From 2005 to 2009, children made more than 2 million outpatient visits and almost 3 million emergency department (ED) visits for mild traumatic brain injury.¹ The actual number of mild traumatic brain injury cases is difficult to assess because patients may seek treatment in a variety of medical or school settings, or not at all. However, there is evidence that these numbers are increasing; in 2007, there were 461,000 ED visits for traumatic brain injury among children aged 14 years and younger; by 2013, that number had increased to 642,000.^2,3

The detection, evaluation, and management of pediatric patients with mild traumatic brain injury is complicated by the lack of standardization and evidenced-based guidance. The short- and potential long-term effects of mild traumatic brain injury can have significant consequences that affect a child’s ability to function physically, cognitively, and psychologically.^4–6 Although most pediatric patients no longer experience symptoms within 1 to 3 months, a subset of patients may have protracted symptoms.⁷ The ED clinician plays a critical role by recognizing patients with mild traumatic brain injury, conducting and documenting an appropriate focused examination, providing symptom management, guiding preventive measures, and providing sound discharge instructions.

The Centers for Disease Control and Prevention’s (CDC’s) recent guideline optimizes and standardizes evidence-based acute clinical care for injured children.⁸ This guideline draws on a methodologically rigorous⁹ systematic review of a search encompassing more than 34,000 articles spanning 25 years of research.¹⁰ Two public comment periods, one round of external peer review, and 2 rounds of review by academic organizations such as the American College of Emergency Physicians informed the final guideline.

The guideline focused on 6 clinically relevant questions that addressed decisionmaking in the diagnosis of mild traumatic brain injury, prognostic indicators in the pediatric population with mild traumatic brain injury, and management and treatments (Figure 1). Nineteen evidence-based recommendation sets were developed with these 6 questions as a foundation. The clinical questions and guideline recommendations use the term “mild traumatic brain injury.” However, in recognition of the heterogeneity of patient presentations, the research reviewed for the guideline encompassed a functional definition of mild traumatic brain injury. The definition used was inclusive of concussive signs or symptoms after direct or indirect head injury, as well as a Glasgow Coma Scale score of 13 to 15, with or without the complication of intracranial injury on neuroimaging, and regardless of the potential to require a hospital admission or neurosurgical intervention.

Although the CDC guideline is intended for use in a variety of clinical settings and by different categories of health care providers, several strongly supported recommendations are critical for ED clinicians in their practice setting. These recommendations are described below and listed in Figure 2. Broadly, these recommendations encompass diagnosis, prognosis, management and treatment. A modified Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess confidence in the evidence and reflect a strength of recommendation.

A guideline does not have influence if not implemented into practice. To facilitate implementation, CDC has developed free and publicly available guideline implementation tools applicable to ED management and discharge, available at http://www.cdc.gov/HEADSUP. These tools range from validated screening tools to assess young patients to discharge instructions and symptombased recovery tips for parents to support their child’s recovery (Figure 3).

The ED clinician plays an important role in the recognition and management of mild traumatic brain injury because he or she may be the first health care provider to evaluate an injured child. The new CDC evidence-based guideline provides strong support for intervention in the ED through a structured framework of recommendations. Key practice-changing features include using validated and age-appropriate postconcussion symptom rating scales to aid in diagnosis and prognosis, and incorporating specific recommendations for counseling at ED discharge. To learn more about the guideline and the methodology for developing it, visit http://www.cdc.gov/HEADSUP.