Pediatric Head Trauma: Part II

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Pediatric Head TraumaPart II

• Joshua Rocker, MD
• Pediatric Emergency Medicine
• Schneider Childrens Hospital

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Outline

• Definitions
• Epidemiology
• Evaluation
• Evidence
• Summary

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Definitions

• Traumatic Brain Injury
• Any blow or jolt to the head or acceleration/
  deceleration of the head which may cause an
  injury
• Closed Head Injury
• An example of a TBI without any penetrating
  injury into the brain

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Minor Closed Head Trauma

• An example of a Closed Head Injury with
• Normal mental status
• Normal neurological exam
• Normal fundoscopic exam
• No physical signs of skull fracture

Mgmt of minor closed head injury in children.
Committee on QI, AAP, Commission on Clinical
Policies Research, AAFP. Pediatrics 1999
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Epidemiology of Pediatric Head Injury
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Childrens Health Act of 2000

• Big financial backing by Congress for research in
  pediatrics.
• Mandated the CDC to report on incidence and
  prevalence of traumatic brain injuries.

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Head Injuries The numbers!

• Trauma- 1 cause of mortality and morbidity gt 6
  mo.
• Head injury is the 1 cause of death in these
  traumas

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Traumatic Brain Injury- all ages

• 1.4 million in the US per year
• 835,000 - male
• 561,000 - female
• 50,000 deaths
• 235,000 hospitalizations
• 1.1 million treated and discharged from ER

National Center for Injury Prevention and
Control, CDC, 1995-2000
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Pediatric TBI

• 2,685 deaths
• 37,000 hospitalizations
• 435,000 emergency department visits (Langlois et
  al. 2004).
• Approximately 75 of TBIs that occur each year
  are concussions or other forms of mild TBI. (CDC
  2003).

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Head Injuries the differences

• Age
• Infants- fall or non-accidental
• vs.
• Adolescent- sports, MVAs
• Sex
• males females (2-41)

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Evaluation
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MCHI Evaluation

• ABCs
• Stabilize cervical spine if necessary
• Secondary survey
• Stabilize other injuries if necessary
• Obtain appropriate HPI and PMH

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Evaluation

• IMAGE!!!???
• CT
• Skull X-ray
• MRI
• Observe
• ??????????????????????????

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Considerations

• Prevalence of TBI
• The that need intervention
• Efficacy of treatment
• Poor outcome if delay diagnosis
• and
• Risk associated with imaging

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Risks of Imaging

• Head CT approx 150-600x more radiation exposure
  then a CXR.
• Brenner, et al, determined the estimated lifetime
  cancer mortality risks attributed to the
  radiation exposure from a single head CT in a one
  year old is 0.07 (1 in 1400)
• Brenner, DJ, Elliston, CD, Hall, EJ, and Berdon,
  WE. Estimated Risks of Radiation-Induced Fatal
  Cancer from Pediatric CT. American Journal of
  Roentgenology. 2001. 176 289-296.

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Risk of imaging

• Risk of sedation, if needed
• Risk of pursuing false positive

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The Evidence

• Show me the money!!!

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AAP Guidelines

• Technical Report Minor Head Injury in Children
• Pediatrics, Dec. 1999
• Conclusion- The literature on mild head trauma
  does not provide a sufficient scientific basis
  for evidence-based recommendations about most of
  the key issues in the clinical management.

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Problems

• There were no large pediatric trauma studies
  which address the major management issues in
  minor head trauma
• Most were small and retrospective

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AAP Guidelines

• The Management of Minor Closed Head Injury in
  Children
• Pediatrics Dec, 1999
• Literature Review- 64 articles
• Inclusion
• 2-20 y/o
• Isolated minor head trauma

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AAP Guidelines Case 1

• MCHI and no LOC
• Obtain thorough history and physical
• Observation in clinic, office, ER or home
• Reliability of family essential for dispo
• No radiological studies recommended
• (Remember MCHI nl mental status, nl
  neurological exam, nl fundoscopic exam, no
  physical signs of skull fracture)

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AAP Guidelines Case 2

• MCHI with brief LOC (lt1 min)
• Thorough history and physical
• Observation optional
• CT optional
• Skull radiographs not recommended

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Data

• Wide variability of inclusion criteria of
  studies.
• Children with hx of LOC, amnesia, HA or vomiting
  at time of evaluation have a 0-7 prevelance of
  ICI.
• 2-5 of children with MCHI with LOC may require
  neurosurgical intervention.

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Data

• Limited predictive value of HA, vomiting or
  lethargy.
• Conflicting data on the urgency for diagnosis
  subdural or epidural.

