Minor Head Injury In Children

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Minor Head Injury In Children

• Larry Kleiner
• Medical Director, Dept of Neurosurgery
• The Children's Medical Center

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Head Trauma
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Definition of Mild head injury

• Prejudice against children
• doesnt account for asymetry
• prejudice against facial injury/intubation
• doesnt account for brainstem reflexes

• Glasgow Coma Scale 13-15
• simple
• reproducible
• functional
• valid predicteur

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Modification of the GCS

• Eye opening spontaneous 4
• to sound
  3
• to pain
  2
• none
  1

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Modification of the GCS

• Verbalization

• Appropriate for age 5
• fixes and follows
• social smile
• cries but consolable 4
• persistent irritability 3
• restless,lethargy 2
• none 1

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Modification of the GCS

• Motor Response

• Spontaneous 6
• localizes to pain 5
• withdraws 4
• decorticate 3
• decerebrate 2
• none 1

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Modification of GCS

• Glasgow-Liege Scale
• includes brainstem reflexes
• increases prediction of outcome
• from 76 to 90 with a .9 confidence level

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Modification of the GCS

• Brainstem reflexes/scoring the GLCS
• fronto-orbicluar 5
• vertical-oculocephalics 4
• pupillary reaction to light 3
• horizontal-oculocephalics
  2
• oculo-cardiac
  1
• none
  0

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Epidemiology

• 7-8 million head injuries/year
• 1.5-2.0 million/year with LOC/amnesia
• - 80 considered minor

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Epidemiology

• Trauma leading cause of death age 1-19
• head injury direct cause in 30-50
• major factor in 75
• in MVAs
• 75 have head injuries
• 20 have spinal cord injuries

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Epidemiology

• Head injury overview
• 110 has loss of consciousness
• 250-500,00 hospitalizations/year
• 4,000 deaths/year
• 15-20,000 prolonged hospitalizations/year

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Demographics

• Compared to severe head injuries
  generally younger
• higher frequency of students
• percentage of males is less
• alcohol less frequently involved

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Demographics

• Pediatric head Injury
• higher death rate under the age of two
• bimodal distribution- bikes/cars
• 90 are closed, non-penetrating
• mortality 1-5
  but rises to 17 if coma gt12hr.
• 10 of the deaths are lt ten years of age

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Demographics

• Children arent little adults
• Infants arent little children

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Physiology Unique to Children

• Skull
• relation to spine
• deformability
• thickness
• open sutures
• open fontanel

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Physiology Unique to Children

• Meninges
• wider subarachnoid space over convexity(shear/tear
  ), over all smaller in proportion to brain (less
  buoyancy)
• dura adherently applied to bone

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Physiology Unique to Children

• Brain
• Increased water content
• autoregulatory mechanisms
• pressure/volume compliance shifted left
• contracoup
• post traumatic unconsciousness

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Pediatric post-concussive Syndrome

• Characteristics
• Stunned/unresponsive
• pupils dilated,fixed or
• anisocoric
• bradycardia
• pallor
• perspiration
• vomiting

• Mechanism
• 1. most likely
• vasovagal effect
• 2. some consider
• post-traumatic
• seizure effect

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Treatment

• Efficacy of head trauma sheets
• 66 referred to the document
• 84 found it answered all questions

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Sequellae at 48 hours

• headaches 51
• dizziness 14
• sleepy 14
• naus/vomit 12

• behavioral changes 7
• memory deficits 5
• visual changes 3
• hearing problems 2
• pupillary change 1.5

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Sequellae

• At one week these signs and symptoms are
  approximately halved
• 27 yet to return to normal function at 48hr,
  13 at by one week
• 50 with residual complaints at 3 months
• recovery from cognitive deficits1-3months

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Sequellae

• 10-15 have surgical lesions
• EDH, SDH, ICH, Depressed skull Fx
• lt1 demonstrate talk and die phenomena

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sequellae

• Post Traumatic Seizures
• In isolation impact or early sz (lt1 week)
• not indicative of severe head injury
• not indicative of inc. risk for epilepsy
• 50 occurred in mild group with normal CT
• No role for anticonvulsants

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Classification of Injury

• Primary
• scalp laceration, avulsion
• skull Fx ping-pong linear , depressed
• open/closed, comminuted, basilar
• neck soft tissue, bone, vascular
• brain focal, diffuse

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Primary Head Injuries

• Skull fractures of concern
• open,depressed
• crosses suture lines
• crosses known vascular channels
• arterial
• dural sinuses
• enters into sinuses
• basilar

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Classification of Head Injury

• Secondary
• swelling
• hemorrhage
• edema
• vasospasm
• seizures
• hypotension
• ischemia

• Metabolic
• hypoxia/hypercarbia
• hypo/hypernatremia
• hyperglycemia
• hormonal dysregulation
• dysautonomia
• nutritional

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CT Scans of Intracranial Hemorrhage
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Mechanism of Injury

