Clarifying Murky Waters: Is observation enough? Head and Cervical - PDF document

2/1/2013 Objectives Clarifying Murky Waters: Ø Is observation enough? Head and Cervical Spine Ø Whom to image? Injuries in Children Ø How to image?  Skull films vs. CT  Role for ultrasound?  C spine plain films vs CT Judith R. Klein, MD, FACEP vs MRI Assistant Professor of Emergency Medicine UCSF-SFGH Emergency Services Ø Whom to admit? 1 2 Pediatric head trauma: what’s the Why worry? big deal?  #1 cause of death  3 to 6% incidence of age 1-14 years TBI post minor head  70% of fatal child trauma injuries  Up to 20% of kids < 2  >7K deaths years old with TBI are  60K hospitalizations, asymptomatic!  >600K ED visits per year 3 4 Who gets imaged? Implications of imaging  40-50% with CHI to ED get imaged!!  Cognitive development  Higher CT rates:  Lifetime cancer risk  white race from 1 head CT:  older  1:1500 ( 1 yr old)  general vs pediatric hospital  1:5000 ( 10 yr old )  emergent triage status  < 10% of CT’s have  attending treated any TBI  0.5% of CT’s with clinically important (CI) TBI 5 5 6 6 1

2/1/2013 GCS>14: To CT or not To CT?? The Science  Reduce # of CT’s performed  Several CDRs available  Radiation/brain dev  Only 2 included infants  Sedation  PECARN rule the best:  $$$$ IQ  Identify all TBI or just  Largest, 25 centers Identify TBI Cancer CI TBI? $$$  Lots of young kids Sedation  NSU intervention  Clear reference  Hospital >2 standard for CI TBI nights/intubation>24 hrs  Best validation  Death/long term neurological sequelae 7 8 8 PECARN Minor Head Trauma Under 2 years old Decision Rule  Derivation and validation study  42K kids GCS>14: >10K under 2 yrs Why identify all TBI: implications for sports/other activities?  <2 years:  100% NPV for CI TBI and all TBI  >2 years:  99.9% NPV for CI TBI  98.4% NPV for all TBI  CT by 20-25% Kuppermann et al. Lancet 2009 Kuppermann, Lancet 2009 9 Over 2 years old Severe Mechanism  MVA with ejection, rollover or death of another occupant  Pedestrian or bike w/o helmet vs. car Why identify all TBI: implications for sports/other activities?  Fall >3 ft (<2 yr) or >5 ft (>2 yr)  High impact object to head Kuppermann et al. Lancet 2009 12 12 2

2/1/2013 Back to Baby Leo Well, can I just do a skull x-ray?  CT cons:  Skull film cons:  Imaging?  Radiation  Hard to read  A good idea..  Cost  Not sensitive/specific  Imaging for <3 enough  Transport from ED months with scalp  If (+)  still need to do  Sedation hematoma + >3 ft fall CT  Thin skull  easily fractured  strong correlation with TBI Survey says: CT 13 14 Ultrasound and skull fracture? Baby Leo gets a CT  How do I keep him  Skull fx 4-20x likelihood of TBI still?  15-30% with skull fx TBI  Swaddle  Dextrose H 2 0  Prospective study*:  Acetaminophen  55 patients  CT shows a skull  100% sensitivity fracture over  95% specificity posterior fossa  Include in CDR for low risk?  Admit?  If US +, then CT? If US -,  YES observe? *Parri, J Emerg Med 2012. 15 15 16 Admit criteria for skull fracture Case #2: Wild Bill  20 month old rolls  Very young-->higher down 12 stairs bleeding risk  “Few seconds of  Depressed LOC” Cried. Ate.  Widely diastatic  Physical Exam:  High energy mechanism  GCS?  High risk location (sutures, posterior fossa,  Talk his language dural sinus)  3 cm temporal  Poor home situation hematoma  To CT or not to CT? 17 18 3

