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Despite considerable efforts to advance the science surrounding traumatic brain injury (TBI), formal efforts supporting the current and future implementation of scientific findings within clinical practice and healthcare policy are limited. While many and varied guidelines inform the clinical management of TBI across the spectrum, clinicians and healthcare systems are not broadly adopting, implementing, and/or adhering to them. As part of the Brain Trauma Blueprint TBI State of the Science, an expert workgroup was assembled to guide this review article, which describes: (1) possible etiologies of inadequate adoption and implementation; (2) enablers to successful implementation strategies; and (3) strategies to mitigate the barriers to adoption and implementation of future research.

Objective: As part of an initiative led by the Brain Injury Special Interest Group Mild Traumatic Brain Injury (TBI) Task Force of the American Congress of Rehabilitation Medicine (ACRM) to update the 1993 ACRM definition of mild TBI, the present study aimed to characterize current expert opinion on diagnostic considerations. Design: Cross-sectional web-based survey. Setting: Not applicable. Participants: An international, interdisciplinary group of clinician-scientists (N=31) with expertise in mild TBI completed the survey by invitation between May and July 2019 (100% completion rate). Interventions: Not applicable. Main Outcome Measures: Ratings of agreement with statements related to the diagnosis of mild TBI and ratings of the importance of various clinical signs, symptoms, test findings, and contextual factors for increasing the likelihood that the individual sustained a mild TBI, on a scale ranging from 1 (“not at all important”) to 10 (“extremely important”). Results: Men (n=25; 81%) and Americans (n=21; 68%) were over-represented in the sample. The survey revealed areas of expert agreement (eg, acute symptoms are diagnostically useful) and disagreement (eg, whether mild TBI with abnormal structural neuroimaging should be considered the same diagnostic entity as “concussion”). Observable signs were generally rated as more diagnostically important than subjective symptoms (Wilcoxon signed ranks test, Z=3.77; P

Pediatric head injury is a common presenting complaint in the emergency department (ED), often requiring neuroimaging or ED observation for diagnosis. However, the traditional diagnostic neuroimaging modality, head computed tomography (CT), is associated with radiation exposure while prolonged ED observation impacts patient flow and resource utilization. Recent scientific literature supports abbreviated, or focused and shorter, brain magnetic resonance imaging (MRI) as a feasible and accurate diagnostic alternative to CT for traumatic brain injury. However, this is a relatively new application and its use is not widespread. The aims of this review are to describe the science and applications of abbreviated brain MRI and report a model protocol's development and ED implementation in the evaluation of children with head injury for replication in other institutions.

Asthma is the most common chronic illness in children, with >700,000 emergency department (ED) visits each year. Asthma is a respiratory disease characterized by a combination of airway inflammation, bronchoconstriction, bronchial hyperresponsiveness, and variable outflow obstruction, with clinical presentations ranging from mild to life‐threatening. Standardized ED treatment can improve patient outcomes, including fewer hospital admissions. Informed by the most recent guidelines, this review focuses on the optimal approach to diagnosis and treatment of children with acute asthma exacerbations who present to the ED.

When the fourth edition of the Brain Trauma Foundation's Guidelines for the Management of Severe Traumatic Brain Injury were finalized in late 2016, it was known that the results of the RESCUEicp (Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension) randomized controlled trial of decompressive craniectomy would be public after the guidelines were released. The guideline authors decided to proceed with publication but to update the decompressive craniectomy recommendations later in the spirit of “living guidelines,” whereby topics are updated more frequently, and between new editions, when important new evidence is published. The update to the decompressive craniectomy chapter presented here integrates the findings of the RESCUEicp study as well as the recently published 12-mo outcome data from the DECRA (Decompressive Craniectomy in Patients With Severe Traumatic Brain Injury) trial. Incorporation of these publications into the body of evidence led to the generation of 3 new level-IIA recommendations; a fourth previously presented level-IIA recommendation remains valid and has been restated. To increase the utility of the recommendations, we added a new section entitled Incorporating the Evidence into Practice. This summary of expert opinion provides important context and addresses key issues for practitioners, which are intended to help the clinician utilize the available evidence and these recommendations. The full guideline can be found at: https://braintrauma.org/guidelines/guidelines-for-the-management-of-severe-tbi-4th-ed#/.

Background: The targeting rule was adopted by the National Collegiate Athletic Association (NCAA) in 2008 to discourage dangerous contact during collegiate American football competition. Although targeting rules have been emphasized as a means to reduce concussion rates, there is currently no evidence that targeting plays are higher risk for concussion than other plays in American football. Purpose: To compare the rate of concussion occurring during targeting versus nontargeting plays in American collegiate football. Study Design: Cross-sectional study. Methods: Concussions occurring in games in the 2016-2019 Pac-12 Conference were classified as having occurred during either (1) a play where a targeting penalty was called or (2) all other plays. Targeting plays were further categorized to either those in which the call was upheld or those overturned by the on-field official after replay review. The number of targeting plays and the total number of plays during games were also recorded. Concussion incidence (per 1000 plays) and risk ratios were calculated. Results: Overall, 538 games with 68,670 plays were reviewed, during which 213 concussions occurred (15 during plays where targeting was called and 198 on other plays) and 141 targeting penalties were called. The incidence of concussion was 106.4/1000 plays for targeting plays (including 141.2/1000 upheld targeting fouls and 53.6/1000 overturned targeting fouls) and 2.9/1000 plays for nontargeting plays. The risk of concussion during targeting plays was 36.9 (95% CI, 22.4-60.7) times greater than that for all other plays. The risk of concussion during targeting plays upheld was 49.0 (95% CI, 28.5-84.2) times greater than that for all other plays. Conclusion: Concussion risk was significantly higher during plays in which targeting was called, especially those in which targeting fouls were upheld. Clinical Relevance: This study supports eliminating or reducing targeting from American football. The results of this study suggest that players should be screened for concussion after targeting plays are called.

