Bonk An Evidence Based Approach Pediatric Head Trauma Dr … · 2020. 1. 13. · BONK: Objectives Learn the pathophysiology of head trauma Learn 10 CDC best practice recommendations

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An Evidence Based Approach to Pediatric Head Trauma

Danny G. Thomas MD MPHAssociate Professor of PediatricsPediatric Emergency MedicineMedical College of Wisconsin

BONK: Objectives

Learn the pathophysiology of head trauma

Learn 10 CDC best practice recommendations for the treatment and management of concussion

Review some of the clinical research behind these recommendations

Pediatric Head Trauma: A Significant Burden Clinical Challenges in the ED• Manage children with moderate and

severe TBI• Defined by GCS

• Identify children with significant intracranial injury

• Neurosurgical interventions due to secondary pathology

• Improving outcomes of mild TBI

Severity of Traumatic Brain Injury as defined by GCS

GCSMild 13-15Moderate 9-12Severe <9

Secondary Pathology

• Epidural Hematoma• Better prognosis with

mortality rate is up to 50%

• Subdural Hematoma• Poor prognosis with

mortality rates up to 90%

ED Management of Moderate to Severe TBIGlasgow Coma Scale ≤12

• Goals = prevent secondary injury• Identify operative lesions• Manage Airway• Manage increased intracranial pressure• Prevent Hypoxia / Hypercarbia / Hypoglycemia• Prevent Hypotension• Adequate Sedation and Analgesia… no magic bullet

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Typical Head Trauma Presentations to the Pediatric ED look like…

4 m/o Female

Hx: Fall from Dad’s shoulders to linoleum

Sx: Brief loss of consciousness, but now has no symptoms

9 y/o Male

Hx: Hit with a baseball bat at recess

Sx: No loss of consciousness, headache and vomiting

15 y/o Male

Hx: Head to head contact during a during tackle

Sx: No loss of consciousness, but has significant amnesiaSevere Headache and dizziness

Identify intracranial injury Who to CT?: Strategies

Some of Them?

• Just patients with any signs or symptoms

• Most with ICI have at least some signs or symptoms

All of them!

• Limited data on asymptomatic pts

• Low but non-zero rate of intracranial injury needing an intervention

Brenner D and Hall E. N Engl J Med 2007;357:2277-2284

Estimated Organ Doses and Lifetime Cancer Risks from Typical Single CT Scans of the Head and the Abdomen

Diagnostic Recommendations:1. Recommend using risk factors to determine which patients

need an emergent CT scan • Not routinely recommended: MRI, SPECT, Skull Xray, Serum Markers

Guideline on the Diagnosis and Management of mTBI

PECARN Head Injury StudyMethods and Subjects

• Prospective Cohort Study, < 18 yo

• N= 42,412 patients from 25 EDs

• Presented within 24 hrs blunt head injury

• mTBI = GCS 14 -15

• 1°Outcome = “ci-TBI” (“clinically important”)• Defined as Death, Neurosurgery, Intubation,

Hospital admission > 2 nights

33,785Derivation Set

8,627Validation Set

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Prediction Rules for No “ciTBI”Age younger than 2 years

• Normal Mental Status• No palpable skull fracture• No scalp hematoma - except frontal• No LOC or LOC < 5 seconds• Non-severe injury mechanism• Acting normally according to parents

(NPV 100%; Sensitivity 100%)

Kupperman N, et al. The Lancet, 2009. 374: 1160 – 1170

PECARN Imaging Guidelines <2 y/o


• Normal Mental Status• No LOC• No vomiting• Non-severe injury• No basilar fracture• No severe headache

(NPV 99.95%; Sensitivity 96.8%)


Prediction Rules for No “ciTBI”Age older than 2 years


PECARN Imaging Guidelines >2 y/o

PECARN subanalyses

• No need to admit for observation after normal CT • VP Shunt and Bleeding disorder alone do not increase

risk of ci-TBI

Isolated factors NOT predictive of CiTBI• Severe Mechanism • Prolonged Vomiting

• Loss of Consciousness • Amnesia

• Scalp hematomas (<2 y/o) • Not acting Normal per parent

Benefits of Brief ED Observation• 5433 (14%) patients in the PECARN study underwent

