Clarifying Murky Waters: 4 feet onto sidewalk during removal from - PDF document

2/16/2014 Case #1: Newborn Leo  2 month old dropped Clarifying Murky Waters: 4 feet onto sidewalk during removal from Head Injuries in Children car seat  Cried/fed since  PE: small frontal hematoma Judith R. Klein, MD, FACEP  To image or not to Assistant Professor of Emergency Medicine image, that is the UCSF-SFGH Emergency Services question 1 2 Pediatric head trauma: what’s the Objectives big deal? Ø Is observation enough?  #1 cause of death Ø Whom to image? age 1-14 years Ø How to image?  70% of fatal child  Skull films vs. CT injuries  Role for ultrasound?  >7K deaths Ø Whom to admit?  60K hospitalizations, Ø Return to play?  >600K ED visits per year 3 4 1

2/16/2014 Who gets imaged? Why worry?  40-50% with CHI to ED get imaged!!  Higher CT rates:  3 to 6% incidence of  white race TBI post minor head trauma  older  Up to 20% of kids < 2  general vs pediatric hospital years old with TBI are  emergent triage status asymptomatic!  attending treated  Second impact syndrome 5 6 6 Implications of imaging GCS>14: To CT or not To CT??  Reduce # of CT’s performed  Cognitive development  Cancer/brain dev  Lifetime cancer risk  Sedation from 1 head CT (3mSv):  $$$$ IQ  Identify all TBI or just  1:1500 (1 yr old) Identify TBI Cancer CI TBI? $$$  1:5000 (10 yr old) Sedation  NSU intervention  < 10% of CT’s have  Hospital >2 any TBI nights/intubation>24 hrs  0.5% of CT’s with  Death/long term clinically important (CI) TBI neurological sequelae 7 7 8 2

2/16/2014 PECARN Minor Head Trauma The Science Decision Rule  Several CDRs available  Derivation and validation study  Only 2 included infants  42K kids GCS>14:  PECARN rule the best: >10K under 2 yrs  Largest, 25 centers  <2 years:  Lots of young kids  100% NPV for CI TBI and all TBI  Clear reference  >2 years: standard for CI TBI  99.9% NPV for CI TBI  Best validation  98.4% NPV for all TBI  CT by 20-25% Kuppermann, Lancet 2009 9 9 10 Under 2 years old Over 2 years old Why identify all TBI: implications for sports/other activities? Why identify all TBI: implications for sports/other activities? Kuppermann et al. Lancet 2009 Kuppermann et al. Lancet 2009 3

2/16/2014 Severe Mechanism Back to Baby Leo  MVA with ejection, rollover or death of  Imaging? another occupant  A good idea..  Pedestrian or bike w/o helmet  Imaging for <3 vs. car months with scalp  Fall >3 ft (<2 yr) hematoma + >3 ft fall or >5 ft (>2 yr)  Thin skull  easily fractured  strong  High impact object to correlation with TBI head 13 13 14 Ultrasound and skull fracture? Well, can I just do a skull x-ray?  CT cons:  Skull film cons:  Skull fx 4-20x likelihood of TBI  Radiation  Hard to read  15-30% with skull fx TBI  Cost  Not sensitive/specific  Prospective study*: enough  Transport from ED  If (+)  still need to do  55 patients  Sedation CT  100% sensitivity  95% specificity  Include in CDR for low risk? Survey says: CT  If US +, then CT? If US -, observe? *Parri, J Emerg Med 2012. 15 16 16 4

2/16/2014 Baby Leo gets a CT Admit criteria for skull fracture  How do I keep him  Very young-->higher still? bleeding risk  Swaddle  Depressed  Dextrose H 2 0  Widely diastatic  Acetaminophen  High energy mechanism  CT shows a skull fracture over  High risk location posterior fossa (sutures, posterior fossa, dural sinus)  Admit?  Poor home situation  YES 17 18 Case #2: Wild Bill Wild Bill: CT or Observation?  20 month old rolls  Rule: CT or 6 hour obs for down 12 stairs all < 2 years with non-frontal  “Few seconds of scalp hematoma  Location, location…: LOC” Cried. Ate. • Temporal > parieto-  Physical Exam: occipital > frontal  GCS?  Severe mechanism?: • Stairs vs. straight fall  Talk his language  LOC too brief to count  3 cm temporal but... hematoma  Verdict: Very careful  To CT or not to CT? observation or CT 19 20 5

2/16/2014 Case #3: The Car’s a Mess... Keeping Bill Still  5 year old helmeted bike vs low speed MV  Sedation choices:  No LOC  Ketamine is OK  V x 3 en route  Rectal methohexital  Mild headache  Dexmedetomidine  PE:  IV/IM pentobarbital  Playing  Etomidate  Small parietal scalp  Avoid versed hematoma Brutane  CT (+) epidural:  To CT or not to CT? Admit 21 22 Discharge home? Let’s talk observation  Criteria:  > 2 years  Normal MS  Isolated vomiting  Vomiting controlled  No LOC  No abuse suspected  Responsible home/  Non-severe reliable transportation mechanism  Normal head CT*  Mild headache  Confused after normal  Consider observation CT? if parents comfortable  Observe x 4-6 hrs -->admit if still AMS Holmes, Annals EM, 2011. 23 24 6

2/16/2014 Case #4: Tell me again what Epidemic: Non-accidental trauma happened to Jane? (NAT)  6-10% of pediatric  18 mo old BIB father trauma: NAT  Vomiting x 3 days  #1 NAT mortality: head  “Tripped at daycare” injury  Suspect NAT: 4 days ago  (+) CT: minor/no  PE: somnolent reported trauma  CT by criteria: +SAH!  Delayed presentation  Changing history  What do you do?  Other injuries  Neurosurgery inconsistent with  Admit reported mechanism  Child Protective  Retinal hemorrhages* Services (CPS) 25 26 Nutshell: Return to sports post concussion  Whom to CT after trauma?  Grading systems not  <2 years: useful • AMS  Stepwise return to • Sx skull fracture • Non frontal scalp hematoma play based on sx: • >5 seconds LOC  No activity • Not acting normally per parent  Light aerobic • Severe mechanism  Sports specific  > 2 years: • AMS exercise • Sx basilar skull fracture  Non contact drills • Vomiting  Contact practice • Severe HA  Return to play • LOC Halstead, Pediatrics 2010 • Severe mechanism 27 28 7

2/16/2014 Nutshell (cont):  Whom to admit?:  All TBI*  High risk skull fractures • Depressed • Wide diastasis • Very young • High energy mechanism • High bleeding risk  Persistent AMS after observation  Poor social/transport situation  Suspected abuse  Neurosurgery discretion 29 30 8