2/1/2013 Wild Bill: CT or Observation? Keeping Bill Still  Rule: CT or 6 hour obs for  Sedation choices: all < 2 years with non-frontal scalp hematoma  Ketamine is OK  Location, location…:  Rectal methohexital • Temporal > parieto-  Dexmedetomidine occipital > frontal  IV/IM pentobarbital  Severe mechanism?:  Etomidate • Stairs vs. straight fall  Avoid versed  LOC too brief to count Brutane but...  CT (+) epidural:  Verdict: Very careful Admit observation or CT 19 20 Case #3: The Car’s a Mess... Let’s talk observation  5 year old helmeted  > 2 years bike vs low speed MV  Isolated vomiting  No LOC  V x 3 en route  No LOC  Mild headache  Non-severe  PE: mechanism  Playing  Mild headache  Small parietal scalp  Consider observation hematoma if parents comfortable  To CT or not to CT? 21 22 Case #4: Tell me again what Discharge home? happened to Jane?  18 mo old BIB father  Criteria:  Vomiting x 3 days  Normal MS  Vomiting controlled  “Tripped at daycare”  No abuse suspected 4 days ago  Responsible home/  PE: somnolent reliable transportation  CT by criteria: +SAH!  Normal head CT*  What do you do?  Confused after neg  Neurosurgery CT?  Admit  Observe x 4-6 hrs  Child Protective -->admit if still abnl Services (CPS) Holmes, Annals EM, 2011. 23 24 4

2/1/2013 Epidemic: Non-accidental trauma Nutshell: (NAT)  Whom to CT after trauma?  6-10% of pediatric  <2 years : trauma: NAT • AMS  #1 NAT mortality: head • Sx skull fracture injury • Non frontal scalp hematoma  Suspect NAT : • >5 seconds LOC  (+) CT: minor/no • Not acting normally per parent reported trauma • Severe mechanism  Delayed presentation  > 2 years :  Changing history • AMS  Other injuries inconsistent with • Sx basilar skull fracture reported mechanism • Vomiting  Retinal hemorrhages* • Severe HA • LOC • Severe mechanism 25 26 Nutshell (cont): Return to sports post concussion  Whom to admit?:  Grading systems not  All TBI useful  High risk skull fractures  Stepwise return to • Depressed play based on sx: • Wide diastasis  No activity • Very young  Light aerobic • High energy mechanism • High bleeding risk  Sports specific  Persistent AMS after observation exercise  Poor social/transport situation  Non contact drills  Suspected abuse  Contact practice  Neurosurgery discretion  Return to play Halstead, Pediatrics 2010 27 28 Some background on pediatric Case #5: Do you have neck pain?? c-spine injuries  6 month old rear car- seat passenger MVA-  Uncommon injury rear-ended (3x more common in  Car-seat/patient in adults) place  More common in  PE: VS nl. Happy, no older kids (> 8 years) signs of trauma  Leading causes:  How do I clear the c-  MVA (<8 yrs) spine?  Sports (>8 yrs)  PVA 29 30 5

2/1/2013 Kids aren’t just little adults… Clearing little c-spines  Unique anatomy:  NEXUS:  Large head  high  3065 kids fulcrum  30 CS injuries:  Higher injuries more • Only 4 injuries 2-8 common in < 8 year old years  Horizontal facets • None < 2 years  slippage/dislocation  Criteria: (100% sens)  Less neck muscle • No neck tenderness  More pre-vertebral soft • No focal neuro sx tissue • No distracting injury  > 8 years more like • Normal MS adult • No intoxication 31 32 Applying NEXUS criteria PECARN: Risk factors for CSI  540 CSI cases/1060 controls  187 kids with c-spine  Risk factors: injury-->NEXUS rules  AMS/focal neuro sx applied:  Neck pain/torticollis  32 kids < 8 yrs: 94% sensitivity  Significant torso injury  155 kids > 8 yrs:  High risk condition 100% sensitivity  Diving/high risk MVA  98% sensitive  * Garton, Neurosurgery, 2008.  CT use by 25% Leonard, Annals EM, 2011. 33 34 34 Modified NEXUS: Case # 6: Johnny Walker Clearing younger c-spines  5 yr old 20 mph PVA  Age appropriate MS/no  BIBA with (+) LOC LOC/no focal neuro sx  Now awake/alert  No distracting  No c/o of neck pain or neurological sx injury/significant torso  Open leg fracture injury  Image: YES  No neck tenderness or  LOC pain/muscle spasm  Distracting injury  Low force  High force mechanism mechanism....  Let them look around 35 36 6