED

Guidelines are often ignored in the handling of pediatric and adolescent head trauma cases in the emergency department (ED), according to two studies presented at the American College of Emergency Physicians (ACEP) annual meeting.

Christina Long, MD, of Loyola University Medical Center in Maywood, Illinois, and colleagues found that most pediatric patients with mild traumatic brain injury (TBI) treated in their ED lacked sufficient screening tool documentation, as well as specific neurologic or trauma exam findings.

Another research team led by Bergthor Jonsson, MD, of the Mayo Clinic in Rochester, Minnesota, found significant differences in CT guideline application between pediatric (ages 12 to 14) and adolescent (ages 15 to 17) groups presenting with head trauma at their center. The pediatric trauma teams were much more likely to follow guidelines, they said.

TBI Study

Of 1,160 pediatric patients, Long and colleagues found that 68.4% did not have injury types documented as per the new Pediatric Emergency Care Applied Research Network (PECARN) guidelines at Loyola University Medical Center. "We found that information was lacking a lot," Long noted.

When assessing how providers issued discharge instructions, they found that following the standard electronic medical record template for concussion or head injury only was the most likely action taken (46.1%). About 20% also included written instructions, 12.4% also included verbal instructions, and about 10% also included written and verbal instructions.

In addition, 3-month follow-up instructions were issued to 93% of the patients given any discharge instructions.

PECARN guidelines are not mandatory, Long noted.

"We're looking for standardization" nationally, she said. "There's a lot of room for improvement."

The team recommended incorporating PECARN screening guidelines into the template and modifying discharge templates to customize them by age and injury mechanism, as well as including a "free text" section.

"In reality, providers are not reading [discharge templates]," Long said, noting that they are too long to read quickly, not updated, nor always age-appropriate. "No one has time to read through these instructions every time."

ED providers follow myriad plans for diagnoses, treatment, and discharge regarding these patients, the researchers reported in their presentation. There is potential for miscommunication between patients and providers, and a lack of patient education about recovery timelines and follow-up care, they said.

"Due to the frequency and long-term consequences associated with pediatric head injuries, it is crucial that adequate counseling is provided in acute care settings, along with uniform terminology for understanding," they wrote in an abstract.

Long and colleagues conducted a retrospective cohort study of patient data from 2017 to 2020, examining screening tools; discharge criteria; and documented discharge instructions, such as pre-written handouts, verbal and written instructions, and other educational materials.

Most of the injuries were sports-related, co-author Kavita Krishnan, a medical student, told MedPage Today.

Pearson's chi-squared and Fisher's exact tests were used to determine associations. The researchers excluded patients with abnormal baseline neurological status, those with positive CT scans for intracranial injury, and those who were transferred from other hospitals.

CT Guideline Study

The Mayo research team found that providers followed CT guidelines for 81% of 57 kids ages 12 to 14 at their level 1 trauma center from 2015 to 2019, in comparison with 49% of 114 kids ages 15 to 17 (P<0.001).

When CT scans were not indicated, they were still performed for 31 of 36 younger kids and 39 of 66 older kids (P<0.001).

Among the 13 cases in which CT scans were indicated for the younger kids, 12 scans were performed. All 29 older kids were scanned when indicated (P=0.13).

The researchers suggested that providers should increase their awareness of head imaging guidelines. Guideline compliance should be reviewed periodically, Jonsson told MedPage Today.

The team conducted a retrospective observational study, excluding patients who were transferred from another hospital, those suffering from isolated burn injuries, and those in cardiac arrest on arrival.

The retrospective design was a study limitation, the team acknowledged.

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