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

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Clarifying Murky Waters: Head Injuries in Children

Judith R. Klein, MD, FACEP Assistant Professor of Emergency Medicine UCSF-SFGH Emergency Services

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Case #1: Newborn Leo

• 2 month old dropped

4 feet onto sidewalk during removal from car seat

• Cried/fed since
• PE: small frontal

hematoma

• To image or not to

image, that is the question

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Objectives

Ø Is observation enough? Ø Whom to image? Ø How to image?

• Skull films vs. CT
• Role for ultrasound?

Ø Whom to admit? Ø Return to play? 4

Pediatric head trauma: what’s the big deal?

• #1 cause of death

age 1-14 years

 70% of fatal child

injuries

• >7K deaths
• 60K hospitalizations,
• >600K ED visits per

year

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Why worry?

• 3 to 6% incidence of

TBI post minor head trauma

• Up to 20% of kids < 2

years old with TBI are asymptomatic!

• Second impact

syndrome

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Who gets imaged?

• 40-50% with CHI to ED get imaged!!
• Higher CT rates:

 white race  older  general vs pediatric hospital  emergent triage status  attending treated 6 7

Implications of imaging

• Cognitive development
• Lifetime cancer risk

from 1 head CT (3mSv):

 1:1500 (1 yr old)  1:5000 (10 yr old)

• < 10% of CT’s have

any TBI

• 0.5% of CT’s with

clinically important (CI) TBI

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GCS>14: To CT or not To CT??

• Reduce # of CT’s

performed

 Cancer/brain dev  Sedation  $$$$

• Identify all TBI or just

CI TBI?

 NSU intervention  Hospital >2

nights/intubation>24 hrs

 Death/long term

neurological sequelae

Cancer Identify TBI IQ $$$ Sedation

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The Science

• Several CDRs available
• Only 2 included infants
• PECARN rule the best:

 Largest, 25 centers  Lots of young kids  Clear reference

standard for CI TBI

 Best validation 9 10

PECARN Minor Head Trauma Decision Rule

• Derivation and

validation study

• 42K kids GCS>14:

>10K under 2 yrs

• <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, Lancet 2009

Why identify all TBI: implications for sports/other activities?

Kuppermann et al. Lancet 2009

Under 2 years old

Why identify all TBI: implications for sports/other activities?

Kuppermann et al. Lancet 2009

Over 2 years old

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Severe Mechanism

• MVA with ejection, rollover or death of

another occupant

• Pedestrian or bike w/o helmet
• vs. car
• Fall >3 ft (<2 yr)
• r >5 ft (>2 yr)
• High impact object to

head

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Back to Baby Leo

• Imaging?

 A good idea..

• Imaging for <3

months with scalp hematoma + >3 ft fall

• Thin skulleasily

fracturedstrong correlation with TBI

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Well, can I just do a skull x-ray?

• Skull film cons:

 Hard to read  Not sensitive/specific

enough

 If (+) still need to do

CT

• CT cons:

 Radiation  Cost  Transport from ED  Sedation

Survey says: CT

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Ultrasound and skull fracture?

• Skull fx 4-20x likelihood of TBI
• 15-30% with skull fx TBI
• Prospective study*:

 55 patients  100% sensitivity  95% specificity

• Include in CDR for low risk?

 If US +, then CT? If US -,

• bserve?

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*Parri, J Emerg Med 2012.

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Baby Leo gets a CT

• How do I keep him

still?

 Swaddle  Dextrose H20  Acetaminophen

• CT shows a skull

fracture over posterior fossa

• Admit?

 YES 18

Admit criteria for skull fracture

• Very young-->higher

bleeding risk

• Depressed
• Widely diastatic
• High energy mechanism
• High risk location

(sutures, posterior fossa, dural sinus)

• Poor home situation

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Case #2: Wild Bill

• 20 month old rolls

down 12 stairs

• “Few seconds of

LOC” Cried. Ate.

• Physical Exam:

 GCS?  Talk his language  3 cm temporal

hematoma

• To CT or not to CT?

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Wild Bill: CT or Observation?

• Rule: CT or 6 hour obs for

all < 2 years with non-frontal scalp hematoma

 Location, location…:

• Temporal > parieto-
• ccipital > frontal

 Severe mechanism?:

• Stairs vs. straight fall

 LOC too brief to count

but...

• Verdict: Very careful
• bservation or CT

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Keeping Bill Still

• Sedation choices:

 Ketamine is OK  Rectal methohexital  Dexmedetomidine  IV/IM pentobarbital  Etomidate  Avoid versed

• CT (+) epidural:

Admit

Brutane

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Case #3: The Car’s a Mess...

• 5 year old helmeted

bike vs low speed MV

• No LOC
• V x 3 en route
• Mild headache
• PE:

 Playing  Small parietal scalp

hematoma

• To CT or not to CT?

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Let’s talk observation

• > 2 years
• Isolated vomiting
• No LOC
• Non-severe

mechanism

• Mild headache
• Consider observation

if parents comfortable

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Discharge home?

• Criteria:

 Normal MS  Vomiting controlled  No abuse suspected  Responsible home/

reliable transportation

 Normal head CT*

• Confused after normal

CT?

 Observe x 4-6 hrs

• ->admit if still AMS

Holmes, Annals EM, 2011.

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Case #4: Tell me again what happened to Jane?

• 18 mo old BIB father
• Vomiting x 3 days
• “Tripped at daycare”

4 days ago

• PE: somnolent
• CT by criteria: +SAH!
• What do you do?

 Neurosurgery  Admit

 Child Protective

Services (CPS)

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Epidemic: Non-accidental trauma (NAT)

• 6-10% of pediatric

trauma: NAT

• #1 NAT mortality: head

injury

• Suspect NAT:

 (+) CT: minor/no

reported trauma

 Delayed presentation  Changing history  Other injuries

inconsistent with reported mechanism

 Retinal hemorrhages*

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Return to sports post concussion

• Grading systems not

useful

• Stepwise return to

play based on sx:

 No activity  Light aerobic  Sports specific

exercise

 Non contact drills  Contact practice  Return to play

Halstead, Pediatrics 2010

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Nutshell:

• Whom to CT after trauma?

 <2 years:

• AMS
• Sx skull fracture
• Non frontal scalp hematoma
• >5 seconds LOC
• Not acting normally per parent
• Severe mechanism

 > 2 years:

• AMS
• Sx basilar skull fracture
• Vomiting
• Severe HA
• LOC
• Severe mechanism

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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

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