Peds symposium pediatric head trauma 2011 -howard final

Management of Pediatric Head Trauma in the Emergency Department: Intracranial and Other Issues

John M. Howard, DOAssistant Director, Emergikids

Alexian Brothers Hospital NetworkApril 16, 2011

Wednesday, April 20, 2011

Disclosure

• I have had no relevant financial relationships with any proprietary entities producing health care goods or services in the past 12 months

Objectives

• Discuss emergency department recognition of intracranial injury via history and physical exam

Objectives

• Discuss indications for neuroimaging

Objectives

• Discuss indications for neuroimaging

• Review management of head trauma cases in the ED: vital sign stabilization, maintenance of respiratory and circulatory parameters, preparation for neurosurgical intervention

WELCOME TO EMERGIKIDS

ROOM A

CC: UNRESPONSIVE, POOR RESP

ROOM A

HPI: 7 MO FELL OFF BED EARLIER IN DAY ~1.5 FT,

ROOM A

“DIDN’T HIT HEAD,” NO LOC, “RECENTLY STARTED CRAWLING”

ROOM A

“DIDN’T HIT HEAD,” NO LOC, “RECENTLY STARTED CRAWLING”

WAS “FINE” EARLIER IN THE DAY...

ROOM B

ROOM BC/C: MVC

HPI: 3 YR MALE IN CARSEAT WITH SNOWBLOWER IN ADJACENT SEAT

ROOM BC/C: MVC

T-BONED BY ONCOMING CAR, LAUNCHING SNOWBLOWER INTO PT

ROOM BC/C: MVC

SLEEPY, BUT AROUSES TO VOICE

ROOM BC/C: MVC

EAR LACERATION EXTENDING IN TO EAC, HEMORRHAGIC OTORRHEA

ROOM BC/C: MVC

EAR LACERATION EXTENDING IN TO EAC, HEMORRHAGIC OTORRHEA

Introduction

• What is the leading cause of death in children and adolescents in US?

Introduction

• What % of these are due to traumatic brain injuries (TBI)? (40%)

Introduction

• What % of these are due to traumatic brain injuries (TBI)? (40%)

• Remember! These are often associated with cervical spine injuries

Introduction

• Goals:

Introduction

• Goals:

• Identify and stabilize pts with TBI

Introduction

• Goals:

• Minimize factors that contribute to secondary brain injury

Introduction

• Goals:

• Hypoxia

Introduction

• Goals:

• Hypoxia

• Hypotension

Definitions

• Defined by GCS

Mild (Concussion) 13-15*

Moderate 9-12

Severe <9

Definitions

Definitions• *Minor head trauma

(GCS 15):

• Chidren < 2 yrs: H+P blunt trauma to scalp/skull/brain and is alert to voice/touch

(GCS 15):

• Chidren < 2 yrs: H+P blunt trauma to scalp/skull/brain and is alert to voice/touch

• Children >/= 2 yrs: normal MS on initial exam, no focal neuro findings, no exam findings for skull fx

Definitions

• Mild Traumatic Brain Injury (GCS 13-15): brief LOC, disorientation, vomiting

Definitions

• Concussion: Trauma-induced disturbance of neuro fxn and MS, +/- LOC.

Definitions

• Concussion: Trauma-induced disturbance of neuro fxn and MS, +/- LOC.

• Associated sx’s: HA, vomiting, amnesia, AMS

Epidemiology

• Children 0-14 years in US, TBI accounts for:

Epidemiology

• 475,000 ED visits/yr

Epidemiology

• 50,000 hospital admissions/yr < 17 yrs(2000)

Epidemiology

• 29% < 4 yrs old

Epidemiology

• 29% < 4 yrs old

• 52% 10-17 yrs old

Epidemiology

Epidemiology • In developed countries: TBI most common

cause of death and disability in childhood

• 3,000 children die each year in US from head injuries

• Overall mortality among children with TBI seen in ED or requiring hospitalization

• 4.5%

• 10.4% adults

Epidemiology: Mechanism

• Falls

• MVC

• Pedestrian/bicycle accidents

• Projectiles

• Assaults

• Sports-related

• Inflicted head injuries

• Unknown?

Epidemiology

• Highest morbidity/mortality:

Epidemiology

• < 4 yrs

Epidemiology

• < 4 yrs

• Low GCS initially

Epidemiology

• < 4 yrs

• Coagulopathy

Epidemiology

• < 4 yrs

• Coagulopathy

• Hyperglycemia

Epidemiology

• < 4 yrs

• Coagulopathy

• Hyperglycemia

• Hypotension

Incidence

Incidence• True incidence: ...?

