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Management of minor and moderate head trauma in children

Ramona Åstrand MD, PhD

Department of Neurosurgery, Rigshospitalet,

Copenhagen

Scandinavian Neurotrauma Committee (SNC)

Scandinavian Neurotrauma Committee

DNPS 2017 - Ramona Åstrand

Management of minor and moderate head trauma in children

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Nomenclature

• head trauma

• head injury

• cerebral trauma

• traumatic brain injury (TBI)

• clinically important TBI (ciTBI)

• significant intracranial injury (SII)

Department of Neurosurgery

DNPS 2017 - Ramona Åstrand - Management of minor and

moderate head trauma in children


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Incidence rates for TBI in Europe


Peeters et al. 2015. Acta Neurochir DOI 10.1007/s00701-015-2512-7

• Average annual incidence rate (all TBI): 326 per 100.000

• Overall incidence rate (admitted TBIs): 262 per 100.000 per year

550

101

221

350



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Glasgow Coma Score (GCS) scale for

non-verbal children

Modified Head Injury Severity Scale (HISS)

• GCS

• Amnesia or loss of consciousness

• Focal neurology



Severity scales



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Severity of head trauma

• Minimal – mild head trauma (80-90%)

• GCS 14-15

• < 1% with intracranial haematoma

• Moderate head trauma (< 10%)

• GCS 9-13

• 5-10% with intracranial haematoma

• Severe head trauma (5-10%)

• GCS 3-8

• 25-35% with intracranial haematoma





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Mortality and morbidity (head trauma)

• 1% af all deaths

• 15% af deaths among 15-45 years old

• Substantial morbidity

• Post-concussion symptoms

• Young adults/adolescents with permanent brain damage

• The “silent epidemic”

• No immediate visible problems post-trauma

• Underestimation of the incidence

• Unawareness of the impact of TBI





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Injury mechanisms

• Road accidents (21-50%)

• Car

• Cycling

• Pedestrian

• Fall injury (36-51%)

• Sports and other (14%)

• Violence (14%)





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Intracranial injuries

• Acute subdural haematoma

• Epidural haematoma

• Intraparenchymal

haematoma

• Contusions

• Diffuse axonal injury (DAI)

• Subarachnoid haemorrhage

(tSAH)

• Edema

• Ischaemia (dissection)





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Primary to secondary injury

• Diffuse axonal injury

• Continuum from concussion to diffuse axonal injury

• Direct injury on neurons – axons, glia and vascular structures

• Intact blood brain barrier - Normal ICP

• Focal injury

• Development of vasogenic edema

• Disrupted blood brain barrier

• Cerebral ischaemia

• Hypoxia/hypotension

• Elevated ICP

• Vascular lesions





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Head injury guidelines in adults

• 2000 Scandinavian Neurotrauma Committee (SNC) head injury guidelines

• 2000 New Orleans Criteria (>5 yrs)

• 2001 Canadian Head Injury rule (>16 yrs)

• 2002 European Federation of Neurological Societies (EFNS)

• 2003 NICE (>5 yrs)

• 2007 CHIP prediction rule (>15 yrs)

• 2013 SNC revised guidelines (>17 yrs)




Scandinavian (adult) head injury guidelines Scandinavian Neurotrauma Committee, 2000

Ingebrigtsen et al. 2000 DNPS 2017 - Ramona Åstrand - Management of minor and



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Concerns about the increased use of CT


The Nordic radiation protection authorities want to draw attention to the potential risks involved and avert unjustified CT examinations by implementing the “triple A” concept: Awareness, Appropriateness and Audit.



