2/16/2014

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Clarifying Murky Waters:

Head Injuries in Children

Judith R. Klein, MD, FACEP

Assistant Professor of Emergency Medicine

UCSF-SFGH Emergency Services

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Case #1: Newborn Leo

2 month old dropped 4 feet onto sidewalk during removal from car seat

Cried/fed since

PE: small frontal hematoma

To image or not to image, that is the question

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Objectives

Ø Is observation enough?

Ø Whom to image?

Ø How to image?

Skull films vs. CT

Role for ultrasound?

Ø Whom to admit?

Ø Return to play?

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Pediatric head trauma: what’s the

big deal?

#1 cause of death

age 1-14 years

70% of fatal child

injuries

>7K deaths

60K hospitalizations,

>600K ED visits per

year

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Why worry?

3 to 6% incidence of

TBI post minor head

trauma

Up to 20% of kids < 2

years old with TBI are

asymptomatic!

Second impact

syndrome

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Who gets imaged?

40-50% with CHI to ED get imaged!!

Higher CT rates:

white race

older

general vs pediatric hospital

emergent triage status

attending treated

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Implications of imaging

Cognitive development

Lifetime cancer risk

from 1 head CT (3mSv): 1:1500 (1 yr old)

1:5000 (10 yr old)

< 10% of CT’s have

any TBI

0.5% of CT’s with

clinically important (CI) TBI7 8

GCS>14: To CT or not To CT??

Reduce # of CT’s performed Cancer/brain dev

Sedation

$$$$

Identify all TBI or just CI TBI?

NSU intervention

Hospital >2 nights/intubation>24 hrs

Death/long term neurological sequelae

CancerIdentify TBI

IQ

$$$

Sedation

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The Science

Several CDRs available

Only 2 included infants

PECARN rule the best:

Largest, 25 centers

Lots of young kids

Clear reference

standard for CI TBI

Best validation

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PECARN Minor Head Trauma

Decision Rule

Derivation and validation study

42K kids GCS>14: >10K under 2 yrs

<2 years: 100% NPV for CI TBI

and all TBI

>2 years:

99.9% NPV for CI TBI

98.4% NPV for all TBI

CT by 20-25%Kuppermann, Lancet 2009

Why identify all TBI: implications for sports/other activities?

Kuppermann et al. Lancet 2009

Under 2 years old

Why identify all TBI: implications for sports/other activities?

Kuppermann et al. Lancet 2009

Over 2 years old

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Severe Mechanism

MVA with ejection, rollover or death of

another occupant

Pedestrian or bike w/o helmet

vs. car

Fall >3 ft (<2 yr)

or >5 ft (>2 yr)

High impact object to

head

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Back to Baby Leo

Imaging?

A good idea..

Imaging for <3

months with scalp

hematoma + >3 ft fall

Thin skulleasily

fracturedstrong

correlation with TBI

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Well, can I just do a skull x-ray?

Skull film cons:

Hard to read

Not sensitive/specific

enough

If (+) still need to do

CT

CT cons:

Radiation

Cost

Transport from ED

Sedation

Survey says: CT

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Ultrasound and skull fracture?

Skull fx 4-20x likelihood of TBI

15-30% with skull fx TBI

Prospective study*:

55 patients

100% sensitivity

95% specificity

Include in CDR for low risk?

If US +, then CT? If US -,

observe?

16*Parri, J Emerg Med 2012.

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Baby Leo gets a CT

How do I keep him still? Swaddle

Dextrose H20

Acetaminophen

CT shows a skull fracture over posterior fossa

Admit?

YES

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Admit criteria for skull fracture

Very young-->higher bleeding risk

Depressed

Widely diastatic

High energy mechanism

High risk location (sutures, posterior fossa, dural sinus)

Poor home situation

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Case #2: Wild Bill

20 month old rolls

down 12 stairs

“Few seconds of

LOC” Cried. Ate.

Physical Exam:

GCS?

Talk his language

3 cm temporal

hematoma

To CT or not to CT?20

Wild Bill: CT or Observation?

Rule: CT or 6 hour obs for all < 2 years with non-frontal scalp hematoma

Location, location…:

• Temporal > parieto-occipital > frontal

Severe mechanism?:

• Stairs vs. straight fall

LOC too brief to count but...

Verdict: Very careful observation or CT

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Keeping Bill Still

Sedation choices:

Ketamine is OK

Rectal methohexital

Dexmedetomidine

IV/IM pentobarbital

Etomidate

Avoid versed

CT (+) epidural:

Admit

Brutane

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Case #3: The Car’s a Mess...

5 year old helmeted bike vs low speed MV

No LOC

V x 3 en route

Mild headache

PE: Playing

Small parietal scalp hematoma

To CT or not to CT?

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Let’s talk observation

> 2 years

Isolated vomiting

No LOC

Non-severe

mechanism

Mild headache

Consider observation

if parents comfortable

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Discharge home?

Criteria: Normal MS

Vomiting controlled

No abuse suspected

Responsible home/ reliable transportation

Normal head CT*

Confused after normal CT?

Observe x 4-6 hrs -->admit if still AMS

Holmes, Annals EM, 2011.

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Case #4: Tell me again what

happened to Jane?

18 mo old BIB father

Vomiting x 3 days

“Tripped at daycare” 4 days ago

PE: somnolent

CT by criteria: +SAH!

What do you do?

Neurosurgery

Admit

Child Protective Services (CPS)

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Epidemic: Non-accidental trauma

(NAT) 6-10% of pediatric

trauma: NAT

#1 NAT mortality: head injury

Suspect NAT:

(+) CT: minor/no reported trauma

Delayed presentation

Changing history

Other injuries inconsistent with reported mechanism

Retinal hemorrhages*

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Return to sports post concussion

Grading systems not useful

Stepwise return to play based on sx:

No activity

Light aerobic

Sports specific exercise

Non contact drills

Contact practice

Return to playHalstead, Pediatrics 2010 28

Nutshell: Whom to CT after trauma?

<2 years:

• AMS

• Sx skull fracture

• Non frontal scalp hematoma

• >5 seconds LOC

• Not acting normally per parent

• Severe mechanism

> 2 years:

• AMS

• Sx basilar skull fracture

• Vomiting

• Severe HA

• LOC

• Severe mechanism

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Nutshell (cont):

Whom to admit?:

All TBI*

High risk skull fractures

• Depressed

• Wide diastasis

• Very young

• High energy mechanism

• High bleeding risk

Persistent AMS after observation

Poor social/transport situation

Suspected abuse

Neurosurgery discretion

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