• > 2 yrs w/ minor head trauma + normal neuro exam

• 3-7% with intracranial injury (ICI)

• < 2 yrs w/ minor head trauma + normal neuro exam

• 3-10% with ICI

• Many of these pts have no clinical symptoms

• 3-10% with ICI

• Many of these pts have no clinical symptoms

• Most have scalp hematomas

Clinical Features

Symptom Percentage Comment

LOC 5% (< 2), 13% (>2)Longer duration of

LOC assoc with CITBI*

HA 45% Preverbal children = irritable

Vomiting 14% Assoc w/ slight risk of TBI

Sz 0.6% Smaller studies report larger %

Skull Fx 15-30% Mostly linear when assoc w/ ICI

*Clinically Important TBI

Clinical Features

• Scalp hematomas:

Clinical Features

• When < 1 yr, large size or location (parietal or temporal) may be assoc w/ fx

Clinical Features

• Others:

Clinical Features

• Others:

• Transient cortical blindness or confusional states

Types of Brain Injury

• Diffuse brain injury (DBI): most common type of severe TBI

• acceleration or deceleration

• mildest form = Concussion

• Diffuse axonal injury (DAI): more severe form

• Tissue shearing at interface of grey-white matter

• Associated with focal injuries:

• Cerebral Contusions

• Intracranial Hemorrhage

http://www.braininjury.com/children.html

• Focal injuries: Cerebral contusion:

• Usually due to acceleration/deceleration injury

• Coup, contracoup, or both

• Focal injuries: Intracranial hemorrhage

• Epidermal hematoma: arise from middle meningeal artery or others

• Subdural hematoma: rupture of bridging veins

• Subarachnoid hematoma: tearing of small vessels in pia mater

Associated Injuries

• Multiple trauma

• Cervical spine injury

Pathophysiology

• Two insult model:

Pathophysiology

• Primary event--direct injury to brain parenchyma

Pathophysiology

• Impaired Autoregulation -->

Pathophysiology

• Cerebral hypoperfusion -->

Pathophysiology

• increased metabolic demand...

Pathophysiology

• increased metabolic demand...

• Secondary event--result of exogenous insults: hypoxia and hypotension

Evaluation

• Prompt recognition: Interventions, Follow up, Neuroimaging

Evaluation

• Emergent stabilization

Evaluation

• Primary survey: A, B, C’s, and identification of life-threatening conditions

Evaluation

• Primary survey: A, B, C’s, and identification of life-threatening conditions

• Secondary survey: Head-to-toe exam with thorough neurological evaluation

Evaluation: History

• Obvious vs. Subtle:

Evaluation: History

• Prolonged LOC or AMS

Evaluation: History

• Persistent vomiting

Evaluation: History

• Severe HA

Evaluation: History

• Severe HA

• Progression of symptoms

Evaluation: History

• Severe HA

• Progression of symptoms

• Occult: Inflicted head injury

Evaluation: Physical Exam

• General assessment

• Vitals + Pulseox:

• Hypoxia, hypotension

• Irregular respirations, bradycardia, hypertension...

• Cervical spine immobilization!

• Calculation of GCS!

• Scalp abnormalities: AF, hematoma, depression?

• Basilar skull fx? periorbital ecchymosis, Battle’s sign, hemotympanum, CSF otorrhea/rhinorrhea

Evaluation: Physical

• Focused neuro exam: LOC, pupils, EOM, fundoscopic eval, brainstem reflexes (gag, cornea), DTR’s, response to pain?

• Any Abnormalities noted may signal in increase in ICP or possible herniation...!

Herniation

• Signs of herniation:

• Uncal herniation --> CN III palsy --> hemiplegia

• Changes in respiratory patterns, pupil size, vestibuloocular reflexes, posture

• Cushing’s triad

Evaluation: Laboratory Studies

• Trauma labs: Hct, Type + Screen, UA

• Blood glucose*, serum electrolytes, osmolarity

• Coagulation studies*

• * = abnormality associated with poor outcome in TBI

Evaluation: Imaging

• Mild TBI: Skull radiographs for:

• Unclear hx,

• R/O FB,

• Screen for fx in asymptomatic pts 3-24 mos with scalp hematomas

Medline ® Abstract for Reference 39of 'Minor head trauma in infants and children'