ED observation• OBSERVED GROUP:

• ~4% less likely to get a CT • No difference in rate significant TBI

• Observation can reduce CT use• Why?: Patients seen immediately, look “sicker”

• Observation for patients with intermediate risk could save $92 million per year over current practice

PEDIATRICS, 127 (6): 1067-1073 JUN 2011

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How long do we need to observe?

•After 6 hours no risk of significant bleed1

• Retrospective study of ~18 000 pts ( < 14 y/o)

• Rate of delayed deterioration (> 6 hours)• 0 (0%) presented normal GCS• 5 (0.03%) presented with altered GCS

PEDIATRICS Vol. 126 No. 1 July 2010, pp. e33-e39

A Negative CT Does Not Equal Absence of Intracranial Injury.

• CT scans address the tip of the iceberg

• Majority of patients still have persistent symptoms and functional impairment

• Deficits can be detected on advanced neuroimaging, biomarkers, and with neurocognitive testing.

Deaths7,000/yr

Hospitalizations95,000/yr

ED Visits> 500,000/yr

Primary Care Office VisitsAssume numerous, No data

Care Not SoughtAssume numerous, No data

Concussion Definition• Blow to head or indirect force through neck or to body • Trauma-induced alteration in neurologic function

• Signs: Amnesia (retrograde or anterograde) LOC, dazed, etc. • Symptoms: Headache, Nausea, Visual changes, Balance, etc.

• Typical Clinical Presentation• Rapid short-lived impairment• Normal physical examination and neuroimagingNeurometabolic dysfunction, not structural injury

Recognizing the ProblemWhat arrow!? I am here about my headaches.

Case: Female Soccer Player• Off field: 1-5 minutes of post traumatic amnesia

and confusion

• Over the next 1 hr.: Severe headache, visual disturbance, balance problems

• Transported to the ED for evaluation

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Biomechanics of Concussion

Strain causes…

↑Neurons to depolarize

↓then become refractory

↓ Local and global blood flow

Pathophysiology of Head Trauma1.Release of

neurotransmitters and ↓↓ cerebral blood flow

2.Neuron depolarized 3.Excess K+ in the

extracellular space4.Neurons become

refractory 5.Na+/K+ ATP pump

activated6. Increase need for ATP

and glucose7.Mismatch leads to lactate

production 8.Cerebral glucose

metabolism ↓↓ to match blood flow.

Neurometabolic Changes in Concussion: glucose utilization and CBF

Glucose Utilization

Blood Flow

J Cereb Blood Flow Metab, Vol. 21, No. 7, 2001

Concussed rats 2 hours post-injury

Signs/Symptoms Seen in the ED

• Loss of consciousness

• Amnesia

• On Field Signs• Confusion • Dazed or stunned• Answers questions slowly• Repeating questions

• Symptoms • Headache• Nausea/Vomiting• Dizziness/Off-balance• Behavior/Personality

Change• Vision changes• Poor Concentration• Poor memory• Sensitive to light/sound• Numbness /tingling

*Thomas 2011

27%

61%

95%

22%

Assessment Tools:2. Use an age-appropriate symptom rating tool to diagnose

and a combination of tools to assess concussion. • Use a validated symptom scale• May use a validated cognitive test• May use a validated balance test

Guideline on the Diagnosis and Management of mTBI Concussion Diagnosis

• Acute Concussion Evaluation (ACE) and ACE Care Plan

• Validated to identify mTBI• Provides discharge instructions

for children and adults• Available free on

CDC website since 2007

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ACE FormDescription of the injuryhow, location on the head and type of force.

