For the first time, federal officials have issued clinical guidelines for healthcare providers trying to determine if a child has a concussion, recommending that CT scans not be used routinely to diagnose these conditions.
In New Jersey, a growing number of hospitals and providers have already adopted similar protocols in an attempt to accurately diagnose head injuries and protect young patients from unnecessary radiation. As a result, fewer Garden State kids — including scores of student athletes — are getting unnecessary scans today.
CT scans, or computerized tomography scans, use a relatively small amount of radiation to create cross-sections of the body or brain. They have become a critical tool for assessing tissue damage in millions of children nationwide, including thousands of New Jersey youngsters each year.
But some experts are concerned that overuse of the procedure, which is 200 times the strength of a chest X-ray, could harm children subject to repeat scans, even causing cancer. According to national estimates, at least one in three CT scans is not necessary to reach a correct diagnosis.
In an effort to clarify these practices for providers nationwide — and limit unnecessary exposure to radiation — the federal Centers for Disease Control and Prevention issued a 19-point recommendation with standardized protocols for diagnosing, assessing, managing, and treating mild traumatic brain injury (mTBI), also known as concussions. Published last week in the medical journal JAMA Pediatrics, the voluntary guidelines encompass 25 years of research, the CDC said.
Steps to take before CT scans
At the top of the CDC’s list: using carefully validated scales to assess mental status and other factors that can indicate a concussion, before turning to the CT scanner to diagnose the condition. The protocol also outlines steps to assess risk factors for long-term recovery, including family history, and provide clear guidance for patients and family members on returning to daily activities.
“You can’t see a concussion in a CT scan. There’s no scan that is going to see a concussion. There’s no blood test that is going to see a concussion,” said Dr. John Z. Shumko, the medical director of the RWJBarnabas program dedicated to screening and treating concussions, cardiac conditions, and sports injuries in young athletes ages five through 18.
If a provider finds signs of severe trauma, like altered consciousness or dilated pupils, Shumko said that would be a different story. “But if you don’t have any of those severe symptoms, then a scan doesn’t need to be done,” he added.
Distributing time-tested protocols
Protocols developed by the Matthew J. Morahan III Health Assessment Center for Athletes, which has seen 30,000 youngsters since it launched eight years ago, have been shared among pediatricians and emergency doctors throughout the RWJBarnabas system, Shumko said. The group also offers free screenings in the community throughout the school year.
The system developed by the center’s leaders involves the use of a mobile app that helps physicians, nurses, and athletic officials at associated schools assess youngsters with injuries and quickly connect with care, if needed. Shumko said staff also aims to help parents and other family members understand the pros and cons of various diagnostic and treatment programs, which can now be tailored to meet the specific needs of each patient.
The New Jersey Hospital Association has shown success reducing the use of CT scans at facilities across the state, thanks in large part to the #ScanSmart initiative the trade group launched in 2016. At that point, some 13,000 youngsters were receiving these scans at hospital facilities annually, including nearly half of those treated for head injuries in the emergency room.
But with the creation of clinical protocols to help providers, and a public education campaign to help parents and the public better understand the risks and benefits of the procedure, the use of unnecessary CT scans in assessing minor injuries in children declined by 17 percent in 2017, according to the NJHA.
Soniya Sheth, a pediatric nurse practitioner who leads the NJHA effort, said the work invested by state hospitals here give providers a “head start” in adapting to the new federal guidelines. “The CDC’s recommendations echo many of the protocols that New Jersey’s hospitals have been implementing over the past two years under NJHA’s ScanSmart initiative,” she said.
“The CDC’s very first item — Do not routinely image pediatric patients to diagnose mild traumatic brain injury — is a central part of our outreach,” Sheth added. “We want pediatric providers, as well as parents, to know that a CT scan isn’t necessary in all cases, and in fact it could pose risks to a child through radiation exposure.”
CDC conducted comprehensive review
According to the CDC, which is part of the U.S. Department of Health and Human Services, developing the guidelines involved an in-depth review of scientific literature, feedback from experts, public input, and comments for partner organizations. While the guide focuses on children, officials hope to use it as a baseline for recommendations for diagnosing mTBI in all age groups.
In addition to specific steps for clinicians, the agency has posted tools and resources for parents and others who care for young athletes, many of whom are likely to suffer bumps on the head at some point.
Shumko, with RWJBarnabas, agreed the CDC’s recommendations will be helpful for hospital systems or independent facilities that have not yet crafted protocols of their own, as well as members of the public. “It’s a big step,” he said, “but we’ve been doing that for years.”