pediatric head trauma: part ii joshua rocker, md pediatric emergency medicine schneider children’s...

Pediatric Head Trauma:Pediatric Head Trauma:Part II Part II

Joshua Rocker, MD

Pediatric Emergency Medicine

Schneider Children’s Hospital

OutlineOutline

DefinitionsEpidemiologyEvaluationEvidenceSummary

DefinitionsDefinitions Traumatic Brain Injury

– Any blow or jolt to the head or acceleration/ deceleration of the head which may cause an injury

Closed Head Injury– An example of a TBI without any penetrating injury

into the brain

Minor Closed Head TraumaMinor Closed Head TraumaAn example of a Closed Head Injury

with:– Normal mental status– Normal neurological exam– Normal fundoscopic exam– No physical signs of skull fracture

“Mgmt of minor closed head injury in children.” Committee on QI, AAP, Commission on Clinical Policies & Research, AAFP. Pediatrics 1999

Epidemiology of Pediatric Epidemiology of Pediatric Head InjuryHead Injury

Children’s Health Act of 2000Children’s Health Act of 2000

Big financial backing by Congress for research in pediatrics.

Mandated the CDC to report on incidence and prevalence of traumatic brain injuries.

Head Injuries: The numbers!Head Injuries: The numbers!Trauma- #1 cause of mortality and

morbidity > 6 mo.

Head injury is the #1 cause of death in these traumas

Traumatic Brain Injury- all Traumatic Brain Injury- all agesages

1.4 million in the US per year– 835,000 - male– 561,000 - female

50,000 deaths235,000 hospitalizations1.1 million treated and discharged from

ER

National Center for Injury Prevention and Control, CDC, 1995-2000

Pediatric TBIPediatric TBI2,685 deaths 37,000 hospitalizations435,000 emergency department visits

(Langlois et al. 2004). Approximately 75% of TBIs that occur

each year are concussions or other forms of mild TBI. (CDC 2003).

Head Injuries: the differencesHead Injuries: the differencesAge:

Infants- fall or non-accidental

vs.

Adolescent- sports, MVAs

Sex:

males : females (2-4:1)

EvaluationEvaluation

MCHI: EvaluationMCHI: Evaluation

ABC’sStabilize cervical spine if necessarySecondary surveyStabilize other injuries if necessary

Obtain appropriate HPI and PMH

EvaluationEvaluation

IMAGE!!!???– CT– Skull X-ray– MRI

Observe??????????????????????????

ConsiderationsConsiderations

Prevalence of TBIThe % that need interventionEfficacy of treatmentPoor outcome if delay diagnosis

andRisk associated with imaging

Risks of ImagingRisks of Imaging

Head CT approx 150-600x more radiation exposure then a CXR.

Brenner, et al, determined the estimated lifetime cancer mortality risks attributed to the radiation exposure from a single head CT in a one year old is 0.07% (1 in 1400)

Brenner, DJ, Elliston, CD, Hall, EJ, and Berdon, WE. Estimated Risks of Radiation-Induced Fatal Cancer from Pediatric CT. American Journal of Roentgenology. 2001. 176: 289-296.

Risk of imagingRisk of imaging

Risk of sedation, if needed

Risk of pursuing false positive

The EvidenceThe Evidence

Show me the money!!!

AAP GuidelinesAAP Guidelines

Technical Report: Minor Head Injury in Children

Pediatrics, Dec. 1999 Conclusion- “The literature on mild head

trauma does not provide a sufficient scientific basis for evidence-based recommendations about most of the key issues in the clinical management.”

ProblemsProblems

There were no large pediatric trauma studies which address the major management issues in minor head trauma

Most were small and retrospective

AAP GuidelinesAAP Guidelines

The Management of Minor Closed Head Injury in Children

Pediatrics Dec, 1999Literature Review- 64 articles Inclusion:

– 2-20 y/o– Isolated minor head trauma

AAP Guidelines: Case 1AAP Guidelines: Case 1

MCHI and no LOC– Obtain thorough history and physical– Observation in clinic, office, ER or home

Reliability of family essential for dispo

– No radiological studies recommended

(Remember: MCHI= nl mental status, nl neurological exam, nl fundoscopic exam, no physical signs of skull fracture)

AAP Guidelines: Case 2 AAP Guidelines: Case 2

MCHI with brief LOC (<1 min)– Thorough history and physical– Observation optional– CT optional– Skull radiographs not recommended

DataData

Wide variability of inclusion criteria of studies.

Children with hx of LOC, amnesia, HA or vomiting at time of evaluation have a 0-7% prevelance of ICI.