Presence of amnesia and it’s duration

Loss of consciousness, SeizuresEarly signs (dazed, repeating questions, etc)

ACE Form

ACE Care Plan

• Evidence based discharge instructions

• Specific recommendations regarding:• Return to school• Return to work • Sports and exertion• Follow up plan

• ~36% of concussed athletes will have a balance problem in first 24 hrs post-injury

• How to assess• BESS • Tandem Gait

Acute Balance Assessment

Guskiewicz , Clin Sports Med 30 (2011) 89–102

• Emerging evidence suggests up 50% may experience dizziness post-injury• How to assess

• Vestibular Ocular-Motor Screening (VOMS)1. Smooth pursuits 2. Saccades3. Vestibular ocular reflex4. Visual motion sensitivity 5. Near-point-of-convergence distance

Vestibular/Oculomotor AssessmentManagement Recommendations (cont.):3) Acute Post-traumatic headache may warrant CT scan (if

severe or worsening)• Avoid opiates in headache treatment• Counsel patients about analgesic overuse and rebound headache

4) Counsel patients on proper sleep hygiene3) May refer to specialist for sleep problems


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ED Symptom Management• There is no standardized approach to the management

of acute concussion symptoms.

• Immediate sleep and rest may be the most effective strategy.

A good laugh and a long sleep are the best cures in the doctor’s book. – Irish Proverb

• Fatigue/sleepiness immediately follows mTBI suggests that it serves some biologic purpose

• mTBI is metabolic mismatch

• Sleep has restorative benefits• Decreased synaptic activity (Cirelli et al)• Increased ATP stores (Dworak et al)

Common Post Concussive Symptoms• Headache

• Oral analgesic• NSAID (Ibuprofen,

naproxen)• Acetaminophen • Opiates

• Nausea / Vomiting• Oral antiemetics

• Ondansetron• Prochlorpromazine

• IV ED Migraine Pathway• IV fluid bolus• NSAID(e.g. Ketorolac)• Dopamine receptor antagonist

(e.g. Prochrolpromazine, metoclopromide)

• Ergotamine, Triptans, Opiates• Sleep and reassessment

After ED Evaluation… time to Discharge… but

• What are our discharge instructions?

• Who should follow up with a specialist?

• How long should they rest?

• Where should parents go for help?

Management Recommendations:5) Provide education and reassurance

6) Restrict physical and cognitive activity for the first several days then gradually resume activity with close monitoring• May assess and emphasize the importance of social support in

recovery

7) Monitor all high risk patients with mTBI• If not improving within 4 weeks refer for assessment and

rehabilitation

Guideline on the Diagnosis and Management of mTBI • Zemek et. al conducted the 5P study

• 9 EDs -Pediatric Emergency Research Canada (PERC) network

• Multicenter derivation and validation model• Recruited 3063 mTBI patients 5-17 y/o

• Subject completed a survey of predictive factors• Primary outcome: (31% , N=801)

• Proportion with persistent concussion symptoms at 1 month

ED Risk Factor Assessment

2006Derivation Set

1057Validation Set

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Risk Increases:• Age• Gender• Past Concussion*• H/o Migraine• Answers questions slowly• BESS errors• Headache• Sensitivity to noise• Fatigue

5 P Clinical Risk Score

Zemek et al. JAMA. 2016;315(10):1014-1025

Clinical Risk Score

Zemek et al. JAMA. 2016;315(10):1014-1025

• Low Risk (0-3)• 4-12% risk

• Medium Risk (4-8)• 16-48% risk

• High Risk (9-12)• 57-81% risk

Improving outcomes of mild TBI• Identify patients at high risk for negative outcomes

• Provide education and reassurance

• Provide guidance on safe return to activity

• Reduce post-concussive symptoms and cumulative injury

• Ponsford et. al. patients and families seen 1-week post injury and given an education booklet had less symptoms and less stress 3 months after injury

The Knowledge: Discharge Education

LOST in TRANSLATION:

• Only 42% of patient diagnosed with concussion are given concussion discharge instructions. (Seabury 2018)

• Similarly, less than 44% reported seeing a medical practitioner by 3 months. (Seabury 2018)

Risks of Exertion During Recovery• Risks associated with return to

sports• Animal models show early

physical and mental exertion impairs healing

• Few human studies have suggested exertion may have negative effects.