Scandinavian guidelines for initial management of adult patients with minimal, mild and

moderate head injury



Undén et al. BMC Medicine 2013, 11:50


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Pediatric head trauma guidelines



• 1999 American Association of Pediatrics (>2 yrs)

• 2001 Schultzman (AAP) (<2 yrs)

• 2006 CHALICE (Dunning et al) (0-16 yrs)

• 2009 PECARN (Kuppermann et al) (<2 yrs, 2-18 yrs)

• 2016 SNC pediatric head trauma guidelines (<18 yrs)


CHALICE 2006 Head CT if at least 1 criterium fulfilled

History • LOC > 5 min

• Amnesia >5min

• Abnormal drowsiness

• 3 vomits after head injury

• Suspicion of non-accidental injury

• Seizure after head injury

Examination • GCS < 14 or GCS < 15 if <1yr

• Skull injury or tense fontanel

• Signs of basal skull fracture

• Focal neurology

• Bruise, swelling, laceration > 5cm if <1yr

old

Mechanism • High-speed road traffic accident (65 km/h)

• Fall of > 3 m in height

• High-speed injury from a projectile or an object


Rigshospitalet


moderate head trauma in children Dunning et al. Arch. Dis. Child. 2006;91;885-891

CT rate 14%

PECARN 2009

Prediction variables

< 2 yrs (A) • Altered mentalstatus

• Skull fracture (palpable/unclear)

• Scalp haematoma

• temporal/parietal/occipital

• Loss of consciousness

• ≥ 5s

• Mechanism of injury

• severe

• Acting normally per parent

• no

2 yrs (B)

• Altered mentalstatus

• Clinical signs of basilar skull fracture (yes)

• Loss of consciousness

• yes or suspected

• History of vomiting (yes)

• Severe headache

• Mechanism of injury

• severe

14%

27-32%

CT


Rigshospitalet



Kuppermann et al. Lancet 2009; 374: 1160–70

NPV = 99.95%; sensitivity 96.8%


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Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study



• Use of CT scans in children to deliver cumulative doses of about 50 mGy

might almost triple the risk of leukaemia and doses of about 60 mGy (2-3

scans) might triple the risk of brain cancer

• These cancers are relatively rare, the cumulative absolute risks are small:

• in the 10 years after the first scan for patients younger than 10 years, one excess

case of leukaemia and one excess case of brain tumor per 10.000 head CT scans

is estimated to occur

• Clinical benefits should outweigh the small absolute risks


Pearce et al. Lancet 2012; 380: 499–505



Videnskab / 3. apr 2017

Skandinavisk retningslinje for

initial håndtering af minimale,

lette og moderate hovedtraumer

hos børn

Statusartikel

Läkartidningen. 2017;114:EFMZ Nya skandinaviska riktlinjer för

att handlägga skallskador hos

barn

Översikt

2013;110:CEY9

Uppdaterad handläggning av

vuxna med skallskada

SNC:s nya riktlinjer ger

vägledning vid minimal, lätt och

medelsvår skada

Rapport

2016; 136:1512-3

Skandinaviske retningslinjer

for hodeskader hos barn

Kommentar og debatt

2013; 133:2342-3

Nye retningslinjer for

hodeskader

Kommentar og debatt

2014;176:V09130559

Initial håndtering af minimale,

lette og moderate hovedtraumer

hos voksne

Videnskab



http://tidsskriftet.no/kommentardebatt-artikler




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Work process

• CEBM-2

• Evidence grades 1-5

• QUADAS-2

• Study quality, bias and useability

• GRADE – Rating quality of evidence and strength of recommendations

• Evidence: High, moderate, low, very low

• Rekommendations: Strong, weak or none

• Delphi process 1 – 3 (SNC and stakeholders)

• Evaluation of recommendations and guidelines

• Consensus meeting

J Low Risk L High Risk ? Unclear

Risk ?