2-5% of children with MCHI with LOC may require neurosurgical intervention.

DataData

Limited predictive value of HA, vomiting or lethargy.

Conflicting data on the urgency for diagnosis subdural or epidural.

DataData

Point:

no real consistency in evidence.

Evidence: Baseline to Evidence: Baseline to comparecompare

Masters SJ, et al. Skull radiograph examinations after head trauma: N Engl J Med 1987; 316:84-91

Prospective study 7035 patients- from 31 ERs 5252 categorized as low risk for ICI

– asymptomatic or with one or more of the following: HA, dizziness, scalp hematoma, lac, contusion or abrasion.

– No LOC. 0 had ICI Conclusion: Radiographic studies in low risk patients can be

avoided.

Evidence in PediatricsEvidence in Pediatrics

No large prospective studies: Limited data.

Dietrich, et al, Ann Emer Med, 1993 322 consecutive head CTs on trauma patients

– 5% of patients with GCS of 15 had evidence of ICI– Loss of consciousness, amnesia for the event, a Glasgow

Coma Scale (GCS) of less than 15, or the presence of a neurologic deficit were more common in children with intracranial injury (P < .05).

– Vomiting, seizures, and headache were not discriminating clinical features.

– No single characteristic consistently identified the children with an intracranial injury

Evidence in PediatricsEvidence in Pediatrics Dacey, RG, et al, J Neurosurg, 1986

– 610 children with NCHI with GCS >12 11% had skull fractures 3% required NS intervention 2 pts (0.3%) of the patients with GCS of 15 with nl skull Xray required

NS

Hennes, et al, Am J Dis Child, 1988– 55 patients

3 with moderate injury and 8 with mild injury= all with normal CT

Chen, et al, Neurosur, 1993– 74 patients with epidurals and a GCS >11

After the 3-day period, in the absence of neurological symptoms, the presence of the EDH may not be an indication for surgical evacuation or hospitalization beyond 7 days

More StudiesMore Studies

Dunning, et alDunning, et al

A meta-analysis of variables that predict significant injury in minor head trauma

Archives of Disease in Childhood, 2003

16 studies pooled22,420 patients

DunningDunning

Increased relative risk of ICI:– Reduced level of

consciousness (5.5)– Focal neuro deficit

(9.4)– Skull fracture (6.1)– LOC (2.2)

No increased risk of ICI (less reliable data)– HA– Seizure– Vomiting

Palchak, et al (#1)Palchak, et al (#1)

A Decision Rule for Identifying Children at Low Risk for Brain Injuries After Blunt Head Trauma

Annals of Emerg Med, Oct, 2003

University of California, Davis

Palchak #1Palchak #1

Prospective- 3 year study<18 y/oAll severitiesExcluded trivial traumas

– Fall from ground level– Walking/running into stationary objects if

only PE is scalp lac/abrasion.

Palchak (#1)Palchak (#1)

Outcome variables:– TBI on CT– TBI requiring acute intervention


2,640 eligible, 2043 (77%) enrolledMean age- 8.3CT scans on 1271 (62.2%)98 (7.7%) with TBI on CT75/98 required intervention (76.5%)29 (27.6%) of the patients with TBI

requiring acute intervention didn’t have +CT for TBI


Predictor variable– Amnesia– LOC– HA– Sz– Vomiting– Clinical SF– Focal ND– Scalp hematoma <2– AMS

Relative Risk of +CT– 2.1– 2.6– 1.5– 2.4– 2.3– 5.5– 5.3– 2.6– 6.8


Predictor variable– Amnesia– LOC– HA– Sz– Vomiting– Clinical SF– Focal ND– Scalp hematoma <2– AMS

RR of acute intervent– 4.7– 7.6– 4.5– 5.3– 3.5– 11.3– 10.6– 1.2– 21.7

Palchak (#1)Palchak (#1) Decision tree

for predicting

+CT


Decision tree

for predicting

intervention


Decision tree

for predicting

+CT with

GCS 14-15


Decision tree

for predicting

+CT in

children <2

Palchak, et al (#2)Palchak, et al (#2)

Does an Isolated History of LOC or Amnesia Predict Brain Injuries in Children After Blunt Head Trauma?

PEDIATRICS, June 2004University of California, Davis


2043 patients in ER for trauma eval over a 3 year period (same data set)– <18 y/o, mean 8.3 yrs

62% underwent CT7.7% with CT + for TBI

– 23% of that 7.7% did not require intervention

42% with hx of LOC and/or amnesia


Risk of TBI increased if LOC – (3.7% v 9.7%)

Risk of TBI with LOC or amnesia and absence of other findings was ZERO.

