pediatric head trauma joshua rocker, md pediatric emergency medicine schneider children’s hospital
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Pediatric Head TraumaPediatric Head Trauma
Joshua Rocker, MD
Pediatric Emergency Medicine
Schneider Children’s Hospital
Parents present a 10 month old male to ER stating he fell down while walking and he is currently not himself.
Head Injuries: The numbers!Head Injuries: The numbers!Trauma- #1 cause of mortality and
morbidity >1y/o.
Head injury is the #1 cause of death in these traumas
Head injuries: The numbers!!Head injuries: The numbers!!600,000 ER visits
100,000 hospitalizations
7,000 deaths
29,000 permanent disability
Head Injuries: the mechanism!Head Injuries: the mechanism!Falls- 37%MVA- 18% (most fatal)Pedestrian Struck- 17%Bicycle injuries- 10%
Head Injuries: the differencesHead Injuries: the differencesAge:
Infants- fall or non-accidental
vs.
Adolescent- sports, MVAs
Sex:
males : females (2-4:1)
Pathophysiology:Pathophysiology:Cerebral Perfusion Pressure (CPP)=
Mean Arterial Pressure (MAP) –
Intracranial Pressure (ICP).
Pathophysiology- lastly…Pathophysiology- lastly…Axonal Injury-
– Primary pathological feature of traumatic head injury.
– Traumatic forces exert strain and/or torque on axons which may reversibly or irreversibly damage them.
Location, Location, LocationLocation, Location, Location(Anatomy, Anatomy, Anatomy)(Anatomy, Anatomy, Anatomy)
Case #1Case #1 Parents present with a 3 day old male who was a
product of a NSVD without any complications. His birth weight was 9lb 4oz. He now appears to be yellow tinged and has a swelling to the right side of the occiput.
Case #1Case #1Parents present with a 3 day old male who
was a product of a NSVD without any complications. His birth weight was 9lb 4oz. He now appears to be yellow tinged and has a swelling to the right side of the occiput.
Amita?? What’ya think?
ScalpScalp 5 Layers:
– Skin– Subcutaneous tissue– Galea aponeurosis– Loose areola tissue– pericranium
Skull- Skull fracturesSkull- Skull fractures Types:
– linear, diastatic, depressed
compound, basilarLinear – 75-90%
– Location key
Signs of Basilar Skull FractureSigns of Basilar Skull Fracture
Yes, this is a question to you Nikhil?
Basilar Skull FractureBasilar Skull Fracture Fx of petrous portion of
temporal bone:
hemotympanum, hemorrhagic or CSF
otorrhea, Battle sign
Fx of anterior skull base: CSF rhinorrhea, raccoon eyes
Subdural HemorrhageSubdural HemorrhageDirect trauma or accel-decelBridging veinsOften with underlying brain
injurySeizures
Clinical ApproachClinical Approach History Symptoms Primary Survey
– ABCD (GCS)
Secondary Survey
Spinal Injury? Suspect Child Abuse?
Modified GCSModified GCS Eye Opening • Motor
– Spontaneous Normal – To speech W/D to touch– To pain W/D to pain– None Decorticate Decerebrate
Verbal None – Coos, Babbles– Cries to Pain– Moans to Pain– None
Non-accidental head injuries Non-accidental head injuries (aka- child abuse)(aka- child abuse)
In 2000 child abuse and neglect was responsible for 1200 deaths.
44% under 1 y/o.Head injury #1 cause of death.
Child abuse- numbersChild abuse- numbersVictims
– Median age 4.6 months– Range 7 d to 58 months
Perpetrators– 50% fathers, 20% male partner, 12% mothers
Child Abuse- Risk factorsChild Abuse- Risk factorsPerpetrators
– Young and/or single parent– Lower level of education– Unstable family structure– Stress in family– DV– Alcohol/drug abuse– depression
Victims– Multiple birth– Young age– Prematurity– Chronic illness– Difficult temperament
Child abuse- LOOK OUTChild abuse- LOOK OUT 60% with history or clinical evidence of previous abuse Retinal Hemorrhages
– Not pathognomonic (50-100% will have)– Seen in:
Birth trauma, accidental injuries, bleeding d/o, glutaric aciduria, infections, etc
Skeletal Fracture– 20-50%– Classic metaphyseal avulsion lesions (CML)– Posterior Rib
Cutaneous bruising– From autopsy- only 21%
Last case!Last case! A 9 month old male with CF presents with
sleepiness after falling off the sofa (onto a hard wood floor) where the parents placed the child to sleep for the night. The family lives in a crowded one bedroom apartment with grandparents.
The father smells of alcohol.
Its 2 AM.
Case cont…Case cont…The child is sleeping.Vitals normal.Small hematoma over the temporal region.
What do you do?
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