SPC1

Slide 48

SPC1 have suggested?Santiago Parrilla, Charimar, 12/10/2019

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Effect of Exertion on Recovery

Athletes with highest and lowest levels of cognitive and physical activity had more symptoms and worse neurocognitive performance

5-point activity scale coded on chart review

Athletes with moderate levels of post-injury activity had the best performance at follow-up

Group 2 (School and light activity) did best

*Majerske 2008

Concussion Management• Based on expert consensus*

• Recommend: • 24-48 hours of rest• Gradual step-wise return to activity

• Some clinicians advocate “Cocoon Therapy”

*International Symposium on Concussion in Sport, Vienna 2001 to Berlin 2016

http://www.stamfordadvocate.com/default/article/Local-doctor-has-novel-approach-to-concussions-190953.php

METHODS

3 Day Follow up assessment; Diary collected

Neurocognitive tests and BESS in ED (N = 99)

Strict Rest(N= 45)

Usual Care(N=43)

Patient completes 3 Day Activity / Symptom Diary

R a n d o m i z a t i o n

Patient presenting to ED and assessed for eligibility (N= 1376)

Study Overview:

Excluded (n=1277)o Inclusion not met: 1006o Declined : 93o Excluded: 178 ADHD: 56 (31%) Language: 28 (16%) Distance: 27 (15%) MD opt out: 24 (14%) Injured: 21 (12%) Can’t F/U: 16 (9%) ICI: 6 (3%)

Study Period 05/10-12/12

Patient completes 4-10 Day Activity / Symptom Diary

10 Day Follow up assessment; Diary collectedPEDIATRICS 135(2) Feb 2015

Background

Results: Compliance

• Intervention group reported less school and after school activity for days 2-5 post concussion (3.8 vs. 6.7 hours total, p < 0.05)

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Day‐1 Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10

Usual [C] Strict [I]

Mean School Attendance

Pre‐injury

• Both groups exhibited ~20% decrease in energy expenditure and physical activity level in the first 5 days post injury

PEDIATRICS 135(2) Feb 2015Background

Results• Both groups exhibited ~20% decrease activity level in

the first 5 days post injury• REST group reported less school and after school

activity for days 2-5 post concussion• No significant difference between groups in

neurocognitive or balance scores at 3 or 10 days

Results: Total and daily PCSS

• Intervention group reported greater symptoms over the course of the study (187.9 vs 131.9, p <0.03)

1 2 3 4 5 6 7 8 9 10

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Time To Symptom Resolution (PCSS ≤ 7)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10

Intervention

Standard of care

• It took 4 days longer for 50% of the intervention group to report symptom resolution

% R

epo

rtin

g P

ersi

sten

t S

ymp

tom

s

Time

Clinical Implications• Support the current standard of care• Strict activity limits immediately after mTBI offer no benefit

over current standard of care • Potential for discharge instructions to influence perception

of illness and symptom reporting• Similar results have been found:

• Prescribed rest not beneficial in college students post-concussion (Buckley 2016)

• Early activity associated with reduced risk of persistent post-concussive symptoms (Grool 2016)

Does Activity Worsen Symptoms?

BACKGROUND

DESIGN

Rationale

• Symptoms after concussion can be exacerbated or return with physical and mental exertion

Objective• To characterize the incidence, course, and clinical

significance of symptom exacerbations (“spikes”)

Silverberg et al Jama Pediatrics,October 2016

Results

More symptomatic in the ED and

throughout the observation period,

but did not differ from the group

without symptom spikes at 10 days

Symptom spikes occur in 1/3

patients

BAD NEWS:• Symptom spikes WERE seen

…with a sudden increase in mental activity (returning to school and extracurricular activities)

ResultsGOOD NEWS:• Symptom spikes NOT seen

…with increases in physical activity or moderate increases in mental activity (some school to more school)

