Evidence-Based Management of Pediatric Head Trauma

Mariann Nocera, MD

Siraj Amanullah, MD, MPH

November 13, 2014

Discuss the types and mechanisms of blunt head trauma in children

Discuss the management of blunt head trauma in children

Evaluate the evidence behind the management of pediatric blunt head trauma

Objectives

Trauma is the leading cause of death in children >1 year

TBI is the leading cause of trauma-related death

>600,000 ED visits annually

60,000 hospitalizations

6,000 deaths

Pediatric Head Trauma

http://www.cdc.gov/traumaticbraininjury/data/index.html

Assessing and managing a patient

with head trauma

Standard GCS

Eye Opening

4 Spontaneous

3 To verbal stimuli

2 To pain

1 None

Pediatric GCS

Eye Opening

4 Spontaneous

3 To speech

2 To pain

1 None

Glasgow Coma Scale

J Trauma Acute Care Surg.

Standard GCS

Best Verbal Response

5 Oriented

4 Confused

3 Inappropriate words

2 Incomprehensible sounds

1 None

Pediatric GCS

Best Verbal Response

5 Coos, babbles

4 Irritable, cries

3 Cries to pain

2 Moans to pain

1 None

Glasgow Coma Scale

J Trauma Acute Care Surg.

Standard GCS

Best Motor Response

6 Follows commands

5 Localizes pain

4 Withdraws to pain

3 Flexion to pain

2 Extension to pain

1 None

Pediatric GCS

Best Motor Response

6 Normal spontaneous moves

5 Withdraws to touch

4 Withdraws to pain

3 Abnormal flexion

2 Abnormal extension

1 None

Glasgow Coma Scale

J Trauma Acute Care Surg.

Management: Airway

Intracranial pressure

Normal hemodynamic status

Seizure prophylaxis

Appropriate radiological investigations

Hospitalization

Severe / Moderate Head Injury

Severe Moderate Minor

GCS 3 8 9 12 13 15

97 % of patients seen in ED with blunt head trauma

Risk of TBI 0-7 % if GCS is 15

<1 % require surgery

Classifications of Head Injuries

J Trauma Acute Care Surg.

???

Severe Moderate Minor

GCS 3 8 9 12 13 15

GCS Risk of TBI

15 ~2-3%

14 ~7-8%

13 ~25%

Risk of TBI

Indications of Head Imaging - Hasbro Blunt Head Injury

GCS ≤14 or AMS, palpable skull fracture, focal neurologic findings

CT Recommended

History of LOC History of vomiting Significant headache Concerning mechanism Behavioral changes (esp <2 years) Scalp hematoma (<2 years)

Observation Consider CT based on: - Worsening signs or symptoms - Clinical judgment

CT not recommended

No

No

Yes

Yes

Clinically-important traumatic brain injury

Goal: Identify low-risk patients with GCS 15 who do not need to have head CT, not to identify patients for whom CT scans should be obtained.

