Evidence-Based Management of Pediatric Head Trauma
Mariann Nocera, MD
Siraj Amanullah, MD, MPH
November 13, 2014
Discuss the types and mechanisms of blunt head trauma in children
Discuss the management of blunt head trauma in children
Evaluate the evidence behind the management of pediatric blunt head trauma
Objectives
Trauma is the leading cause of death in children >1 year
TBI is the leading cause of trauma-related death
>600,000 ED visits annually
60,000 hospitalizations
6,000 deaths
Pediatric Head Trauma
http://www.cdc.gov/traumaticbraininjury/data/index.html
Assessing and managing a patient
with head trauma
Standard GCS
Eye Opening
4 Spontaneous
3 To verbal stimuli
2 To pain
1 None
Pediatric GCS
Eye Opening
4 Spontaneous
3 To speech
2 To pain
1 None
Glasgow Coma Scale
J Trauma Acute Care Surg.
Standard GCS
Best Verbal Response
5 Oriented
4 Confused
3 Inappropriate words
2 Incomprehensible sounds
1 None
Pediatric GCS
Best Verbal Response
5 Coos, babbles
4 Irritable, cries
3 Cries to pain
2 Moans to pain
1 None
Glasgow Coma Scale
J Trauma Acute Care Surg.
Standard GCS
Best Motor Response
6 Follows commands
5 Localizes pain
4 Withdraws to pain
3 Flexion to pain
2 Extension to pain
1 None
Pediatric GCS
Best Motor Response
6 Normal spontaneous moves
5 Withdraws to touch
4 Withdraws to pain
3 Abnormal flexion
2 Abnormal extension
1 None
Glasgow Coma Scale
J Trauma Acute Care Surg.
Management: Airway
Intracranial pressure
Normal hemodynamic status
Seizure prophylaxis
Appropriate radiological investigations
Hospitalization
Severe / Moderate Head Injury
Severe Moderate Minor
GCS 3 8 9 12 13 15
97 % of patients seen in ED with blunt head trauma
Risk of TBI 0-7 % if GCS is 15
<1 % require surgery
Classifications of Head Injuries
J Trauma Acute Care Surg.
???
Severe Moderate Minor
GCS 3 8 9 12 13 15
GCS Risk of TBI
15 ~2-3%
14 ~7-8%
13 ~25%
Risk of TBI
Indications of Head Imaging - Hasbro Blunt Head Injury
GCS ≤14 or AMS, palpable skull fracture, focal neurologic findings
CT Recommended
History of LOC History of vomiting Significant headache Concerning mechanism Behavioral changes (esp <2 years) Scalp hematoma (<2 years)
Observation Consider CT based on: - Worsening signs or symptoms - Clinical judgment
CT not recommended
No
No
Yes
Yes
Clinically-important traumatic brain injury
Goal: Identify low-risk patients with GCS 15 who do not need to have head CT, not to identify patients for whom CT scans should be obtained.
PECARN Clinically-important TBI
Death from TBI
Neurosurgical intervention
Intubation ≥24 hours for TBI
Hospital admission ≥2 nights for TBI in association with TBI on CT
ciTBI: 0.9 %
Definition of clinically important TBI
<2 years
Altered mental status
Scalp hematoma
Loss of consciousness
Mechanism of injury
Skull fracture
Acting normally per parent
≥2 years
Altered mental status
Loss of consciousness
Vomiting
Basilar skull fracture
Mechanism of injury
Severe headache
Prediction Rule
MVC with patient ejection, death of another passenger, rollover
Pedestrian or bicyclist without helmet struck by a motorized vehicle
Falls more than 3 feet < 2 years or more than 5 feet ≥ 2 years
Head struck by a high-impact object
Severe mechanism of injury
< 2 years of age
≥ 2 years of age
Online Tool
http://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm/
< 2 years
Altered mental status
Scalp hematoma
Loss of consciousness
Mechanism of injury
Skull fracture
Acting normally per parent
≥ 2 years
Altered mental status
Loss of consciousness
Vomiting
Basilar skull fracture
Mechanism of injury
Severe headache
Prediction Rule
ciTBI with non-isolated vomiting: 2.5 %
ciTBI with isolated vomiting : 0.2 %
Isolated vomiting
ciTBI with no LOC: 0.5 %
ciTBI with any LOC: 2.5 %
ciTBI with isolated LOC: 0.5 %
Isolated loss of consciousness
ciTBI with isolated severe mechanism , <2 years: 0.3 %
ciTBI with isolated severe mechanism , ≥2 years: 0.5 %
Isolated severe injury mechanism
ciTBI with isolated scalp hematoma: 0.4 %
<6 months more at risk < 3 months with any scalp hematomas
Older infants with larger temporal or parietal scalp hematomas
Isolated scalp hematoma (<2 years)
ciTBI with isolated headache: “very low”
Isolated headache
Intracranial pathology in patients with basilar skull fracture: 21 %
Isolated basilar skull fracture
TBI is the most common cause of death and disability among pediatric trauma patients
Most children do not have a clinically-important traumatic brain injury
Low-risk criteria have been validated to help manage patients and identify those who DO NOT need head CT
Summary
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Injury Prevention & Control: Traumatic Brain Injury. Centers for Disease Control and Prevention. http://www.cdc.gov/traumaticbraininjury/data/index.html. Accessed 10.15.2014
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References