OBJECTIVE Female athletes may be more likely to sustain a concussion and may vary in symptom presentation and neurocognitive impairments as compared with males. Scientific literature is limited by subjective assessments and underproportioned representation of women-the scope and etiology of sex-based differences are unknown. This study investigates sex-based differences in sports concussion assessments among college varsity athletes. DESIGN AND SETTING Retrospective study of an institution's athletic head injury database. PARTICIPANTS Acute postinjury and baseline data from 111 college athletes sustaining concussions between 2016 and 2018, diagnosed by a concussion specialist physician. MAIN OUTCOME MEASURES Concussion assessments examined included the Sports Concussion Assessment Tool (SCAT5) and Vestibular Oculomotor Screening (VOMS) performed within 3 days (24-72 hours) of injury. RESULTS No significant difference by sex was observed in the SCAT5 total symptom evaluation scores or severity scores, Standardized Assessment of Concussion, or Balance Error Scoring System (P > .05) within 3 days of head injury. Females did report more "pressure in the head" severity scores from baseline to postconcussion (2.7 ± 1.5 increased symptomatology in females vs 1.8 ± 1.3 increase in males, P = .007). The VOMS test resulted in significant sex differences in smooth pursuit [0.6 ± 1.4 increase in females (P < .001) vs 0.2 ± 0.6 increase in males (P = .364)], horizontal saccades [0.6 ± 1.2 increase in females (P < .001) vs 0.2 ± 0.5 increase in males (P = .149)], and vertical saccades [0.9 ± 1.9 increase in females (P < .001) vs 0.3 ± 0.7 increase in males (P = .206)]. CONCLUSION Our study did not show sex-based differences in baseline or acute postconcussive symptom reporting in most concussion assessment parameters, challenging previous research suggesting that females report more symptoms than males. Females did have significant differences in symptom provocation using the VOMS.

The "Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines" published in Pediatric Critical Care Medicine in 2019 provides new and updated recommendations applicable to the emergency department management of children with severe traumatic brain injury. Practice-changing takeaways include specific recommendations for administration of 3% hypertonic saline, administration of seizure prophylaxis, and avoiding hyperventilation.

Objectives To assess the reliability and effect of exercise on sideline dynamic visual performance measures of ocular-motor function using a portable visual assessment system (EYE-SYNC®). Design Prospective cohort study. Methods Healthy student athletes, ages 18–25 years, performed eye-tracking six times—three times consecutively prior to and after practice—using EYE-SYNC® goggles. Ocular-motor performance was assessed by calculating five gaze error outcomes between target position and actual gaze position to inform dynamic visual synchronization. We assessed reliability by calculating the intraclass correlation coefficient (ICC) for each outcome (we defined the standard deviation of tangential error (SDTE) as our primary outcome) and calculated differences in mean pre- and post-practice scores. Results ICCs for the SDTE score were 0.86 (95% confidence interval, CI: 0.82–0.9) and 0.88 (0.84–0.91) at pre- and post-practice, respectively. 133 (89%) and 135 (90%) of 150 athletes had at least one measurement at pre- and post-practice, respectively. 117 (78%) and 122 (81%) athletes had more than one SDTE score at pre- and post-practice, respectively. The absolute mean (SD) differences between pre- and post-practice mean scores ranged from 0.02 (0.05) for horizontal gain to 0.1 (0.5) for SDTE. Conclusions We observed high ICC scores indicating excellent reliability of visual synchronization measurements, suggesting that one measurement would be sufficient. Most athletes had similar scores before and after practice, indicating little change in visual performance following exercise. EYE-SYNC® goggles have the potential for use in obtaining objective visual performance measures of ocular-motor function for sideline assessment of concussion and return to play decisions.

OBJECTIVE: The recently published Centers for Disease Control and Prevention evidence-based guideline on pediatric mild traumatic brain injury (mTBI) was developed following an extensive review of the scientific literature. Through this review, experts identified limitations in existing pediatric mTBI research related to study setting and generalizability, mechanism of injury and age of cohorts studied, choice of control groups, confounding, measurement issues, reporting of results, and specific study design considerations. This report summarizes those limitations and provides a framework for optimizing the future quality of research conduct and reporting. RESULTS: Specific recommendations are provided related to diagnostic accuracy, population screening, prognostic accuracy, and therapeutic interventions. CONCLUSION: Incorporation of the recommended approaches will increase the yield of eligible research for inclusion in future systematic reviews and guidelines for pediatric mTBI.