TISkull radiograph interpretation of children younger than two years: how good are pediatric emergency physicians?AUChung S, Schamban N, Wypij D, Cleveland R, Schutzman SASOAnn Emerg Med. 2004;43(6):718. STUDY OBJECTIVE: We determine pediatric emergency physicians' accuracy in interpreting skull radiographs of children younger than 2 years and determine the characteristics of misidentified skull radiographs.METHODS: A set of 31 skull radiographs (16 with fractures, 15 normal) was compiled from children younger than 2 years who were evaluated for head trauma in a pediatric emergency department from March 3, 1997, to March 3, 1998. A pediatric radiologist reinterpreted the films and agreed with all of the original readings in the final set. Participants (attending level physicians) were asked to identify the presence, location, and pattern of any fracture. Skull radiograph interpretation was considered radiographically correct if the presence, location, and pattern of fracture were correctly identified and was considered diagnostically correct if the presence of a fracture was recognized.RESULTS: Twenty-five of 26 eligible pediatric emergency physicians completed the study. The mean of each participant's radiographically correct interpretation was 65%+/-10% (mean+/-SD), and diagnostically correct interpretation was 80%+/-9%. The group's mean sensitivity for diagnostically correct interpretation was 76%+/-15%, and specificity was 84%+/-14%. Shorter fractures were identified correctly less often (63%<or =5 cm versus 93%>5 cm; mean difference 30%; 95% confidence interval 21% to 39%). Diagnostically correct rates did not differ according to age of patient, physician practice location, years in practice, or practice in ordering skull radiographs.CONCLUSION: Pediatric emergency physicians have limited accuracy in interpreting skull radiographs of children younger than 2 years. Shorter fractures are more commonly misinterpreted.ADDivision of Emergency Medicine, Children's Hospital, Harvard Medical School, Boston, MA 02115, USA. sarita.chung@tch.harvard.eduPMID15159702

Evaluation: Imaging

• Head CT preferred initial modality for children with severe TBI

Evaluation: Imaging

• By definition, all children with moderate to severe TBI have an abnormal neuro evaluation and should have head CT

Evaluation: Imaging

• By definition, all children with moderate to severe TBI have an abnormal neuro evaluation and should have head CT

• Imaging for mild TBI is more complex...

THE CT DEBATE...Wednesday, April 20, 2011

Evaluation: Imaging

• Increased use of CT in US

Evaluation: Imaging

• 13% to 22% b/t 1995 and 2003

Evaluation: Imaging

• 13% to 22% b/t 1995 and 2003

• Goal: eliminate pediatric pts receiving head CT in minor head trauma

Evaluation: Imaging

• 13% to 22% b/t 1995 and 2003

• More likely to occur in community hospitals

Evaluation: Imaging

• 13% to 22% b/t 1995 and 2003

• More likely to occur in community hospitals

• Rare, significant injuries vs risks of CT

Evaluation: Imaging

• Lifetime risk for cancer in pediatric pts with head CT? (1:1500 HEAD CT)

Evaluation: Imaging

• Worse for children vs. adults

Evaluation: Imaging

• Longer subsequent lifetime

Evaluation: Imaging

• Greater sensitivity to radiation in some developing organs

Evaluation: Imaging

• Greater sensitivity to radiation in some developing organs

• Sedation issues

Evaluation: Imaging

• Goal: identify pts with clinically important TBI:

• neurosurgery,

• ET intubation > 24 hrs,

• hospitalized > 2 days

Evaluation: Imaging

• Predictors of Intracranial Injury (ICI)

Evaluation: Imaging

• Consistent: skull fx, focal neuro deficit, depressed MS

Evaluation: Imaging

• Consistent: skull fx, focal neuro deficit, depressed MS

• Variable: sz, LOC, amnesia, vomiting, < 2 yrs, trauma mechanism, scalp swelling (pt < 1yr), HA

FOCUS! 2 MOST IMPORTANT

SLIDES AHEAD!

FOCUS! 2 MOST IMPORTANT

SLIDES AHEAD!

