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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
Palchak (#1)Palchak (#1)
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
Palchak (#1)Palchak (#1)
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
Palchak (#1)Palchak (#1)
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
Palchak (#1)Palchak (#1)
Decision tree
for predicting
intervention
Palchak (#1)Palchak (#1)
Decision tree
for predicting
+CT with
GCS 14-15
Palchak (#1)Palchak (#1)
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
Palchak (#2)Palchak (#2)
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
Palchak (#2)Palchak (#2)
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.
Palchak (#2)Palchak (#2)
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!!