It is widely appreciated that the spectrum of traumatic brain injury (TBI), mild through severe, contains distinct clinical presentations, variably referred to as subtypes, phenotypes, and/or clinical profiles. As part of the Brain Trauma Blueprint TBI State of the Science, we review the current literature on TBI phenotyping with an emphasis on unsupervised methodological approaches, and describe five phenotypes that appear similar across reports. However, we also find the literature contains divergent analysis strategies, inclusion criteria, findings, and use of terms. Further, whereas some studies delineate phenotypes within a specific severity of TBI, others derive phenotypes across the full spectrum of severity. Together, these facts confound direct synthesis of the findings. To overcome this, we introduce PhenoBench, a freely available code repository for the standardization and evaluation of raw phenotyping data. With this review and toolset, we provide a pathway toward robust, data-driven phenotypes that can capture the heterogeneity of TBI, enabling reproducible insights and targeted care.

Background: There is heterogeneity in neurosensory alterations following mild traumatic brain injury. Commonly assessed neurosensory symptoms following head injury include symptom reports and measures of oculomotor impairment, auditory changes, and vestibular impairment. Hypothesis/Purpose: Neurosensory alterations are prevalent acutely following mild traumatic brain injury secondary to blunt head trauma during collegiate varsity sports and may vary by sex and sport. Study Design: Retrospective study of a large collegiate athletic database. Methods: Analyses were performed using an established single University dataset of 177 male and female collegiate varsity athletes who were diagnosed with concussion/mild traumatic brain injury between September 2013 and October 2019. Descriptive and comparative analyses were performed on individual and grouped acute concussion assessments pertaining to neurosensory alterations obtained within 72 h of injury using components of the Sports Concussion Assessment Tool Version 5 and Vestibular/Ocular-Motor Screening. Results: Females had significantly more abnormal smooth pursuit (p-value: 0.045), convergence (p-value: 0.031), and visual motion sensitivity tests results (p-value: 0.023) than males. There were no differences in neurosensory alterations when grouped by overall auditory, vestibular, or oculomotor impairments. The majority of sports-related concussions occurred during football (50, 28.25%), wrestling (21, 11.86%), water polo (15, 8.47%), and basketball (14, 7.91%). Abnormal vestibular assessments were high in these top four sports categories, but statistically significant differences in overall auditory, vestibular, or oculomotor impairments were not reached by individual sport. However, water polo players had higher abnormal individual assessments related to balance reports on the sideline (60.00%, p-value: 0.045) and in the clinic setting (57.14%, p-value: 0.038) as compared to all other sports. Conclusion: While neurosensory alterations are prevalent in both male and female athletes acutely post-concussion, females have a higher incidence of abnormalities in smooth pursuit, convergence, and visual motion sensitivity and may benefit from early rehabilitation.

Whiplash injuries may disrupt normal cervical afferent and efferent projections. Oculomotor abnormalities have been reported in chronic whiplash cases, but there is limited knowledge of their presence in acute whiplash and how acute assessment may target early intervention. We present a literature review and case study of a 22-year-old female presenting with an acute concussion and whiplash secondary to a high-speed motor vehicle collision. Smooth pursuit eye-movement abnormalities were observed in relative cervical rotation in the setting of clinical examination of cervicogenic dysfunction. Treatment was focused on cervical manual therapy. While concussive symptoms resolved after seven days, eye-tracking showed a mild improvement and continued to exist in relationship with cervicogenic dysfunction. After completing physical therapy twice weekly for two weeks and in-home exercises, clinical signs and symptoms of whiplash-associated cervicogenic dysfunction and abnormal smooth pursuit eye-movement resolved across all cervical positions. This case highlights the need for ocular-motor impairment assessment following acute whiplash, specifically during cervical rotation. Early intervention should focus on cervical manual therapy and may be important in supporting altered cervical afferents causing oculomotor dysfunctions following acute whiplash.

Background Traumatic brain injury (TBI) often results in elevations in intracranial pressure (ICP) that are refractory to standard therapies. Several studies have investigated the utility of external lumbar drainage (ELD) in this setting. Objective To evaluate the safety and efficacy of ELD or lumbar puncture with regard to immediate effect on ICP, durability of the effect on ICP, complications, and neurological outcomes in adults with refractory traumatic intracranial hypertension. Methods A systematic review and meta-analysis were conducted beginning with a comprehensive search of PubMed/EMBASE. Two investigators reviewed studies for eligibility and extracted data. The strength of evidence was evaluated using GRADE methodology. Random-effects meta-analyses were performed to calculate pooled estimates. Results Nine articles detailing 6 studies (N = 110) were included. There was moderate evidence that ELD has a significant immediate effect on ICP; the pooled effect size was -19.5 mmHg (95% CI -21.0 to -17.9 mmHg). There was low evidence to indicate a durable effect of ELD on ICP up to at least 24 h following ELD. There was low evidence to indicate that ELD was safe and associated with a low rate of clinical cerebral herniation or meningitis. There was very low evidence pertaining to neurological outcomes. Conclusion Given preliminary data indicating potential safety and feasibility in highly selected cases, the use of ELD in adults with severe TBI and refractory intracranial hypertension in the presence of open basal cisterns and absence of large focal hematoma merits further high-quality investigation; the ideal conditions for potential application remain to be determined.

