Peds symposium pediatric head trauma 2011 -howard final

Management of Pediatric Head Trauma
in the Emergency Department:
Intracranial and Other Issues
John M. Howard, DO
Assistant Director, Emergikids
Alexian Brothers Hospital Network
April 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


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


ROOM A
CC: UNRESPONSIVE,
POOR RESP


ROOM A
CC: UNRESPONSIVE,
POOR RESP

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


ROOM A
CC: UNRESPONSIVE,
POOR RESP


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


ROOM A
CC: UNRESPONSIVE,
POOR RESP


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

WAS “FINE” EARLIER IN
THE DAY...


ROOM B


ROOM B
C/C: MVC


ROOM B
C/C: MVC

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


ROOM B
C/C: MVC

WITH SNOWBLOWER IN
ADJACENT SEAT

T-BONED BY ONCOMING
CAR, LAUNCHING
SNOWBLOWER INTO PT


ROOM B
C/C: MVC

WITH SNOWBLOWER IN
ADJACENT SEAT

T-BONED BY ONCOMING
CAR, LAUNCHING
SNOWBLOWER INTO PT

SLEEPY, BUT AROUSES TO
VOICE


ROOM B
C/C: MVC

WITH SNOWBLOWER IN
ADJACENT SEAT

T-BONED BY ONCOMING
CAR, LAUNCHING
SNOWBLOWER INTO PT

SLEEPY, BUT AROUSES TO
VOICE

EAR LACERATION
EXTENDING IN TO EAC,
HEMORRHAGIC OTORRHEA

Introduction


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

Mild
13-15*
(Concussion)

• Deﬁned by GCS Moderate 9-12

Severe <9


Deﬁnitions


Deﬁnitions
• *Minor head trauma
(GCS 15):


Deﬁnitions
(GCS 15):

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


Definitions
(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


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


Epidemiology
accounts for:

• 475,000 ED visits/yr


Epidemiology
accounts for:


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


Epidemiology
accounts for:


yrs(2000)

• 29% < 4 yrs old


Epidemiology
accounts for:


yrs(2000)

• 29% < 4 yrs old

• 52% 10-17 yrs old


Epidemiology
• In developed countries: TBI most common
cause of death and disability in childhood


Epidemiology

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


Epidemiology

head injuries

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


Epidemiology

head injuries

hospitalization

• 4.5%


Epidemiology

head injuries

hospitalization

• 4.5%

• 10.4% adults

Epidemiology:
Mechanism
• Falls
• Assaults
• MVC
• Sports-related

• Pedestrian/
bicycle • Inﬂicted head
injuries
accidents
• Unknown?
• Projectiles


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: ...?


Incidence

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


Incidence


• 3-7% with intracranial injury (ICI)


Incidence



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


Incidence




• 3-10% with ICI


Incidence




• 3-10% with ICI

• Many of these pts have no clinical symptoms


Incidence




• 3-10% with ICI

• Many of these pts have no clinical symptoms

• Most have scalp hematomas


Clinical Features
Symptom Percentage Comment

Longer duration of
LOC 5% (< 2), 13% (>2) LOC assoc with
CITBI*
Preverbal children
HA 45% = irritable

Assoc w/ slight risk
Vomiting 14% of TBI

Smaller studies
Sz 0.6% report larger %

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

*Clinically Important TBI


Clinical Features


Clinical Features
• Scalp hematomas:


Clinical Features

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


Clinical Features

size or location
may be assoc w/ fx

• Others:


Clinical Features

size or location
may be assoc w/ fx

• Others:

• Transient cortical
blindness or
confusional states


Types of Brain Injury



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



type of severe TBI

• acceleration or deceleration



type of severe TBI

• acceleration or deceleration

• mildest form = Concussion


• Diffuse axonal injury (DAI): more severe
form


form

• Tissue shearing at interface of grey-
white matter


form

white matter

• Associated with focal injuries:


form

white matter


• Cerebral Contusions


form

white matter


• Cerebral Contusions

• Intracranial Hemorrhage


Types of Brain
Injury

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


Types of Brain
Injury
• Focal injuries: Cerebral
contusion:



Types of Brain
Injury
contusion:

• Usually due to acceleration/
deceleration injury



Types of Brain
Injury
contusion:

• Usually due to acceleration/
deceleration injury

• Coup, contracoup, or both



Types of Brain
Injury


Types of Brain
Injury
• Focal injuries: Intracranial
hemorrhage


Types of Brain
Injury
hemorrhage

• Epidermal hematoma: arise from
middle meningeal artery or others


Types of Brain
Injury
hemorrhage


• Subdural hematoma: rupture of
bridging veins


Types of Brain
Injury
hemorrhage


• Subdural hematoma: rupture of
bridging veins

• Subarachnoid hematoma: tearing
of small vessels in pia mater


Associated Injuries

• Multiple trauma

• Cervical spine injury


Pathophysiology


Pathophysiology
• Two insult model:


Pathophysiology

• Primary event--direct injury to brain
parenchyma


Pathophysiology

parenchyma

• Impaired Autoregulation -->


Pathophysiology

parenchyma


• Cerebral hypoperfusion -->


Pathophysiology

parenchyma



• increased metabolic demand...


