Recognizing MTBI in Pediatric Patients

Prompt diagnosis of symptoms is required to prevent long-term sequelae


By Mehrdad Mehr, MD


Mild Traumatic Brain Injury (MTBI), often referred to as “concussion,” is defined as head injury with a temporary loss of brain function. The physical, cognitive and emotional symptoms that result from the structural and neuropsychiatric insult to the brain may be subtle enough that MTBI remains undiagnosed. A retrospective survey in 2005 suggested that 88 percent of concussions go unrecognized. Therefore, it is imperative to be vigilant about the recognition of the broad spectrum of associated symptoms and implement the necessary measures to prevent long-term sequelae.


Physical, cognitive and affective symptoms are present with MTBI. The most common physical components are headaches, dizziness, nausea, vomiting and lack of motor coordination. Visual symptoms, including light sensitivity and tinnitus, are also reported. Seizures that occur during or immediately after the injury are likely secondary to a momentary disruption of brain function and not predictive of post-traumatic epilepsy.


Mehrdad Mehr,, MD


Post-traumatic amnesia, a hallmark of concussion, as well as confusion, disorientation and difficulty focusing with short attention span are common cognitive symptoms. Loss of consciousness may occur and is not correlated with the severity of the concussion if it is brief. Restlessness, irritability, lethargy, loss of interest in favorite activities or items, and inappropriate display of emotions in response to a situation are characteristic of the affective symptoms seen with MTBI.


The diagnosis of MTBI is based on the physical exam (with emphasis on the neurological assessment), duration of unconsciousness (typically less than 30 minutes), post-traumatic amnesia of less than 24 hours, and a Glasgow Coma Score (GCS) of 13-15. Computerized Tomography (CT) of the head is recommended for a GCS of less than 14, though most concussive head injuries without complications cannot be detected by CT scan or Magnetic Resonance Imaging (MRI). Abnormalities have been reported with MRI and Single-Photon Emission Computerized Tomography (SPECT) imaging in patients with the post-concussion syndrome. MTBI may or may not produce abnormal electroencephalogram (EEG) results.


After checking for immediate signs of injury and their appropriate management in an emergency department and/or inpatient setting, physical and cognitive rest is indicated until the symptoms clear. Cognitive rest includes reducing activities that require concentration and attention, including school work, video games and text messaging. Even leisure reading commonly worsens symptoms. Sufferers should also receive adequate sleep at night and during the day.


Athletes must be symptom-free before they can resume physical activity, and even then should progress through a series of graded steps – for example, light aerobic activity followed by sport-specific activities such as running drills and non-contact training drills. They should then graduate to full-contact practice followed by game participation. Advancement up this ladder requires a 24-hour period of being symptom-free. If symptoms appear, the individual should drop back to the prior level and advance only when symptom-free.


MTBI has a mortality rate of almost zero and problems are seldom permanent. Outcomes are usually excellent. However, one concussion makes the brain more susceptible to another. Smaller subsequent impacts may cause the same or worse symptom severity.


Given that repeated concussions may increase risk in later life of dementia, Parkinson’s disease and depression, recognition, treatment and guidance of MTBI become the foundation for improved long-term outcome.


Patients admitted with asthma exacerbations are placed on an asthma pathway.  This pathway includes four phases.  Phase one consists of continuous administration of high-dose, short-acting beta agonist (SABA) and takes place in the intensive care unit.


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