Spontaneous subarachnoid hemorrhage (SAH) from a brain aneurysm, if untreated in the acute phase, leads to loss of functional independence in about 30% of patients and death in 27–44%. To evaluate for SAH, the American College of Emergency Physicians (ACEP) Clinical Policy recommends obtaining a non-contrast brain computed tomography (CT) scan followed by a lumbar puncture (LP) if the CT is negative. On the other hand, current evidence from prospectively collected data suggests that CT alone may be sufficient to rule out SAH in patients who present within 6 h of symptom onset while anecdotal evidence suggests that CT angiogram (CTA) may be used to detect aneurysms, which are the probable cause of SAH. Since many different options are available to emergency physicians, we examined their practice pattern variation by observing their diagnostic approaches and their adherence to the ACEP Clinical Policy. We developed, validated, and distributed a survey to emergency physicians at three practice sites: (1) Stanford Healthcare, California, (2) Intermountain Healthcare (five emergency departments), Utah, and (3) Ottawa General Hospital, Toronto. The survey questions examined physician knowledge on CT and LP's test performance and used case-based scenarios to assess diagnostic approaches, variation in practice, and adherence to guidelines. Results were presented as proportions with 95% CIs. Of the 216 physicians surveyed, we received 168 responses (77.8%). The responses by site were: (1) (n = 38, 23.2%), (2) (n = 70, 42.7%), (3) (n = 56, 34.1%). To the CT and LP test performance question, most physicians indicated that CT alone detects > 90% of SAH in those with a confirmed SAH [n = 150 (89.3%, 95% CI 83.6–93.5]. To the case-based questions, most physicians indicated that they would perform a CTA along with a CT [n = 110 (65.5%, 95% CI 57.8–72.6)], some indicated a LP along with a CT [n = 57, 33.9% 95% CI 26.8–41.6)], and a few indicated both a CTA and a LP [n = 16, 9.5%, 95% CI 5.5–15.0]. We also observed practice site variation in the proportion of physicians who indicated that they would use CTA: (1) (n = 25, 65.8%), (2) (n = 54, 77.1%), and (3) (n = 28, 50.0%) (p = 0.006). Survey responses indicate that physicians use some or all of the imaging tests, with or without LP to diagnose SAH. We observed variation in the use of CTA by site and academic setting and divergence from ACEP Clinical Policy.

OBJECTIVEThere remains uncertainty regarding the appropriate level of care and need for repeating neuroimaging among children with mild traumatic brain injury (mTBI) complicated by intracranial injury (ICI). This study’s objective was to investigate physician practice patterns and decision-making processes for these patients in order to identify knowledge gaps and highlight avenues for future investigation.METHODSThe authors surveyed residents, fellows, and attending physicians from the following pediatric specialties: emergency medicine; general surgery; neurosurgery; and critical care. Participants came from 10 institutions in the United States and an email list maintained by the Canadian Neurosurgical Society. The survey asked respondents to indicate management preferences for and experiences with children with mTBI complicated by ICI, focusing on an exemplar clinical vignette of a 7-year-old girl with a Glasgow Coma Scale score of 15 and a 5-mm subdural hematoma without midline shift after a fall down stairs.RESULTSThe response rate was 52% (n = 536). Overall, 326 (61%) respondents indicated they would recommend ICU admission for the child in the vignette. However, only 62 (12%) agreed/strongly agreed that this child was at high risk of neurological decline. Half of respondents (45%; n = 243) indicated they would order a planned follow-up CT (29%; n = 155) or MRI scan (19%; n = 102), though only 64 (12%) agreed/strongly agreed that repeat neuroimaging would influence their management. Common factors that increased the likelihood of ICU admission included presence of a focal neurological deficit (95%; n = 508 endorsed), midline shift (90%; n = 480) or an epidural hematoma (88%; n = 471). However, 42% (n = 225) indicated they would admit all children with mTBI and ICI to the ICU. Notably, 27% (n = 143) of respondents indicated they had seen one or more children with mTBI and intracranial hemorrhage demonstrate a rapid neurological decline when admitted to a general ward in the last year, and 13% (n = 71) had witnessed this outcome at least twice in the past year.CONCLUSIONSMany physicians endorse ICU admission and repeat neuroimaging for pediatric mTBI with ICI, despite uncertainty regarding the clinical utility of those decisions. These results, combined with evidence that existing practice may provide insufficient monitoring to some high-risk children, emphasize the need for validated decision tools to aid the management of these patients.

While most children with mild traumatic brain injury (mTBI) without intracranial injury (ICI) can be safely discharged home from the emergency department, many are admitted to the hospital. To support evidence-based practice, we developed a decision tool to help guide hospital admission decisions. This study was a secondary analysis of a prospective study conducted in 25 emergency departments. We included children under 18 years who had Glasgow Coma Scale score 13–15 head injuries and normal computed tomography scans or skull fractures without significant depression. We developed a multi-variable model that identified risk factors for extended inpatient management (EIM; defined as hospitalization for 2 or more nights) for TBI, and used this model to create a clinical risk score. Among 14,323 children with mTBI without ICI, 20% were admitted to the hospital but only 0.76% required EIM for TBI. Key risk factors for EIM included Glasgow Coma Scale score less than 15 (odds ratio [OR] = 8.1; 95% confidence interval [CI] 4.0–16.4 for 13 vs. 15), drug/alcohol Intoxication (OR = 5.1; 95% CI 2.4–10.7), neurological Deficit (OR = 3.1; 95% CI 1.4–6.9), Seizure (OR = 3.7; 95% CI 1.8–7.8), and Skull fracture (odds ratio [OR] 24.5; 95% CI 16.0–37.3). Based on these results, the CIDSS(2) risk score was created. The model C-statistic was 0.86 and performed similarly in children less than (C = 0.86) and greater than or equal to 2 years (C = 0.86). The CIDSS(2) score is a novel tool to help physicians identify the minority of children with mTBI without ICI at increased risk for EIM, thereby potentially aiding hospital admission decisions.

