CRANIUM; IT’S NOT JUST A GAME: MILD & MODERATE TRAUMATIC BRAIN INJURIES IN CHILDREN

Andrew W. Kiragu, MD, FAAPInterim Chief of Pediatrics

Medical Director, PICUHennepin County Medical CenterAssistant Professor of Pediatrics

University of Minnesota

FACES OF TBI

Disclosures

• I have no relevant financial relationships with the manufacturers of any commercial products and/or commercial services discussed in this CME activity

• I do not intend to discuss any unapproved commercial product/device in this presentation

GOALS OF THE PRESENTATION

• Discuss a representative case of pediatric TBI

• Review epidemiology, evaluation and initial management of traumatic brain injury

• Briefly review pathophysiology of TBI

• Review other aspects of TBI management including follow-up, family-centered care and injury prevention

GOALS OF THE PRESENTATION

• Discuss a representative case of pediatric TBI

• Review epidemiology, evaluation and initial management of traumatic brain injury

• Briefly review pathophysiology of TBI

• Review other aspects of TBI management including follow-up, family-centered care and injury prevention

CASE REPORT• Patient FP is an 11 year-old boy who presented to

the ED after being struck by a vehicle while riding his bicycle.

• He was out riding with his friends and they had been going fairly fast downhill when he swerved to avoid an object on the road.

• Swerved into the path of a slow moving truck, was struck and flung off his bike.

• Landed on the pavement and struck his unhelmeted head. He was observed to lose consciousness for about 2-3 minutes.

CASE REPORT

• The driver called 911 and paramedics arrived to find him still lying on the sidewalk somnolent but rousable

• He opened his eyes to voice, was able to talk but was confused and could only localize pain

CASE REPORT

• Initial GCS 12 (E3, V4, M5)

• He was transported to the ED for additional evaluation and treatment

CASE REPORT• Initial Vital signs: T36.7 C, HR124, RR20, BP110/56,

SpO2 98% on RA

• Gen: more awake and somewhat combative. Bruise and swelling noted over forehead and large abrasion noted of right forearm

• HEENT: NC, swelling and bruising of forehead, PERRL, no nasal dc,

• Chest: CTA B

• CV: nl S1S2, RR increased heart rate

CASE REPORT• Abdomen: soft, NT, NABS, no HSM

• Ext: abrasion of R forearm, MAE, WWP

• Neuro: awake but somewhat combative, intermittently following commands, GCS 14(E4, V4, M6)

• Taken for head CT which significant for two small punctate hemorrhage in frontal lobe. Soft tissue swelling of forehead seen. No fracture

• Labs in ED including electrolytes and CBC normal

• Sent to PICU for overnight observation

EPIDEMIOLOGY

• There are approximately 1.7 million traumatic brain injuries sustained in the US annually

• 50,000 die;

• 235,000 are hospitalized; and

• 1.1 million are treated and released from an emergency department.

EPIDEMIOLOGY• Over 85% of the 1.7 million TBI’s occurring

annually in the US are considered mild.

• The average incidence of mild TBI was 503.1 per 100,000 population, with a peak among American Indians/Alaska Natives (1026/100,000 population) and in children younger than 5 years old (1115.2/100,000 population).

• The mechanisms by which children sustain head injury vary by activity, age, helmet use, and geographic location.

EPIDEMIOLOGY

• Among children aged 0 to 14, TBI results in over 400,000 ED visits, 2685 deaths and 37,000 hospitalizations each year. Injury rates are highest among children 0 to 4.

• Approximately 50% of patients hospitalized with TBI are younger than 20

INTRODUCTION• The term concussion has been used

interchangeably with mild traumatic brain injury (TBI)

• Defined as a trauma-induced alteration in mental status that may or may not involve the loss of consciousness (LOC).

• Cerebral concussion is considered a diffuse brain injury and is associated with widespread disruption of brain function.

INTRODUCTION

Wing, R & James, C; Emerg Med Clin N Am 31 (2013) 653–675

INTRODUCTION

• Not usually associated with visible lesions that can be detected by current imaging techniques.