Management: TBI

Management: Airway and Breathing

• Maintaining an oral airway, supplemental O2

• Bag-valve-mask ventilations

• Endotracheal intubation via Rapid sequence intubation (RSI) if:

• Decreasing LOC (GCS < 9)

• Marked respiratory distress

• Hemodynamic instability

• Use cuffed tracheal tubes to protect airway from aspiration

• RSI considerations:

• Pretreat with Lidocaine --> minimizes increase in ICP that can be associated with airway manipulation

• Sedation --> Etomidate and thiopental* = neuroprotective

• Paralysis --> Succinylcholine (+/-) vs. Rocuronium

• Role of Hyperventilation

HYPERVENTILATION

DECREASE PCO2

CEREBRAL VASOCONSTRICTION

DECREASED CEREBRAL PERFUSION

REDUCTION OF INTRACRANIAL

PRESSURE

HYPERVENTILATION

DECREASE PCO2

PRESSURE

HYPOPERFUSION = HYPOXIA?

HYPERVENTILATION

DECREASE PCO2

PRESSURE

HYPOPERFUSION = HYPOXIA?

IDEAL PACO2 35-38...*

Management: Fluid Managment

• Outcome is poor for pts with severe TBI and initial hypotension

• Target blood pressure to maintain cerebral perfusion pressure is not clearly defined, but may be age-dependent.

• Maintain SBP > 5th percentile, as a minimum

• Isotonic fluids preferred (vs. hypertonic)

Management: Other

Head positioning Hyperventilation

Sedation/paralysis AVOID HYPERGLYCEMIA

Antiseizure Corticosteroids (?)

Hyper-/Hypothermia Emergent surgery

Hyperosmolar Tx

Management: Monitoring

• HR, BP, Pulse oximetry

• Capnography: end-tidal CO2

• ICP monitoring if abn head CT or GCS 3-8

ED Management Decisions

• Immediate neurosurgical evaluation required for:

• Focal injuries identified on CT

• Depressed, basilar, widely diastatic skull fx

• Increased ICP

• Deteriorating clinical condition

• Children with signs of herniation:

• O2, breathing, BP

• Hyperosmolar Tx (Mannitol)

• Mild hyperventilation (PaCO2 30-35)

• Immediate neurosurgical evaluation

Disposition: Minor Head Trauma

• May go home after observation period without deterioration and/or negative head CT --> F/U PCP IN 24 HRS

• If home, f/u if worsening HA, persistent vomiting, AMS, gait/coordination issues, sz

• Admit: brain injury, depressed/basilar skull fracture (with Neurosurg), AMS, persistent vomiting, suspected abuse, unreliable caretakers

Disposition: TBI

• Children in field with GCS < or = 12 should go directly to pediatric trauma center.

• Once stabilized, pts should be transferred from community hospital to peds trauma center if:

• GCS < or = 8

• GCS < or = 12 with associated major injuries

• Deterioration in clinical condition / GCS drop

Return to Play Guidelines

• Children/adolescents at increased risk for Second Impact Syndrome

• Diffuse cerebral swelling after 2nd concussion -- rare, often FATAL.

• Any LOC or symptoms of concussion > 15 minutes -- no sports until asymptomatic x 7 days

NFL Players Association

What is the cumulative effect of recurrent mild

Some final words...

http://www.cdc.gov/traumaticbraininjury/prevention.html

ROOM A: 7 MO MALE

ACTIVE SZ

INTUBATED, ANTICONVULSANTS

URGENT NEUROSURG CONSULT

MANNITOL

ROOM A: 7 MO MALE

ACTIVE SZ

INTUBATED, ANTICONVULSANTS

URGENT NEUROSURG CONSULT

MANNITOL

ROOM B: 3 YR MALE

bibliographyLanglois, JA, Rutland-Brown, W, Thomas, KE. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta 2006.

Schneier AJ, Shields BJ, Hostetler SG, et al. Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States. Pediatrics 2006; 118:483.

White JR, Farukhi Z, Bull C, et al. Predictors of outcome in severely head-injured children. Crit Care Med 2001; 29:534.

Luerssen TG, Klauber MR, Marshall LF. Outcome from head injury related to patient's age. A longitudinal prospective study of adult and pediatric head injury. J Neurosurg 1988; 68:409.

Vavilala MS, Muangman S, Tontisirin N, et al. Impaired cerebral autoregulation and 6-month outcome in children with severe traumatic brain injury: preliminary findings. Dev Neurosci 2006; 28:348.

Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009; 374:1160.

McCrory P. Does second impact syndrome exist? Clin J Sport Med 2001; 11:144.

Kirkwood MW, Yeates KO, Wilson PE. Pediatric sport-related concussion: a review of the clinical management of an oft-neglected population. Pediatrics 2006; 117:1359.

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ROOM C

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