Summary Background Benzodiazepine-refractory, or established, status epilepticus is thought to be of similar pathophysiology in children and adults, but differences in underlying aetiology and pharmacodynamics might differentially affect response to therapy. In the Established Status Epilepticus Treatment Trial (ESETT) we compared the efficacy and safety of levetiracetam, fosphenytoin, and valproate in established status epilepticus, and here we describe our results after extending enrolment in children to compare outcomes in three age groups. Methods In this multicentre, double-blind, response-adaptive, randomised controlled trial, we recruited patients from 58 hospital emergency departments across the USA. Patients were eligible for inclusion if they were aged 2 years or older, had been treated for a generalised convulsive seizure of longer than 5 min duration with adequate doses of benzodiazepines, and continued to have persistent or recurrent convulsions in the emergency department for at least 5 min and no more than 30 min after the last dose of benzodiazepine. Patients were randomly assigned in a response-adaptive manner, using Bayesian methods and stratified by age group ( 65 years), to levetiracetam, fosphenytoin, or valproate. All patients, investigators, study staff, and pharmacists were masked to treatment allocation. The primary outcome was absence of clinically apparent seizures with improved consciousness and without additional antiseizure medication at 1 h from start of drug infusion. The primary safety outcome was life-threatening hypotension or cardiac arrhythmia. The efficacy and safety outcomes were analysed by intention to treat. This study is registered in ClinicalTrials.gov , NCT01960075 . Findings Between Nov 3, 2015, and Dec 29, 2018, we enrolled 478 patients and 462 unique patients were included: 225 children (aged 65 years). 175 (38%) patients were randomly assigned to levetiracetam, 142 (31%) to fosphenyltoin, and 145 (31%) were to valproate. Baseline characteristics were balanced across treatments within age groups. The primary efficacy outcome was met in those treated with levetiracetam for 52% (95% credible interval 41–62) of children, 44% (33–55) of adults, and 37% (19–59) of older adults; with fosphenytoin in 49% (38–61) of children, 46% (34–59) of adults, and 35% (17–59) of older adults; and with valproate in 52% (41–63) of children, 46% (34–58) of adults, and 47% (25–70) of older adults. No differences were detected in efficacy or primary safety outcome by drug within each age group. With the exception of endotracheal intubation in children, secondary safety outcomes did not significantly differ by drug within each age group. Interpretation Children, adults, and older adults with established status epilepticus respond similarly to levetiracetam, fosphenytoin, and valproate, with treatment success in approximately half of patients. Any of the three drugs can be considered as a potential first-choice, second-line drug for benzodiazepine-refractory status epilepticus. Funding National Institute of Neurological Disorders and Stroke, National Institutes of Health.

Aim: Postconcussion symptom-rating scales are frequently used concussion assessment tools that do not align directly with new expert, consensus-based concussion subtype classification systems. This may result in delays in concussion diagnosis, subspecialty referral and rehabilitative strategies. Objective: To determine the representation of subtype-directed symptomatology in common postconcussion symptom-rating scales. Methods: Literature review and expert consensus were used to compile commonly used concussion symptom-rating scales. Statistics were generated to describe the degree of representation of the consensus symptom set. Results: The percentage of symptoms representing each subtype/associated condition is low overall (15–26%). The ocular-motor (11%) and vestibular subtypes (19%) and cervical strain (5%)-associated condition were the most under-represented and also had the greatest unmet needs. Conclusion: Concussion subtypes do not have equal representation on commonly used concussion symptom-rating scales. There is a need for a subtype-directed symptom assessment to allow for increased accuracy of diagnosis and to guide management.

Given the lack of evidence regarding effective pharmacological and non-pharmacological interventions for pediatric mild traumatic brain injury (mTBI) and the resultant lack of treatment recommendations reflected in consensus guidelines, variation in the management of pediatric mTBI is to be expected. We therefore surveyed practitioners across 15 centers in the United States and Canada who care for children with pediatric mTBI to evaluate common-practice variation in the management of pediatric mTBI. The survey, developed by a panel of pediatric mTBI experts, consisted of a 10-item survey instrument regarding providers' perception of common pediatric mTBI symptoms and mTBI interventions. Surveys were distributed electronically to a convenience sample of local experts at each center. Frequencies and percentages (with confidence intervals [CI]) were determined for survey responses. One hundred and seven respondents (71% response rate) included specialists in pediatric Emergency Medicine, Sports Medicine, Neurology, Neurosurgery, Neuropsychology, Neuropsychiatry, Physical and Occupational Therapy, Physiatry/Rehabilitation, and General Pediatrics. Respondents rated headache as the most prevalently reported symptom after pediatric mTBI, followed by cognitive problems, dizziness, and irritability. Of the 65 (61%; [95% CI: 51,70]) respondents able to prescribe medications, non-steroidal anti-inflammatory medications (55%; [95% CI: 42,68]) and acetaminophen (59%; [95% CI: 46,71]) were most commonly recommended. One in five respondents reported prescribing amitriptyline for headache management after pediatric mTBI, whereas topiramate (8%; [95% CI: 3,17]) was less commonly reported. For cognitive problems, methylphenidate (11%; [95% CI: 4,21]) was used more commonly than amantadine (2%; [95% CI: 0,8]). The most common non-pharmacological interventions were rest ("always" or "often" recommended by 83% [95% CI: 63,92] of the 107 respondents), exercise (59%; [95%CI: 49,69]), vestibular therapy (42% [95%CI: 33,53]) and cervical spine exercises (29% [95%CI: 21,39]). Self-reported utilization for common pediatric mTBI interventions varied widely across our Canadian and United States consortium. Future effectiveness studies for pediatric mTBI are urgently needed to advance the evidence-based care.