• The primary injury mechanism for a concussion is thought to be from a rotational acceleration force .

• No head injury should be considered minor.

EPIDEMIOLOGY

• Falls

• Motor vehicle crashes

• Sports and recreational injuries

• Violence including child abuse and child on child violence

EPIDEMIOLOGY

• Severity

• Mild 80-85%

• Moderate to Severe 12-15%

• Fatal 4-5%

EPIDEMIOLOGY• Average cost of hospitalization for a child with

mild TBI $10,000 up to $3+ million for severe TBI leading to PVS.

• The annual cost of hospitalization for TBI estimated in the US at $100 billion.

• Immeasurable price to individual and family and to society as a whole.

• Head injury the single greatest cause of lost potential productivity in children.

EVALUATION• History

• Physical Examination

• Laboratory evaluation

• Imaging

• Cognitive evaluation/Neuropsychology

• PT/OT/SLP

EVALUATION• Primary Survey

• Airway

• Breathing

• Circulation

• Disability

• Exposure

• Neurologic Assessment

• Pupillary response

• Responsiveness

• Glasgow Coma Scale

• Modified Glasgow Coma Scale

EVALUATION

Wing, R & James, C; Emerg Med Clin N Am 31 (2013) 653–675

EVALUATION• Head CT imaging an important tool in the

management of TBI.

• Provides valuable information regarding the type, location, and severity of intracranial injuries, skull fractures, and cervical spine injuries.

• Newer improved technology allows faster and more detailed imaging to be obtained.

• Unfortunately, increased CT use leads to increased radiation exposure as well as increased costs

EVALUATION

Advances in Imaging: MRI DTI Tractography

RISK FACTORS FOR DELAYED

COMPLICATIONS

• Age of less than 2 years a moderate risk factor for ICI after head trauma.

• Lower threshold for imaging studies of younger children because historical and clinical factors may not be available or present for assessment

PECARN Guidelines

Kupperman, n et al. Lancet 2009; 374: 1160–70

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY

• Impact -head striking a surface or being struck by object

• Inertial (translational, rotational or both)

• Penetrating

• Anoxic

PATHOPHYSIOLOGY• Are potentially preventable and are caused by:

• Hypoxia/ischemia

• Energy failure

• Brain swelling/edema

• Excitotoxicity

• Necrosis/Apoptosis

• Inflammation

SPORTS CONCUSSIONS

SPORTS CONCUSSIONS

• High concussion risk organized sports such as wrestling and boxing described as early as 776 BC

• Sports related concussions recognized historically but remain a frequent and controversial topic

• Increased concern, awareness and prevention efforts including at the legislative level

SPORTS CONCUSSIONS

• Differences between sports concussions and concussions from other etiologies

• Sports concussions a particular problem in pediatrics

• Children at increased risk

SPORTS CONCUSSIONS• More than 300 000 sport-related concussions

occur annually in the United States

• More than 60 000 cases of concussions occur at the high school level, with football accounting for the majority of these.

• Approximately 4% of high school and collegiate football players sustain concussions during each season.

• 1 250 000 student-athletes participating at the high school level

SPORTS CONCUSSIONS

• Recent concerns over the health of athletes who sustain concussions.

• Practice guidelines and parameters for evaluating and managing the head-injured athlete have been developed.

• The various guidelines released have raised controversy since not enough data on concussion grades and return-to-play criteria

SPORTS CONCUSSIONS

• Baseline and post concussion neuropsychological testing

• ImPACT testing (Immediate Post-Concussion Assessment and Cognitive Testing)

• Return to play guidelines

• Return to school guidelines

SPORTS CONCUSSIONS

• Heads Up Campaign-CDC

• Information for coaches, parents and student athletes regarding concussions

• Guidelines for recognition and treatment

SPORTS CONCUSSIONS

SPORTS CONCUSSIONS

Thiessen, ML & Woolridge, DP; Pediatr Clin N Am 53 (2006) 1 – 26

SPORTS CONCUSSIONS

Thiessen, ML & Woolridge, DP; Pediatr Clin N Am 53 (2006) 1 – 26

OUTCOMES OF MTBI• Related to:

