When Elsa Slips. More Than Brain Freeze: Pediatric Head Trauma - - PDF document

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Driscoll Children’s Hospital

Presents

When Elsa Slips…. More Than Brain Freeze: Pediatric Head Trauma

Alicia Hart, MD, FACEP, FAAFP CCMC Trauma Medical Director Del Mar EMS Medical Director Why Are We Here?

• Develop a strategy for the evaluation of pediatric head trauma.
• Learn the types of pediatric head injuries.
• Discuss the management of minor head injury.
• Discuss the management of moderate and severe head trauma.
• Identify risk factors and signs of non-accidental trauma.
• Head injuries account for ~500,000 ED visits, 37,000 hospitalizations, and >2000

deaths every year in the United States

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Olaf

• Olaf is a delightful and active 2 year old boy. He

loves warm hugs and summertime. His grandma came over to visit. In his excitement to run to grandma, he slipped and fell. He hit his occiput

• n the tile floor of his home. There was no LOC.
• When you enter the exam room, Olaf is playing

with a toy and drinking from a sippy cup. Minor Head Trauma

• Healthy child that is over 2 years old.
• GCS of 14-15 at initial exam.
• No abnormal or focal neuro findings.
• No sign of skull fracture.
• No severe mechanism.
• No vomiting.

PECARN

• Pediatric Emergency Care Applied Research Network
• Studied 42,412 children in 25 North American pediatric ED
• Who do we need to image to detect CLINICALLY SIGNIFICANT head injuries?

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Olaf’s Disposition

• After a thorough physical exam....

– We will discuss head injury precautions and recommend follow up with the patient’s doctor. – Discuss reasons to return to the ED. – We will advise AGAINST imaging. – Discharge Olaf home.

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Kristoff and Sven Kristoff is an adventurous 7 y/o boy and Sven is his 5 y/o tag-a-long brother. They were riding through the neighborhood on the spiffy new motorized scooter he got for Christmas. He ran into a parked

• car. Neither child was wearing a helmet. There

was no LOC in either child. Sven has been vomiting and has been acting “whiny” according to mom. Kristoff is complaining of a mild headache. Sven-Physical Exam

• An adorable 5 y/o male that is developmentally appropriate.
• He is vomiting during the exam. He tells you “my head hurts”.
• You note a 3 cm hematoma to the occiput. No focal neuro deficits.
• Mother is anxious and appropriate. She reports that dad is a trial attorney and is
• n his way to the hospital.

Intermediate Risk Patients

• Seizures
• LOC
• Amnesia
• Vomiting
• Age less than 2 years
• Nonfrontal scalp hematoma in children younger than one year of age
• Persistent or worsening headache
• Significant trauma mechanism

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What do we do with the Intermediate Risk Patient?

• Neuroimaging?

– The lifetime risk of death due to cancer caused by radiation from

• ne head CT
• 1 in 1500 in a one year old infant
• 1 in 5000 in a 10 year old child
• Shared Decision Making

– Observation for 4-6 hours

Discharge Criteria

• No suspicion of inflicted injury
• Easily arousable with light touch with normal GCS
• Return to baseline
• If vomiting, able to tolerate fluids
• No other injuries requiring admit
• Competent caregivers who can follow discharge

instructions

Discharge Instructions

• Return if

–Persistent or worsening headaches –Vomiting –Change in mental status or behavior –Unsteady gait –Seizure or LOC –Bloody/clear rhinorrhea or otorrhea –Focal weakness or numbness –Irritability –Difficulty staying awake or being aroused

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Elsa

• Elsa is a sweet 8 y/o girl who loves playing dress up. She

put on her mom’s heels and was playing with her sister. She tripped and fell down one flight of stairs. She landed

• n tile. Her mother found her unconscious after hearing

the fall.

• 911 was notified and the child arrived fully immobilized.

She has a large temporal hematoma. She is vomiting. Her GCS is 9.

Types of Brain Injury

• Diffuse brain injury

– Occurs from acceleration or deceleration injuries – Mildest form-concussion

• Diffuse axonal injury

– Severe form of diffuse brain injury – Shearing at the interface of the gray and white matter

• Focal injuries

– Contusions or intracranial hemorrhages

• Epidural hematoma
• Subdural hematoma
• Subarachnoid hemorrhage

Subdural Hematoma

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Epidural Hematoma Subarachnoid Hemorrhage Intracranial Hemorrhage

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Management of Severe Brain Injury

• Airway and breathing

– Consider RSI

• Fluid Management
• Head positioning

– 30 degrees

• Sedation
• Seizure prophylaxis
• Avoid hyperthermia/hypothermia
• Hyperosmolar therapy
• Neurosurgery consultation and transfer to trauma center

Who do we have to image?

• History

–Witnessed LOC >5 minutes –History of amnesia >5 minutes –Abnormal drowsiness –Three or more episodes of vomiting –Suspicion of non accidental trauma –Seizure in a patient with no history of epilepsy

Who do we have to image?

• Examination

–GCS <14 or GCS <15 if <1 year old –Penetrating trauma or depressed skull injury –Tense fontanelle –Signs of a basilar skull fracture –Focal neuro deficits –Bruise, swelling, or laceration >5 cm if <1 year old

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Who do we have to image?

• Mechanism

–High speed traffic accident >40 mph –Fall >3 m –High speed injury from a projectile or an object

Anna

Anna is an 8 month old infant who is brought in by her foster parents. She was brought in for vomiting and “sleeping too much.” Foster mom reports the baby rolled off the couch a few days ago. Vaccines are not up to date. The baby’s parents were killed in a boating accident and she was placed in foster care about 6 weeks ago.

Physical Exam

• Child is lethargic and irritable. She is dirty.
• Multiple areas of bruising in various stages of healing.
• She has tenderness to her upper arms and legs.
• She appears to have retinal hemorrhages.

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Evaluation of suspected nonaccidental trauma

• High level of suspicion
• Laboratory studies

–CBC, coags, electrolytes, liver function panel

• Imaging

–CT, MRI, skeletal survey

• Ophthalmologic exam

Retinal Hemorrhages Posterior Rib Fractures

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Shaken Baby Findings on MRI Management

• Stabilize critical issues.
• Multidisciplinary team to address the concerns and

document concerns of abuse.

• Protect the child.

Prevention of Head Injuries

• Helmet Education
• Car safety Seat checks
• Public education about head injuries
• Public education about shaken baby syndrome.
• Home visitation to high risk homes.

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LET IT GO!!

• No more CT imaging of low risk head injuries
• Use of clinical decision rules to help decide who really

needs imaging

• Use of extended observation to reduce imaging
• Use of shared decision making