In January 2005, PEMFellows.com was created to unify fellows in pediatric emergency medicine. Since then, the website has expanded, contracted, and focused to adapt to the interests of the pediatric emergency medicine practitioner during the internet boom. This review details the innovation of the PEMNetwork, from the inception of the initial website and its evolution into a needs-based, user-directed educational hub. Barriers and enablers to success are detailed with unique examples from descriptive analysis and metrics of PEMNetwork web traffic as well as examples from other online medical communities and digital education websites.

This article is the second in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine (PEM) fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article describes the development of PEM entrustable professional activities (EPAs) and the relationship of these EPAs with existing taxonomies of assessment and learning within PEM fellowship. It summarizes the field in concepts that can be taught and assessed, packaging the PEM subspecialty into EPAs.

Spontaneous subarachnoid hemorrhage (SAH) from a brain aneurysm, if untreated in the acute phase, leads to loss of functional independence in about 30% of patients and death in 27-44%. To evaluate for SAH, the American College of Emergency Physicians (ACEP) Clinical Policy recommends obtaining a non-contrast brain computed tomography (CT) scan followed by a lumbar puncture (LP) if the CT is negative. On the other hand, current evidence from prospectively collected data suggests that CT alone may be sufficient to rule out SAH in patients who present within 6 h of symptom onset while anecdotal evidence suggests that CT angiogram (CTA) may be used to detect aneurysms, which are the probable cause of SAH. Since many different options are available to emergency physicians, we examined their practice pattern variation by observing their diagnostic approaches and their adherence to the ACEP Clinical Policy.We developed, validated, and distributed a survey to emergency physicians at three practice sites: (1) Stanford Healthcare, California, (2) Intermountain Healthcare (five emergency departments), Utah, and (3) Ottawa General Hospital, Toronto. The survey questions examined physician knowledge on CT and LP's test performance and used case-based scenarios to assess diagnostic approaches, variation in practice, and adherence to guidelines. Results were presented as proportions with 95% CIs.Of the 216 physicians surveyed, we received 168 responses (77.8%). The responses by site were: (1) (n = 38, 23.2%), (2) (n = 70, 42.7%), (3) (n = 56, 34.1%). To the CT and LP test performance question, most physicians indicated that CT alone detects 90% of SAH in those with a confirmed SAH [n = 150 (89.3%, 95% CI 83.6-93.5]. To the case-based questions, most physicians indicated that they would perform a CTA along with a CT [n = 110 (65.5%, 95% CI 57.8-72.6)], some indicated a LP along with a CT [n = 57, 33.9% 95% CI 26.8-41.6)], and a few indicated both a CTA and a LP [n = 16, 9.5%, 95% CI 5.5-15.0]. We also observed practice site variation in the proportion of physicians who indicated that they would use CTA: (1) (n = 25, 65.8%), (2) (n = 54, 77.1%), and (3) (n = 28, 50.0%) (p = 0.006).Survey responses indicate that physicians use some or all of the imaging tests, with or without LP to diagnose SAH. We observed variation in the use of CTA by site and academic setting and divergence from ACEP Clinical Policy.

BACKGROUND Concussion is a heterogeneous mild traumatic brain injury (mTBI) characterized by a variety of symptoms, clinical presentations, and recovery trajectories. By thematically classifying the most common concussive clinical presentations into concussion subtypes (cognitive, ocular-motor, headache/migraine, vestibular, and anxiety/mood) and associated conditions (cervical strain and sleep disturbance), we derive useful definitions amenable to future targeted treatments. OBJECTIVE To use evidence-based methodology to characterize the 5 concussion subtypes and 2 associated conditions and report their prevalence in acute concussion patients as compared to baseline or controls within 3 d of injury. METHODS A multidisciplinary expert workgroup was established to define the most common concussion subtypes and their associated conditions and select clinical questions related to prevalence and recovery. A literature search was conducted from January 1, 1990 to November 1, 2017. Two experts abstracted study characteristics and results independently for each article selected for inclusion. A third expert adjudicated disagreements. Separate meta-analyses were conducted to do the following: 1) examine the prevalence of each subtype/associated condition in concussion patients using a proportion, 2) assess subtype/associated conditions in concussion compared to baseline/uninjured controls using a prevalence ratio, and 3) compare the differences in symptom scores between concussion subtypes and uninjured/baseline controls using a standardized mean difference (SMD). RESULTS The most prevalent concussion subtypes for pediatric and adult populations were headache/migraine (0.52; 95% CI = 0.37, 0.67) and cognitive (0.40; 95% CI = 0.25, 0.55), respectively. In pediatric patients, the prevalence of the vestibular subtype was also high (0.50; 95% CI = 0.40, 0.60). Adult patients were 4.4, 2.9, and 1.7 times more likely to demonstrate cognitive, vestibular, and anxiety/mood subtypes, respectively, as compared with their controls (P