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Data

• Point
• no real consistency in evidence.

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Evidence Baseline to compare

• Masters SJ, et al. Skull radiograph examinations
  after head trauma
• N Engl J Med 1987 31684-91
• Prospective study
• 7035 patients- from 31 ERs
• 5252 categorized as low risk for ICI
• asymptomatic or with one or more of the
  following HA, dizziness, scalp hematoma, lac,
  contusion or abrasion.
• No LOC.
• 0 had ICI
• Conclusion Radiographic studies in low risk
  patients can be avoided.

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Evidence in Pediatrics

• No large prospective studies Limited data.
• Dietrich, et al, Ann Emer Med, 1993
• 322 consecutive head CTs on trauma patients
• 5 of patients with GCS of 15 had evidence of ICI
• Loss of consciousness, amnesia for the event, a
  Glasgow Coma Scale (GCS) of less than 15, or the
  presence of a neurologic deficit were more common
  in children with intracranial injury (P lt .05).
• Vomiting, seizures, and headache were not
  discriminating clinical features.
• No single characteristic consistently identified
  the children with an intracranial injury

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Evidence in Pediatrics

• Dacey, RG, et al, J Neurosurg, 1986
• 610 children with NCHI with GCS gt12
• 11 had skull fractures
• 3 required NS intervention
• 2 pts (0.3) of the patients with GCS of 15 with
  nl skull Xray required NS
• Hennes, et al, Am J Dis Child, 1988
• 55 patients
• 3 with moderate injury and 8 with mild injury
  all with normal CT
• Chen, et al, Neurosur, 1993
• 74 patients with epidurals and a GCS gt11
• After the 3-day period, in the absence of
  neurological symptoms, the presence of the EDH
  may not be an indication for surgical evacuation
  or hospitalization beyond 7 days

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More Studies
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Dunning, et al

• A meta-analysis of variables that predict
  significant injury in minor head trauma
• Archives of Disease in Childhood, 2003
• 16 studies pooled
• 22,420 patients

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Dunning

• Increased relative risk of ICI
• Reduced level of consciousness (5.5)
• Focal neuro deficit (9.4)
• Skull fracture (6.1)
• LOC (2.2)

• No increased risk of ICI (less reliable data)
• HA
• Seizure
• Vomiting

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Palchak, et al (1)

• A Decision Rule for Identifying Children at Low
  Risk for Brain Injuries After Blunt Head Trauma
• Annals of Emerg Med, Oct, 2003
• University of California, Davis

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Palchak 1

• Prospective- 3 year study
• lt18 y/o
• All severities
• Excluded trivial traumas
• Fall from ground level
• Walking/running into stationary objects if only
  PE is scalp lac/abrasion.

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Palchak (1)

• Outcome variables
• TBI on CT
• TBI requiring acute intervention

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Palchak (1)

• 2,640 eligible, 2043 (77) enrolled
• Mean age- 8.3
• CT scans on 1271 (62.2)
• 98 (7.7) with TBI on CT
• 75/98 required intervention (76.5)
• 29 (27.6) of the patients with TBI requiring
  acute intervention didnt have CT for TBI

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Palchak (1)

• Predictor variable
• Amnesia
• LOC
• HA
• Sz
• Vomiting
• Clinical SF
• Focal ND
• Scalp hematoma lt2
• AMS

• Relative Risk of CT
• 2.1
• 2.6
• 1.5
• 2.4
• 2.3
• 5.5
• 5.3
• 2.6
• 6.8

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Palchak (1)

• Predictor variable
• Amnesia
• LOC
• HA
• Sz
• Vomiting
• Clinical SF
• Focal ND
• Scalp hematoma lt2
• AMS

• RR of acute intervent
• 4.7
• 7.6
• 4.5
• 5.3
• 3.5
• 11.3
• 10.6
• 1.2
• 21.7

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Palchak (1)

• Decision tree
• for predicting
• CT

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Palchak (1)

• Decision tree
• for predicting
• intervention

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Palchak (1)

• Decision tree
• for predicting
• CT with
• GCS 14-15

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Palchak (1)

• Decision tree
• for predicting
• CT in
• children lt2

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Palchak, et al (2)

• Does an Isolated History of LOC or Amnesia
  Predict Brain Injuries in Children After Blunt
  Head Trauma?
• PEDIATRICS, June 2004
• University of California, Davis

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Palchak (2)

• 2043 patients in ER for trauma eval over a 3 year
  period (same data set)
• lt18 y/o, mean 8.3 yrs
• 62 underwent CT
• 7.7 with CT for TBI
• 23 of that 7.7 did not require intervention
• 42 with hx of LOC and/or amnesia

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Palchak (2)

• Risk of TBI increased if LOC
• (3.7 v 9.7)
• Risk of TBI with LOC or amnesia and absence of
  other findings was ZERO.
• Follow up in 88- no patients had missed TBI.