• Most symptom spikes resolved by the next day

Clinical Implications• Symptom spikes may not themselves be detrimental to

recovery. • Supports clinical guidelines to return to school and light

physical activities after concussion• Certain patients appear susceptible to high and variable

symptom reporting. • As current guidelines recommend rest followed by a

symptom-guided return to activity, patients who are susceptible to high and variable symptom reporting are at risk for self cocooning while perseverating on symptoms

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• Prolonged rest may cause harm through deconditioning which may induce physiologic changes in cerebrovascular control and contribute to post-concussion symptoms

• Healthy volunteers have increased autonomic regulation of the heart after conditioning which is reduced to baseline after deconditioning. (Gamelin 2007)

• Studies have shown patients with mTBI are found to have impaired autonomic modulation (Hanna-Pladdy B 2001, Gall B 2004, Hilz MJ 2011)

Physiologic Harm From Rest• Rest as treatment may worsen symptoms through

the nocebo effect

• 25% of patient given a placebo with describe negative “side effects” (Barsky AJ, 2002)

• Patients with illness often have stressors that exacerbate psychosomatic complaints

Psychologic Harm From Rest

Benefit or No Harm for Activity after concussionModerate Physical Activity Prescribe Aerobic Exercise

Majerske et al (2008) Retrospective Gagnon et al (2009)-Prospective case Series

Brown et al (2014) - Retrospective Leddy et. al (2010)- Prospective case series

Thomas et al (2015) - RCT Baker et al (2012)- Retrospective

Buckley et al (2015) – Prospective cohort Leddy et al (2013) – Quasi-experimental

Grool et al (2016) – Multicenter Prospective cohort Clausen et al (2015) – Prospective cohort

Howell et al (2016) – Prospective Cohort Maerlender et al (2015)- RCT in acute SRC

Taubman et al (2016) – Prospective Cohort Dematteo et al (2015)- Prospective X sectional

Cordingley et al (2016) - Retrospective

Gagnon et al (2016) – Prospective Case series

Kurowski et al (2016) – RCT in PPCS

Chrisman et al (2017) - Retrospective

Leddy et al (2017) – RCT in SRC

Chan et al (2018) – RCT in PPCS

Give it a

Rest.Walk it off.

• Interventions:

• ACTIVITY=

• mHEALTH=

• Looking at impact on high-risk populations

Active Injury Management (AIM) Study

• Subjects will be instructed to try to get 10,000 steps a day by the end of the first week

• Subjects will be instructed to us “resilience” app SuperBetter

• Randomized and receive Comic-based discharge instructions

• Follow-up using a TBI research app

AIM overview

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• Our goal is to determine the safety and potential benefit of early activity and behavioral management.

• We hope that the data from this trial can be rapidly utilized to inform the care we provide to concussed patients.

Active Injury Management Approach

Management Recommendations (cont.):8. Assist patients in returning to school

as symptoms will tolerate• Return to school protocols should be

individualized• Prolonged symptoms may require formal

accommodations which are monitored • Prolonged symptoms with persistent

academic difficulties should be formal evaluated by mTBI specialist


Interventions for mTBI with poor prognosis:9. Patient with Vestibular oculomotor

dysfunction may be referred for rehab.

10. Evaluate cognitive dysfunction post injury and recommend treatment strategies• May refer to specialist for persistent problems

Guideline on the Diagnosis and Management of mTBI Concussion Is Treatable

Individualized approach is key!• Step 1: “When in doubt, sit them out”• Step 2: Resume Activities of Daily living• Step 3: Get back to school (+/- support)• Step 4: Get back to sport (w/ clearance)

Not recovering fast enough, see a specialist• Tx: Rehab, PT, OT, CBT, Medications

Questions? Failure of Knowledge Translation

Documents

Bonk An Evidence Based Approach Pediatric Head Trauma Dr … · 2020. 1. 13. · BONK: Objectives Learn the pathophysiology of head trauma Learn 10 CDC best practice recommendations