Introduction: To rule out sub-arachnoid hemorrhage (SAH) national guidelines for emergency physicians recommends obtaining a non-contrast CT scan and, if negative, a lumbar puncture. However, anecdotal evidence suggests recent adoption of CT non-contrast alone in patients presenting within six hours from symptom onset and an increase in the use of a newer imaging modality, CT angiogram (CTA). Our aim was to examine emergency physicians’ diagnostic approach to SAH diagnosis and their adherence to the current guidelines. Method: We developed, validated, and distributed a survey to emergency physicians at three different emergency departments: Site 1) Stanford Healthcare, California, 2) Intermountain Healthcare, Utah, and 3) The Ottawa Hospital, Ottawa, Ontario. We surveyed emergency physicians with questions on test performance for SAH detection and case based scenarios to assess adherence to guidelines. Results were presented as proportions with 95% CIs. Results: Of the 216 physicians surveyed, we received 168 responses (77.8%). The responses by site were: 1) (n= 38, 23.2%), 2) (n=70, 42.7%), 3) (n=56, 34.1%). Most physicians indicated that non-contrast CT imaging within a 6-hour window detects >90% of SAH in those with a confirmed SAH [n=150 ( 89.3%, 95%CI 83.6 - 93.5)]. In response to the case based scenarios, a majority of the physicians indicated that they would use a non-contrast CT with an additional CTA [n=110 ( 65.5%, 95%CI 57.8- 72.6)], some indicated an additional LP [n=57 (33.9%, 95%CI 26.8 - 41.6)], and a few indicated both an additional CTA and LP[n=16 (9.5%, 95%CI 5.5-15.0)]. We also observed practice site variation in the proportion of physicians who indicated that they would use CTA: 1) (n=25/38, 65.8%), 2) (n= 54/70, 77.1%), and 3) (n=28/56, 50.0%) (p= 0.006). Conclusion: Survey responses indicated a significant variation in the emergency physicians’ use of diagnostic imaging for SAH and divergence from current guidelines. In our future studies, we will explore the reasons for the practice variation and increasing use of CTA as a diagnostic modality in SAH evaluation.

Objectives The Centers for Disease Control and Prevention (CDC) published an evidence-based guideline on the diagnosis and management of pediatric mild traumatic brain injury (mTBI) in 2018. This commentary provides key practice takeaways for sports medicine providers outlined in the Guideline recommendations. Data sources The CDC Pediatric mTBI Guideline was developed through a rigorous scientific process using a modified Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology. A systematic review of the scientific literature published over a 25-year period for all causes of pediatric mTBI formed the basis of the Guideline. Main results The key practice takeaways for sports medicine providers focus on preseason evaluations, neuroimaging, symptom-based assessment, managing recovery, monitoring for persistent symptoms, and return to activity, including sport and school. Conclusions Sports medicine providers play an integral part in the implementation of evidence-based practices that promote appropriate diagnosis and management of mTBI in children. This commentary highlights key practice takeaways that sports medicine providers can implement.

Importance Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States. Objective To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI. Evidence Review The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015. Findings The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment. Conclusions and Relevance This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.

Traumatic Brain Injury (TBI) was chosen as an Emergency Neurological Life Support topic due to its frequency, the impact of early intervention on outcomes for patients with TBI, and the need for an organized approach to the care of such patients within the emergency setting. This protocol was designed to enumerate the practice steps that should be considered within the first critical hour of neurological injury.

Pediatric interpersonal violence is a public health crisis resulting in morbidity and mortality and recidivism. St. Louis City and surrounding areas have the highest rates of youth interpersonal violence nationally. St. Louis Children’s Hospital (SLCH) Social Work in conjunction with Pediatric Emergency Medicine established a novel emergency department (ED)–initiated program to determine whether co-location of services followed by outpatient mentoring reduced the rate of morbidity, mortality, and recidivism in youths experiencing interpersonal violence. SLCH developed the “Empowering Youth Through Interpersonal Violence Prevention Program,” co-locating initial social work services and emergency medical services in the pediatric ED. Youths, ages 8 to 17 years, presenting for interpersonal violence were approached for immediate social work counseling and subsequent individualized outpatient mentoring, developed from national best practices and model programs. A prospective 2:1 randomized, controlled pilot study assessing for youth morbidity, mortality, and recidivism was conducted for program service feasibility from 2012 to 2014. The study was followed by a 1-year retrospective analysis of program service integration as a hospital standard-of-care evaluating the same outcome measures. Of the 24 youths who participated in the pilot study and received the intervention, there was a 4% rate of morbidity and recidivism. Conversely, there was a 3.4% rate of mortality, 6.7% rate of morbidity, and 11.8% recidivism rate in those who refused to participate in services. EYIPP was offered as a service from 2014 to 2015 and 57 youths participated with a 3.5% rate of both morbidity and recidivism. During this time, 78 eligible youths declined services with a 1.1% rate of morbidity, and 2.3% recidivism rate. This novelprogram reduces recidivism, morbidity, and mortality in youths presenting to SLCH for interpersonal violence-related injuries suggesting that co-location of social services in the ED, followed by individualized mentoring may be important for engagement.