PECARN Clinically-important TBI

Death from TBI

Neurosurgical intervention

Intubation ≥24 hours for TBI

Hospital admission ≥2 nights for TBI in association with TBI on CT

ciTBI: 0.9 %

Definition of clinically important TBI

<2 years

Altered mental status

Scalp hematoma

Loss of consciousness

Mechanism of injury

Skull fracture

Acting normally per parent

≥2 years

Altered mental status

Loss of consciousness

Vomiting

Basilar skull fracture

Mechanism of injury

Severe headache

Prediction Rule

MVC with patient ejection, death of another passenger, rollover

Pedestrian or bicyclist without helmet struck by a motorized vehicle

Falls more than 3 feet < 2 years or more than 5 feet ≥ 2 years

Head struck by a high-impact object

Severe mechanism of injury

< 2 years of age

≥ 2 years of age

Online Tool

http://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm/

< 2 years

Altered mental status

Scalp hematoma

Loss of consciousness

Mechanism of injury

Skull fracture

Acting normally per parent

≥ 2 years

Altered mental status

Loss of consciousness

Vomiting

Basilar skull fracture

Mechanism of injury

Severe headache

Prediction Rule

ciTBI with non-isolated vomiting: 2.5 %

ciTBI with isolated vomiting : 0.2 %

Isolated vomiting

ciTBI with no LOC: 0.5 %

ciTBI with any LOC: 2.5 %

ciTBI with isolated LOC: 0.5 %

Isolated loss of consciousness

ciTBI with isolated severe mechanism , <2 years: 0.3 %

ciTBI with isolated severe mechanism , ≥2 years: 0.5 %

Isolated severe injury mechanism

ciTBI with isolated scalp hematoma: 0.4 %

<6 months more at risk < 3 months with any scalp hematomas

Older infants with larger temporal or parietal scalp hematomas

Isolated scalp hematoma (<2 years)

ciTBI with isolated headache: “very low”

Isolated headache

Intracranial pathology in patients with basilar skull fracture: 21 %

Isolated basilar skull fracture

TBI is the most common cause of death and disability among pediatric trauma patients

Most children do not have a clinically-important traumatic brain injury

Low-risk criteria have been validated to help manage patients and identify those who DO NOT need head CT

Summary

Advanced Trauma Life Support, 9th edition. J Trauma Acute Care Surg. 2013 May;74(5):1363-6.

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Dayan PS, Holmes JF, Atabaki S, et al. Association of Traumatic Brain Injuries With Vomiting in Children With Blunt Head Trauma. Annals of emergency medicine 2014;63:657-65.

Dayan PS, Holmes JF, Schutzman S, et al. Risk of traumatic brain injuries in children younger than 24 months with isolated scalp hematomas. Annals of emergency medicine 2014.

Hamilton M, Mrazik M, Johnson DW. Incidence of delayed intracranial hemorrhage in children after uncomplicated minor head injuries. Pediatrics 2010;126:e33-e9.

Injury Prevention & Control: Traumatic Brain Injury. Centers for Disease Control and Prevention. http://www.cdc.gov/traumaticbraininjury/data/index.html. Accessed 10.15.2014

Kadish HA, Schunk JE. Pediatric basilar skull fracture: do children with normal neurologic findings and no intracranial injury require hospitalization? Annals of emergency medicine 1995;26:37-41.

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. The Lancet 2009;374:1160-70.

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MDCalc: PECARN Pediatric Head Injury / Trauma Algorithm. http://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm/. Accessed 10.15.2014

Nigrovic LE, et al. Prevalence of clinically important traumatic brain injuries in children with minor blunt head trauma and isolated severe injury mechanisms. Arch of ped & adol med 2012;166:356-61.

Nigrovic LE, Schonfeld D, Dayan PS, Fitz BM, Mitchell SR, Kuppermann N. Nurse and physician agreement in the assessment of minor blunt head trauma. Pediatrics 2013;132:e689-e94.

Pearce MS, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. The Lancet 2012; 380:499-505

Rabiner JE, Friedman LM, Khine H, Avner JR, Tsung JW. Accuracy of point-of-care ultrasound for diagnosis of skull fractures in children. Pediatrics 2013;131:e1757-e64.

Rogers AJ, et al. Incidental findings in children with blunt head trauma evaluated with cranial CT scans. Pediatrics 2013;132:e356-e63

Schonfeld D, et al. Effect of the duration of emergency department observation on computed tomography use in children with minor blunt head trauma. Annals of emergency medicine 2013;62:597-603.

Smits M, Dippel DW, de Haan GG, et al. External validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head injury. Jama 2005;294:1519-25.

Stanley RM, Hoyle JD, Dayan PS, et al. Emergency Department Practice Variation in Computed Tomography Use for Children with Minor Blunt Head Trauma. The Journal of pediatrics 2014.

Trauma Handbook. Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Department of Surgery, Division of Trauma and Surgical Critical Care. 2014.

Trenchs V, Curcoy AI, Castillo M, et al. Minor head trauma and linear skull fracture in infants: cranial ultrasound or computed tomography? European Journal of Emergency Medicine 2009;16:150-2.

References