An evidence based ED approach to Pediatric minor head injuries

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An evidence based ED approach to Pediatric minor
head injuries

• Itai Shavit, MD

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????? ?-GCS ??? ? ????? ????? ??????? CT ?
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25 ???????? 1999
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2001 gtgtgt 2005We now have more evidence

• Schutzman SA et al. Evaluation and management of
  children younger than two years old with
  apparently minor head trauma proposed
  guidelines. Pediatrics. 2001107983-993
• Simon B et al. Pediatric minor head trauma
  indications for computed tomographic scanning
  revisited.
• J Trauma. 200151231-238
• Palchak MJ et al. A decision rule for identifying
  children at low risk for brain injuries after
  blunt head trauma.
• Ann Emerg Med. 200342(4)495-506
• Dunning J et al. A meta-analysis of variables
  that predict significant intracranial injury in
  minor head trauma.
  Arch Dis Child. 200489653-659

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2001 gtgtgt 2005We now have more evidence

• Palchak MJ et al. Does an Isolated History of
  Loss of Consciousness or Amnesia Predict Brain
  Injuries in Children After Blunt Head Trauma?
• Pediatrics. 2004113507-513
• Reed MJ et al. Can we abolish skull x rays for
  head injury?
• Arch Dis Child. 200590859-864
• Macgregor DM et al. CT or not CT- that is the
  question. Whether it is better to evaluate
  clinically and x ray than to undertake a CT head
  scan.
• Emerg Med J. 200522541-543

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Pediatric MHI ? Adult MHI
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Pediatric Minor head injury
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Occult ICI?
Clinical Indicators of Intracranial Injury in
Head-injured InfantsGreenes and
SchutzmanPediatrics 1999104861-867
A 1-year prospective study of all infants younger
than 2 years of age presenting to a pediatric ED
with head trauma
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(No Transcript)
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Occult ICI?
608 patients 30 (ICI) 12/92 (0-2mo) 13/224
(3-11mo) 5/292 (12-24mo)
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Occult ICI?
Only 16/30 (52) subjects with ICI had at least
one of the following clinical symptoms or signs
of brain injury loss of consciousness, history
of behavior change, seizures, emesis, depressed
mental status, irritability, bulging fontanel,
focal neurologic findings, or vital signs
indicating increased intracranial pressure.

14/30 were
asymptomatic
Of the 14 asymptomatic subjects with ICI,
13 (93) had significant scalp hematoma
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Occult ICI?
Clinical signs of brain injury are insensitive
indicators of ICI in
young infants A substantial fraction of infants
with ICI will be detected through radiographic
imaging of otherwise asymptomatic infants with
significant scalp hematomas Asymptomatic infants
older than 3 months of age who have no
significant scalp hematoma may be safely managed
without radiographic imaging
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Whats the problem. Lets CT them all
Paterson A, Frush DP, Donnelly LF. Helical CT of
the body are settings adjusted for pediatric
patients? AJR Am J Roentgenol.2001 176 297
301 Brenner DJ, Elliston CD, Hall EJ, Berdon W.
Estimated risks of radiation-induced fatal cancer
from pediatric CT. AJR Am J Roentgenol.2001 176
289 296 Donnelly LF, Emery KH, Brody AS, et
al. Minimizing radiation dose for pediatric body
applications of single-detector helical CT. AJR
Am J Roentgenol.2001 176 303 306
Derived from 50-year follow-up of atomic bomb
survivors, medical exposures (especially
radiation oncology) and occupational exposures
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Whats the problem. Lets CT them all
Estimated risks of radiation-induced fatal cancer
from pediatric CT. Brenner D,
Elliston C, Hall E, Berdon W

Am J Roentgenol 2001 176289-96
Assessment of the lifetime cancer mortality
risks
attributable to radiation from pediatric CT
In the United States, of approximately 600,000
abdominal and head CT examinations annually
performed in children under the age of 15 years,
a rough estimate is that 500 of these individuals
will ultimately die from cancer attributable to
the CT radiation
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Radiation Risks and Pediatric Computed Tomography
(CT) A Guide for Health Care Providers
(20/08/2002)
Radiation Risks from CT in Children is a Public
Health Issue

• Radiation exposure is a concern in both adults
  and children.
• However, there are two unique considerations in
  children
• Children are considerably more sensitive to
  radiation than adults, as demonstrated in
  epidemiologic studies of exposed populations.
• 2. Children also have a longer life expectancy,
  resulting in a larger window of opportunity for
  expressing radiation damage.

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EXAM TYPE RELEVANT ORGAN APPROXIMATEEQUIVALENT DOSE TORELEVANT ORGAN (mSv)
Pediatric Head CT ScanUnadjusted Settings(200 mAs, neonate) Brain 60
Pediatric Head CT ScanAdjusted Settings(100 mAs, neonate) Brain 30
Pediatric Abdominal CT ScanUnadjusted Settings(200 mAs, neonate) Stomach 25
Pediatric Abdominal CT ScanAdjusted Settings(50 mAs, neonate) Stomach 6
Chest X-ray (PA/lateral) Lung 0.01 / 0.15
Screening Mammogram Breast 3
The lowest equivalent doses for which increased
cancer risks were observed in A-bomb survivors
were in the range of 50 to 200 mSv (5 to 20 rem).
"Unadjusted" refers to using the same
settings as for adults. "Adjusted" refers to
settings adjusted for body weight.
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The ER doc
. All physicians who prescribe pediatric CT
should continually assess its use on a
case-by-case basis
the Radiologist
.. it is important to limit CT radiation by
following the ALARA (as low as reasonably
achievable) principle. There is a variety of
strategies to limit radiation dose, including
performing only necessary examinations, limiting
the region of coverage, and adjusting individual
CT settings based on indication, region imaged,
and size of the child
P. Frush, L. F. Donnelly, and N. S. Rosen.
Computed Tomography and Radiation Risks What
Pediatric Health Care Providers Should Know.
Pediatrics, October 1, 2003 112(4) 951 - 957
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Risk Minimizers vs. Test Minimizers

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Intra-Cranial Injury ?
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Factors Associated with Intracranial Injury
Historical of Exam Finding Comment
LOC Marginal PPV for detecting ICI
Emesis Marginal PPV for detecting ICI
Scalp Hematoma (lt 2y/o) Good PPV for ICI
Facial Injury Marginal PPV for detecting ICI
Decreased GCS (from 15) Good PPV for detecting ICI
Headache Marginal PPV for detecting ICI
Focal neurologic deficit High PPV for ICI
Amnesia Marginal PPV for detecting ICI

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Factors Associated with Intracranial Injury
Historical of Exam Finding Comment
Irritability Marginal PPV for detecting ICI
Bulging fontanelle High PPV for detecting ICI (not common)
Clinical signs of skull Fx (depressed or basilar) High PPV for ICI
Age lt 1 y/o Increased risk for ICI (expert consensus)
Age lt 3 months High risk for ICI (expert consensus)
Progressively worsening vomiting Increased risk for ICI (expert consensus)
High energy mechanism of injury (fall from height, MVC) High risk for ICI (expert consensus)
LOC gt 1 minute Increased risk for ICI (expert consensus)
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Isolated HI GCS13
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Take home messages .

• Physicians trained in the physical examination of
  young children should see these kids
• Good history (high energy mechanism?) and
• a thorough physical examination is the key
• Isolated HI? GCS 13-15 ? Scalp hematoma?
• Ottorhea? Rinorhea?
• Depressed skull ?
• Does the neurological examination compatible with
  the age of the baby?

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