Pediatric traumatic brain injury accounts for approximately 474,000 emergency department visits, 37,000 hospitalizations, and 3,000 deaths in children 14 years and younger annually in the United States. Acute neurocritical care in children has advanced with specialized pediatric trauma centers and emergency medical services. This article reviews pediatric-specific diagnosis, management, and medical decision making related to the neurocritical care of severe traumatic brain injury.

Importance The appropriate treatment of children with mild traumatic brain injury (mTBI) and intracranial injury (ICI) on computed tomographic imaging remains unclear. Evidence-based risk assessments may improve patient safety and reduce resource use. Objective To derive a risk score predicting the need for intensive care unit observation in children with mTBI and ICI. Design, Setting, and Participants This retrospective analysis of the prospective Pediatric Emergency Care Applied Research Network (PECARN) head injury cohort study included patients enrolled in 25 North American emergency departments from 2004 to 2006. We included patients younger than 18 years with mTBI (Glasgow Coma Scale [GCS] score, 13-15) and ICI on computed tomography. The data analysis was conducted from May 2015 to October 2016. Main Outcomes and Measures The primary outcome was the composite of neurosurgical intervention, intubation for more than 24 hours for TBI, or death from TBI. Multivariate logistic regression was used to predict the outcome. The C statistic was used to quantify discrimination, and model performance was internally validated using 10-fold cross-validation. Based on this modeling, the Children’s Intracranial Injury Decision Aid score was created. Results Among 15 162 children with GCS 13 to 15 head injuries who received head computed tomographic imaging in the emergency department, 839 (5.5%) had ICI. The median ages of those with and without a composite outcome were 7 and 5 years, respectively. Among those patients with ICI, 8.7% (n = 73) experienced the primary outcome, including 8.3% (n = 70) who had a neurosurgical intervention. The only clinical variable significantly associated with outcome was GCS score (odds ratio [OR], 3.4; 95% CI, 1.5-7.4 for GCS score 13 vs 15). Significant radiologic predictors included midline shift (OR, 6.8; 95% CI, 3.4-13.8), depressed skull fracture (OR, 6.5; 95% CI, 3.7-11.4), and epidural hematoma (OR, 3.4; 95% CI, 1.8-6.2). The model C statistic was 0.84 (95% CI, 0.79-0.88); the 10-fold cross-validated C statistic was 0.83. Based on this modeling, we developed the Children’s Intracranial Injury Decision Aid score, which ranged from 0 to 24 points. The negative predictive value of having 0 points (ie, none of these risk factors) was 98.8% (95% CI, 97.3%-99.6%). Conclusions and Relevance Lower GCS score, midline shift, depressed skull fracture, and epidural hematoma are key risk factors for needing intensive care unit–level care in children with mTBI and ICI. Based on these results, the Children’s Intracranial Injury Decision Aid score is a potentially novel tool to risk stratify this population, thereby aiding management decisions.

OBJECTIVE: To provide a review of evidence and consensus-based description of healthcare and educational service delivery and related recommendations for children with traumatic brain injury. METHODS: Literature review and group discussion of best practices in management of children with traumatic brain injury (TBI) was performed to facilitate consensus-based recommendations from the American Congress on Rehabilitation Medicine's Pediatric and Adolescent Task Force on Brain Injury. This group represented pediatric researchers in public health, medicine, psychology, rehabilitation, and education. RESULTS: Care for children with TBI in healthcare and educational systems is not well coordinated or integrated, resulting in increased risk for poor outcomes. Potential solutions include identifying at-risk children following TBI, evaluating their need for rehabilitation and transitional services, and improving utilization of educational services that support children across the lifespan. CONCLUSION: Children with TBI are at risk for long-term consequences requiring management as well as monitoring following the injury. Current systems of care have challenges and inconsistencies leading to gaps in service delivery. Further efforts to improve knowledge of the long-term TBI effects in children, child and family needs, and identify best practices in pathways of care are essential for optimal care of children following TBI. Language: en

BACKGROUND: Firearm related injuries are a significant cause of morbidity and mortality in children. To determine current trends and assess avenues for future interventions, we examined the epidemiology and outcome of pediatric firearm injuries managed at our region's two major pediatric trauma centers. METHODS: Following IRB approval, we conducted a 5-year retrospective review of all pediatric firearm victims, aged ≤16 years, treated at either of the region's two Level-1 pediatric trauma centers; St. Louis Children's Hospital and Cardinal Glennon Children's Medical Center. RESULTS: There were 398 children treated over a 5-year period (2008-2013) for firearm related. Of these children, 314 were black (78.9%). Overall, there were 20 mortalities (5%). Although most patients were between 14-16 years of age (67.6%), younger victims had a greater morbidity and mortality. The majority of injuries were categorized as assault/intentional (65%) and occurred between 6pm and midnight, outside the curfew hours enforced by the city. Despite a regional decrease in the overall incidence of firearm injuries during the study period, the rate of accidental victims per year remained stable. Most accidental shootings occurred in the home (74.2%) and were self-inflicted (37.9%) or caused by a person known to the victim (40.4%). CONCLUSION: Despite a relative decrease in intentional firearm related injuries, a constant rate of accidental shootings suggest an area for further intervention. LEVEL OF EVIDENCE: 4, prognostic and epidemiological. Language: en