• Severity of injury

• Severity of intracranial hypertension

• Secondary brain injuries

• 20% of mild brain injury have some deficit

• 90-100% of moderate to severe will have deficit

OUTCOMES OF MTBI• Neurologic sequelae

• motor deficits

• sensory deficits

• hearing and vision should be formally tested

• Communication difficulties

• Cognitive deficits

• Behavioral problems

OUTCOMES OF MTBI• The short- and long-term complications of

mild TBI in children are poorly understood.

• Postconcussive syndrome refers to the constellation of acute symptoms after a mild TBI.

• These symptoms can be somatic (headache, dizziness, blurriness), emotional (irritability, anxiety), and cognitive (concentration and memory)

POST-CONCUSSION SYNDROME

POST-CONCUSSION SYNDROME• Studies have assessed physical, behavioral, and

cognitive outcomes across the severity continuum of head injuries.

• Speech and feeding difficulties associated with an increasing severity of head injury, but not walking.

• Headaches are among the most common postconcussive symptoms reported

• Also, temper outbursts, dizziness, mood swings, anxiety, and aggressive behavior have been reported.

POST-CONCUSSION SYNDROME

• Children with mild TBI do well in their recovery, but studies have found that not all mildly injured children recover completely.

• In one study 50% of the study group made a good recovery, but only 18.4% made a full recovery without discernible sequelae.

• Unclear what the threshold of injury severity below which the risk of late morbidity could be discounted.

CTE

• Concerns about effects of repetitive head trauma

• Recent professional athlete cases

• NFL money for research etc.

Rehabilitation• Treatment directed at maximizing functional

independence by reducing impairment, disability and handicap.

• Early intervention.

• Interdisciplinary team effort/organization.

• Short-term rehabilitation- consider intra-facility resources

• Long-term rehabilitation-specialized facility(note age-restrictions)

RETURN TO SCHOOL• When children with head injury return to school,

they may be expected to assimilate immediately with the class.

• The child’s teacher may not understand the head injury or even know the child suffered a MHI, which could affect how the child is treated, observed, or graded.

• In one study, teachers knew of the child’s head injury in only 39.8% of the children, and there was a significant linear trend across injury severity groups.

RETURN TO SCHOOL• Special educational needs were provided for

only 65% of the children identified with such needs.

• At follow-up, 18.7% of the children were currently having difficulties with schoolwork

• Interestingly, 18% of the children had been disciplined by the school for problem behavior after sustaining their head injury

Return to Play

Wing, R & James, C; Emerg Med Clin N Am 31 (2013) 653–675

FOLLOW-UP• Pediatric Traumatic Brain Injury Clinic

• Mild/Moderate TBI Clinic

• Primary care Physicians

• Return to school

• Return to sports

• PT/OT/Neuropsychology/SLP

• Brain Injury Association of Minnesota

PREVENTION• All head trauma is potentially preventable.

• Ensure a safe environment for kids.

• Educate regarding motor safety.

• Emphasize helmet use, age-appropriate MV restraints to prevent or attenuate injury.

• Educate about guns (limit access).

• Educate about prevention of inflicted head injuries.

PREVENTION

• Heads Up Campaign by CDC

• National and regional injury prevention programs

• Role of pediatricians

• State and federal legislation

RESEARCH

• Need for ongoing research into brain injury treatment

• Need for increased federal and foundation funding for traumatic brain injury.

Conclusions• Traumatic brain injuries are a common cause of

morbidity and mortality in children

• Damage to the brain cannot be reversed

• Sports related concussions are a continued problem for the pediatric population

• Advances in management of MTBI offer hope for improved outcomes

• Research into the pathophysiology of MTBI crucial

• PREVENTION IS KEY

QUESTIONS?