Pathophysiology

parenchyma



• increased metabolic demand...

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

Evaluation


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


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


Exam
• General assessment


Exam

• Vitals + Pulseox:


Exam


• Hypoxia, hypotension


Exam



• Irregular respirations, bradycardia,
hypertension...


Exam



• Irregular respirations, bradycardia,
hypertension...

• Cervical spine immobilization!


Exam
• Calculation of GCS!

• Scalp abnormalities: AF,
hematoma, depression?

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



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



• 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


Exam
• 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 39
of 'Minor head trauma in infants and children'

39

TI
Skull radiograph interpretation of children younger than two years: how good are pediatric emergency physicians?
AU
Chung S, Schamban N, Wypij D, Cleveland R, Schutzman SA
SO
Ann 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.
AD
Division of Emergency Medicine, Children's Hospital, Harvard Medical School, Boston, MA 02115, USA. sarita.chung@tch.harvard.edu
PMID
15159702


Evaluation: Imaging


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...

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

adults

• Longer subsequent
lifetime


Evaluation: Imaging

adults

lifetime

• Greater sensitivity to
radiation in some
developing organs


Evaluation: Imaging

adults

lifetime

• 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

(ICI)

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


Evaluation: Imaging

(ICI)

• 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!


Management: TBI


Management: Airway
and Breathing


Management: Airway
and Breathing
• Maintaining an oral airway, supplemental O2


Management: Airway
and Breathing

• Bag-valve-mask ventilations


Management: Airway
and Breathing


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


Management: Airway
and Breathing


(RSI) if:

• Decreasing LOC (GCS < 9)


Management: Airway
and Breathing


(RSI) if:


• Marked respiratory distress


Management: Airway
and Breathing


(RSI) if:



• Hemodynamic instability


Management: Airway
and Breathing


(RSI) if:



• Hemodynamic instability

• Use cuffed tracheal tubes to protect airway from
aspiration


Management: Airway
and Breathing
• RSI considerations:


Management: Airway
and Breathing

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


Management: Airway
and Breathing


• Sedation --> Etomidate and thiopental*
= neuroprotective


Management: Airway
and Breathing


• Sedation --> Etomidate and thiopental*
= neuroprotective

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


Management: Airway
and Breathing
• Role of Hyperventilation
HYPERVENTILATION

DECREASE PCO2

CEREBRAL
VASOCONSTRICTION

DECREASED
CEREBRAL
PERFUSION

REDUCTION OF
INTRACRANIAL
PRESSURE

Management: Airway
and Breathing
HYPERVENTILATION

DECREASE PCO2

HYPOPERFUSION = CEREBRAL
HYPOXIA? VASOCONSTRICTION

DECREASED
CEREBRAL
PERFUSION

REDUCTION OF
INTRACRANIAL
PRESSURE

Management: Airway
and Breathing
HYPERVENTILATION

DECREASE PCO2

HYPOPERFUSION = CEREBRAL
VASOCONSTRICTION IDEAL PACO2 35-38...*
HYPOXIA?

DECREASED
CEREBRAL
PERFUSION

REDUCTION OF
INTRACRANIAL
PRESSURE

Management: Fluid
Managment


Management: Fluid
Managment
• Outcome is poor for pts with severe TBI
and initial hypotension


Management: Fluid
Managment

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


Management: Fluid
Managment

dependent.

• Maintain SBP > 5th percentile, as a
minimum


Management: Fluid
Managment

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


ED Management
Decisions
• Immediate neurosurgical evaluation
required for:


ED Management
Decisions
required for:

• Focal injuries identiﬁed on CT


ED Management
Decisions
required for:


• Depressed, basilar, widely diastatic
skull fx


ED Management
Decisions
required for:


skull fx

• Increased ICP


ED Management
Decisions
required for:


skull fx

• Increased ICP

• Deteriorating clinical condition

ED Management
Decisions
• Children with signs of herniation:


ED Management
Decisions

• O2, breathing, BP


ED Management
Decisions


• Hyperosmolar Tx (Mannitol)


ED Management
Decisions



• Mild hyperventilation (PaCO2 30-35)


Disposition: Minor
Head Trauma


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


Disposition: Minor
Head Trauma

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


Disposition: Minor
Head Trauma

• 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


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


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
TBI?


Some ﬁnal words...

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

ROOM A: 7 MO MALE


ROOM A: 7 MO MALE

ACTIVE SZ

INTUBATED,
ANTICONVULSANTS

URGENT NEUROSURG
CONSULT

MANNITOL

ROOM B: 3 YR MALE


bibliography
Langlois, 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.

Questions?
QUESTIONS?


ROOM C


Peds symposium pediatric head trauma 2011 -howard final

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Peds symposium pediatric head trauma 2011 -howard final