Follow up in 88%- no patients had missed TBI.


Conclusion:– LOC and amnesia in isolation appear to

carry no more risk of +CT or of requiring intervention.

– Recommendation to eliminate isolated LOC and/or amnesia as indications for CT in pediatric trauma patients

Schutzman, et alSchutzman, et al

Evaluation and Management of Children Younger than Two Years Old with Apparently Minor Head Trauma: Proposed Guidelines.

Pediatrics, 2001

Used evidence and expert consensus

SchutzmanSchutzman

Question #1: Indications for CT?– Incidence of ICI is 3-6%, with higher incidence in

the younger children.– Clinical predictors:

AMS, focal neuro deficit, scalp swelling, young age, inflicted injury and head injury no clear hx of trauma

LOC and vomiting not risk factors

– Occult ICI more prevalent in 0-6 month range

SchutzmanSchutzman

Question #2 : Indications for skull films? – Skull fractures one of the strongest

predictors for ICI– The incidence of scalp hematoma is 80-

100% sensitive for associated SF. Question #3: If fracture present should

CT be obtained?– If SF present ICI in 15-30%.

SchutzmanSchutzman

Question #4: If CT normal, dispo?– In 3 studies including 261 patients 0 had

late deterioration.Question #5: If SF but normal CT,

dispo?– In 6 studies including 349 patients 0 had

late deterioration.

Schutzman: Schutzman: Management StrategyManagement Strategy

Stratify patients into 4 groups– High risk– Some risk because of concerning

symptoms– Some risk without symptoms– Low risk

SchutzmanSchutzman

High risk– CT indicated!– Qualifications:

AMS, focal neuro deficit, signs of depressed of basilar SF, evidence of SF, irritability, bulging fontanel,

LOC >1min and vomiting >5 times or lasting longer than 6 hours (but not evidence based)

(maintain a low threshold for children <3 months)

SchutzmanSchutzman

Intermediate Risk– Group 1

CT/observation– Qualifications

• 3-4 episodes of vomiting

• Transient LOC (<1 min)

• Hx of lethargy or irritability

• Behavior not baseline

• Nonacute SF (>24 hrs old

Intermediate Risk– Group 2 (Unknown or

concerning mechanism) CT/SR

– Qualifications• Higher force

mechanism• Fall onto hard

surface• Scalp hematoma• Suspect

intentional injury

SchutzmanSchutzman

Intermediate Risk– Dispo

If CT negative Observed for 4-6 hours post-injury and no

concerning symptoms

SchutzmanSchutzman

Low Risk – Observation

Minimal mechanism

HEY!!!!!!!!!!!HEY!!!!!!!!!!!

Just one more study so…..

wake up!!!

Roddy, et alRoddy, et al

Minimal Head Trauma in Children Revisited: Is Routine Hospitalization Required

PEDIATRICS, April 1998

Yale-New Haven Hospital

RoddyRoddy Methods:

– Retrospective review over 3 years 1992-1995– N-267…188 (GCS-15) … 62 (all criteria)

– Inclusion: Admitted for trauma with: 0-16 y/o Had LOC or amnesia An initial Glasgow Coma Scale of 15 a normal neurologic exam a normal head CT scan

– Exclusion: Children with associated injuries requiring admission

RoddyRoddy

– Endpoint: Deterioration in CNS exam new CT findings The need for a prolonged hospital stay

RoddyRoddy

Results:– The mean length of stay was 1.2 days

(range, 1 to 3 days). Prolonged hospitalization occurred in 9 patients (15%). No child developed significant CNS sequelae warranting hospital admission.

– The average patient charge was $2869 per hospital stay. Total charges for these hospitalizations were $177 874.

RoddyRoddy

Conclusion: Children undergoing emergency

department work-up of occult head injury, who have a normal CNS exam and a normal head CT scan, do not seem to be at risk for significant CNS sequelae.

SUMMARYSUMMARY

Very difficult decision!!!

No clear guidelines established by the AAP

More larger studies need to be produced in pediatrics

SUMMARYSUMMARY

KEY POINTS– AMS, focal neuro deficits and skull fractures very

concerning.– HA, sz and vomiting alone less concerning– LOC and amnesia alone may be insignificant– With children under the age of 2 years (especially

under 6 months) one should be conservative– If CT -, minimal risk for neuro sequele.

Confused? Questions?Confused? Questions?

Thank YouThank You

Applaud now!!

pediatric head trauma: part ii joshua rocker, md pediatric emergency medicine schneider children’s...

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