Risk factors 1. Age (years unless otherwise stated, mo = months)

2. Gender

3. GCS < 15

4. Severity of head injury

5. Altered mental status (Definition according to Kupperman et al.)

6. Abnormal behaviour (according to guardian)

7. Drowsiness/lethargy/irritability/ confusion

8. Amnesia

9. Vomiting

10. Headache

11. Loss of consciousness (LOC)

12. Focal neurology

13. Seizures

14. Skull fractures

15. Scalp hematoma and location

16. Scalp laceration

17. Deterioration

18. Signs of increased intracranial pressure (ICP)

19. Helmet use

20. Intoxication

21. Extracranial injury

22. Vertigo

23. Other symptoms

24. Falls

25. Traffic accidents (MVA=motor vehicle accident)

26. Assault

27. Struck by object/Sports trauma

28. Coagulopathy

29. Shunts

30. S100B


Rigshospitalet





Admission for ≥ 24 h §

and

Immediate

CT

y

e

s

yes

All children < 18 years after minimal, mild and moderate head injury within 24 h of

injury

Mild, high-risk

GCS 14-15 and

• Focal neurological deficit, or

• Post-traumatic seizures, or

• Clinical signs of skull base

fracture or depressed skull

fracture

no

Moderate

GCS 9-13




abnormal

Consider discharge with oral and written instructions

for guardians

All children < 18 years after minimal, mild and moderate head injury within 24 h of injury

normal

Observation ≥ 12 h

Alternatively do a CT scan

yes

Mild, medium-risk

GCS 14 or

-------------------

GCS 15

and

• LOC ≥1 min, or

• Anticoagulation medication or

coagulation disorder

no

and

Immediate

CT

y

e

s

ye

s

Mild, high-risk

GCS 14-15 and

• Focal neurological

deficit, or

• Post-traumatic

seizures, or

• Clinical signs of skull

base fracture or

depressed skull

fracture

no

Moderate

GCS 9-13



Mild, low-risk

GCS 15 and

• Post-traumatic amnesia, or

• Severe/ progressive headache, or

• Abnormal behaviour according to

guardian, or

• Repeated vomiting, or

• Suspected/ brief LOC, or

• Shunt, or

• If age < 2 years:

• large, temporal or parietal

scalp hematoma or

• irritability


Consider discharge with oral and written

instructions for guardians

All children < 18 years after minimal, mild and moderate head

injury within 24 h of injury

normal

Observation ≥ 6 h

If multiple risk factors, consider doing a CT

scan

yes

See help sheet for

explanations and further

details.

no

abnormal and

Immediate

CT

y

e

s

yes

normal

Observation ≥ 12 h

Alternatively do a CT scan

yes

Mild, medium-risk

GCS 14 or

-------------------

GCS 15

and

• LOC >1 min, or

• Anticoagulation or

coagulation

disorder

no

Mild, high-risk

GCS 14-15 and

• Focal neurological

deficit, or

• Post-traumatic

seizures, or

• Clinical signs of skull

base fracture or

depressed skull

fracture

no

Moderate

GCS 9-13

Do a CT or repeat CT if clinical deterioration or

fall in GCS points ≥ 2

§ Consider neurosurgical consultation




Consider discharge with oral and written

instructions for guardians

All children < 18 years after minimal, mild and moderate head

injury within 24 h of injury

See help sheet for

explanations and further

details.

y

e

s

Minimal

GCS 15

And none of the

previous risk factors

no


abnormal an

d

Immediate

CT

y

e

s

ye

s

normal normal

Observation ≥ 12

h

Alternatively do a CT

scan

y

e

s

Observation ≥ 6

h

ye

s

Mild, low-risk

GCS 15 and

• Post-traumatic amnesia,

or

• Severe/ progressive

headache, or

• Abnormal behaviour

according to guardian,

or

• Vomiting ≥ 2 times, or

• Suspected/ brief LOC,

or

• Shunt, or

• If age < 2 years: large,

temporal or parietal

scalp hematoma or

irritability

no

Mild, medium-

risk

GCS 14 or

-------------------

GCS 15

and

• LOC >1 min, or

• Anticoagulation

or coagulation

disorder

no

Mild, high-risk

GCS 14-15 and

• Focal

neurological

deficit, or

• Post-traumatic

seizures, or

• Clinical signs of

skull base

fracture or

depressed skull

fracture

no

Moderate

GCS 9-

13

CT or repeat CT if clinical deterioration

or fall in GCS ≥ 2 points.