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Palchak (2)

• Conclusion
• LOC and amnesia in isolation appear to carry no
  more risk of CT or of requiring intervention.
• Recommendation to eliminate isolated LOC and/or
  amnesia as indications for CT in pediatric trauma
  patients

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Schutzman, et al

• Evaluation and Management of Children Younger
  than Two Years Old with Apparently Minor Head
  Trauma Proposed Guidelines.
• Pediatrics, 2001
• Used evidence and expert consensus

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Schutzman

• Question 1 Indications for CT?
• Incidence of ICI is 3-6, with higher incidence
  in the younger children.
• Clinical predictors
• AMS, focal neuro deficit, scalp swelling, young
  age, inflicted injury and head injury no clear hx
  of trauma
• LOC and vomiting not risk factors
• Occult ICI more prevalent in 0-6 month range

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Schutzman

• Question 2 Indications for skull films?
• Skull fractures one of the strongest predictors
  for ICI
• The incidence of scalp hematoma is 80-100
  sensitive for associated SF.
• Question 3 If fracture present should CT be
  obtained?
• If SF present ICI in 15-30.

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Schutzman

• Question 4 If CT normal, dispo?
• In 3 studies including 261 patients 0 had late
  deterioration.
• Question 5 If SF but normal CT, dispo?
• In 6 studies including 349 patients 0 had late
  deterioration.

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Schutzman Management Strategy

• Stratify patients into 4 groups
• High risk
• Some risk because of concerning symptoms
• Some risk without symptoms
• Low risk

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Schutzman

• High risk
• CT indicated!
• Qualifications
• AMS, focal neuro deficit, signs of depressed of
  basilar SF, evidence of SF, irritability, bulging
  fontanel,
• LOC gt1min and vomiting gt5 times or lasting longer
  than 6 hours (but not evidence based)
• (maintain a low threshold for children lt3 months)

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Schutzman

• Intermediate Risk
• Group 2 (Unknown or concerning mechanism)
• CT/SR
• Qualifications
• Higher force mechanism
• Fall onto hard surface
• Scalp hematoma
• Suspect intentional injury

• Intermediate Risk
• Group 1
• CT/observation
• Qualifications
• 3-4 episodes of vomiting
• Transient LOC (lt1 min)
• Hx of lethargy or irritability
• Behavior not baseline
• Nonacute SF (gt24 hrs old

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Schutzman

• Intermediate Risk
• Dispo
• If CT negative
• Observed for 4-6 hours post-injury and no
  concerning symptoms

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Schutzman

• Low Risk
• Observation
• Minimal mechanism

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HEY!!!!!!!!!!!

• Just one more study so..
• wake up!!!

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Roddy, et al

• Minimal Head Trauma in Children Revisited Is
  Routine Hospitalization Required
• PEDIATRICS, April 1998
• Yale-New Haven Hospital

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Roddy

• Methods
• Retrospective review over 3 years 1992-1995
• N-267188 (GCS-15) 62 (all criteria)
• Inclusion Admitted for trauma with
• 0-16 y/o
• Had LOC or amnesia
• An initial Glasgow Coma Scale of 15
• a normal neurologic exam
• a normal head CT scan
• Exclusion Children with associated injuries
  requiring admission

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Roddy

• Endpoint
• Deterioration in CNS exam
• new CT findings
• The need for a prolonged hospital stay

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Roddy

• Results
• The mean length of stay was 1.2 days (range, 1 to
  3 days). Prolonged hospitalization occurred in
  9 patients (15). No child developed significant
  CNS sequelae warranting hospital admission.
• The average patient charge was 2869 per hospital
  stay. Total charges for these hospitalizations
  were 177 874.

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Roddy

• Conclusion
• Children undergoing emergency department work-up
  of occult head injury, who have a normal CNS exam
  and a normal head CT scan, do not seem to be at
  risk for significant CNS sequelae.

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SUMMARY

• Very difficult decision!!!
• No clear guidelines established by the AAP
• More larger studies need to be produced in
  pediatrics

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SUMMARY

• KEY POINTS
• AMS, focal neuro deficits and skull fractures
  very concerning.
• HA, sz and vomiting alone less concerning
• LOC and amnesia alone may be insignificant
• With children under the age of 2 years
  (especially under 6 months) one should be
  conservative
• If CT -, minimal risk for neuro sequele.

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Confused? Questions?
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Thank You

• Applaud now!!