• Translational
• linear
• focal

• Acceleration-deceleration
• rotational
• concussive-shearing forces

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Mechanisms of injury

• Age Related
• birth injury skull fx via canal vs forceps, CN
• posterior fossa SDH
• infant/toddler falls, abuse
• children falls, bikes, pedestrian-MVA, bike-MVA
• teens falls, MVA, assaults

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Triage

• Approach/attitude
• apparent stability DOES NOT
  insignificant injury
• stay directed, utilize protocols- avoid inertia
• repeat neurologic exam looking for change
• consider the mechanism of injury-think broadly
• alcohol level lt.2 doesnt alter neurologic much,
  but consider drug effect

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Triage

• History
• mechanism of injury (should fit what you see)
• neurologic- recent, remote baseline, SZ, HI
• general-medical, drugs
• psychological/educational

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Triage

• Physical Exam
• CGLCS
• pupils
• respiratory pattern
• sensory modalities
• SEARCH FOR FOCALITY!

• reflexes
• DTR
• cutaneous
• mental status

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Signs of Rostro-caudal deterioration

• decreased LOC
• headache
• vomiting
• visual changes
• pupilary change

• Cushing Triad
• loss of function
• motor/sensory
• respiratory pattern
• change

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Triage

• As A Rule
• Any pupillary inequalitygt 1 mm in a head
  injured child must be attributed to an
  intracranial injury until proven otherwise

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Pathophysiology

• Monroe-Kellie doctrine
• three compartments
• blood
• brain
• CSF
• change in one requires reciprocal change in the
  others

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Clinical Findings in 4500 pediatric head injuries

• Initial LOC
• normal 56.0
• confused 30.2
• major impairment 13.8
• Vomiting 30.3
• Skull Fx 26.6
• linear 72.8
• depressed 27.2
• compound 19.7

• Seizures 7.4
• paralysis 3.8
• pupil abn 3.6
• retinal hem 2.6
• subdural hem 5.2
• epidural hem 0.9
• major sequellae 5.9
• mortality 5.4

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Clinical Profile from 937 Pediatric Head Injuries

• 84 CGCS 13-15
• Mean age 5.5
• Malesgtfemales 21
• Fallsgtpedestrian/MVA
• 75 alert on admission
• 13 had surgical lesions
• 0.3 with CGCS died
• avg. length of stay 2.8 days

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Clinical profile

• Presence of Mass lesions
• Glasgow Coma Scale 15 7.1
• Glasgow Coma Scale 14 9.7
• Glasgow Coma Scale 13 13.6

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Identifying Risk Facteurs

• LOC gt16 minutes gt45Xgtrisk of poor outcome
• small punctate hem/ contusion on CT did not
  adversely effect outcome compared to normal CT.
• Linear,basilar,depressed skull Fxs did Not effect
  outcome
• Diastatic and compound depressed skull Fxs had
  poor outcomes respectively 50 vs 14

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Identifying Risk Facteurs

• GCGS and the patients MENTAL STATUS were the
  best predicteurs of potential deterioration or
  the presence of a mass lesion

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Identifying risk facteurs

• Skull X-ray what role if any??
• Not essential for decision making process
• HOWEVER
• presencegtinc risk of lesion\deterioration
• useful in penetrating injuries
• useful in Non-accidental trauma
• useful in following growing Fx of childhood

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Etiologies of delayed detoriation

• Mass lesions EDH/SDH/ICH
• electrolyte imbalance
• cerebral edema
• seizures

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Recommendations

• Glasgow Coma Scale 13-14
• CT scan and admit for observation
• Glasgow Coma Scale 15 with normal neurologic
  exam/mental status, and normal CT discharge with
  home observation . CT optional?
• Relevance of duration/presence of LOC- varied
  opinion.

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RecommendationsConcussion and Sports

• Confusion w/o amnesia/LOC
• asymptomatic observation 1/2 hr
• confusion with amnesia , no LOC
• observe 24 hr, asymptomatic
• return to activity after one week
• LOC formal medical evaluation
• asymptomatic return to activity in 2-4
  wks

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Fail-Safe vs the Doomsday EDH

• Small percentage(lt1) will develop
• a delayed lesion with Normal original CT
• In patients with abnormal CT scans
• 30 of patients
• develop a delayed lesion not present on first CT
  or worsening of original lesion
• Most will occur within the first 24-36 hrs

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Bicycle Facts

• Helmet laws have reduced mortality 80
• Bikes are assoc with more childhood injury than
  any other consumer product operated by children
• Universal use of helmets would prevent one HI
  every 4 min and save a life DAILY

• 400,000 Rx/yr 1/3 HI
• 300deaths/yr 80 HI
• annual cost8 billion
• 2200/yr sustain permanent disability,
• helmets would
  prevent 1700
• helmets reduce risk of injury85

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Is it a crap shoot?
KNOWLEDGE IS POWER