§ Consider neurosurgical consultation

NB! Some may need admission for other reasons

than the head injury

Suspiscion of abusive head trauma / non-accidental

head inury

Bulging or tense fontanel

High-velocity injury mechanism

Consider admitting all children < 1 year of age with

head injury, regardless of symptoms



NB!

• Observation time is measured from the “time of trauma”

• Do a CT or repeat CT if clinical deterioration or fall in GCS points ≥ 2



In-hospital observation

Symptomatic

• every 15 minutes the first 4 hrs

AFTER the time of trauma,

• every 30 minutes the following 4 hrs,

and

• minimum 1 time hourly thereafter

Asymptomatic

• Once hourly

• Level of consiousness (GCS)

• Simple neurological status (normal movement in arms and legs, normal language/speech)

• Pulse

• Children < 2 years: palpation of fontanel

Extra observation:

• Size of pupils and reaction to light

• Intensity of headache

Minimum observation

In general: do not leave the child alone, without supervision



Parental information at early discharge

• Check your child every 4 hrs the first night

• Does he or she seem to be breathing normally?

• Is he or she sleeping in a normal posture?

• Does he or she react as expected to gentle touch?

If not, wake the child to check more thoroughly if he/she is OK

• Sports activities should not be resumed before your child is

without symptoms at rest, and it should be gradually

increased over a period of 1 week.

• Contact information to the emergency department




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Recommendations



• Standards

• Usually based on RCTs, class I evidence or

• Well designed non-RCTs, class II evidence

• Guidelines

• usually based on class III evidence or

• at best, some class II evidence

• Options

• usually based on class III evidence

• educational purposes


Guidelines

• The guidelines are primarily intended as guidance for

physicians who meet this patient category and who are

not experts in this field

• Physicians who have considerable experience with

these patients should naturally be allowed to deviate

from these guidelines according to best clinical

judgement.




Rigshospitalet


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Markers for brain damage


S100B

NSE

MBP

GFAP

spectrin IL-6, IL-8

tau

Ubiquitin C




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S100B reference levels in children


Astrand et al. Clinica Chimica Acta 412 (2011) 2190–2193




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S100B reference levels in infants and children


0-3 yrs

>3 yrs



Castellani et al. Clin Chem Lab Med 2008;46(9):1296–1299

Bouvier et al. Clinical Biochemistry 44 (2011) 927–929

• 446 patients

• <16 yrs old, head trauma, GCS 3-15 (Masters 1-3)

• M1: minimal, GCS 15

• M2: mild, GCS 13-15 + 1 risk factor

• M3: severe, GCS <13

• S100B < 3 hrs after trauma

• CTc in some

Validation study – SHIPP study



Validation study part I

Aim

• To determine the classification performance (accuracy) of the guidelines when applied prospectively (Validation)

• To determine the potential factors for refinement of the guidelines

• To determine the clinical usefulness of the guidelines (physicians’ comfort and ease of using the guidelines)

Inclusion

• Children < 18 yrs old

• Admitted within 24h after head trauma

• GCS 9-15 on admission

• Written parental accept or patient accept if the child is 15-17 years old



Validation study, part II – Serum S100B

• Starts when the part I is up and running

• Includes children with minor head trauma only

• Serum sampling of S100B/biobank sampling is done in the ED after parental/guardian

consent

• Blood is drawn within 12 hours after trauma

• Venous blood (3 ml), stored as two or more aliquots at -80 ◦C until analysis

• Analysis in batches – once a year



Thank you for your attention!

[email protected]

SNC: www.neurotrauma.nu



mailto:[email protected]

Documents

Management of minor and moderate head trauma in childrendnps.dk/wp-content/uploads/2017/01/Aastrand-Management-head-tr… · (head trauma) •1% af all deaths •15% af deaths among