Objectives. Incidence TBI: Leading cause of death & disability due to trauma. 9th Annual NKY TBI Conference 3/27/2015

Transcription

1 Mild Traumatic Brain Injury & Symptom Assessment in Children Becky Cook, DNP, APRN Trauma Nurse Practitioner Objectives Discuss the incidence and mechanisms of injury of mild traumatic brain injury (mtbi) in children Review rationale of early detection of mtbi, scope of symptoms, & symptom screening tools Discuss brain rest guidelines and graded return to activities Incidence TBI: Leading cause of death & disability due to trauma Annually: 6,000 deaths 620,000 ED visits ~ 50% under go CT 60,000 hospitalizations 80% - 90% are mtbi Blackwell, et al, 2007; CDC,

2 Traumatic Brain Injury GCS PTA LOC Mild < 1 day 0 30 min Moderate 9-12 > 1 to < 7 days > 30 to < 24 hrs Severe < 8 > 7 days > 24 hrs Challenges of mtbi Lack of universal definition Rapid resolution of acute symptoms Additional injuries - / + objective evidence of injury on imaging Lack of standard for assessing Age / cooperation of child Age Related Differences Brain development: Birth 5 yrs. Developing brain 60x more sensitive to NMDA (glutamine-mediated N-methyl-D aspirate) & excitotoxic (Field et al., 2003). Immature musculoskeletal system: Less developed neck and shoulder, Inability to transfer energy increasing risk of PCS (Kirkwood et al., 2006 ). Immature brain more vulnerable to injury (Aloi & Rumpe, 2008). Children experience more severe PCS than adults (McCrory et al., 2009). 2

3 Defining mtbi Lack of consensus: Concussion Zurich 4 th International Conference on Concussion in Sport (2012): Complex patho-physiological process affecting the brain, induced by biomechanical forces. CDC, 2007: Direct or indirect forceful impact to brain in association w/ acceleration/deceleration injury leading to neurometabolic dysfunction Commonalities: Functional not structural disturbance + / - LOC, Recovery 7 10 days Defining mtbi Lack of consensus The WHO : MTBI is an acute brain injury resulting from mechanical energy to the head from external physical forces & includes 1 or more: Confusion / disorientation, LOC for < 30 minutes, PTA < 24 hrs Transient neuro abnormalities: GCS minutes post-injury or later Focal signs, seizure Intracranial lesion not requiring surgery (Carroll, et al, 2004) Concussion Cellular disruption, increased permeability, & depolarization: Neuronal suppression. Increased demand for energy & glucose Decreased blood flow creating mismatch between metabolic supply & demand Result: Neuronal dysfunction & increased vulnerability to injury (Halstead, et al, 2010) Jfkls jfkl sjl;d Fjds;ljkfd; 3

4 Intracranial hemorrhage: Epidural Subdural Sub-arachnoid Intraparenchymal contusions Skull fractures Concussion, mild TBI, minor head injury. Head CT Findings mtbi Algorithm Diagnosis Moderate to severe TBI: More readily apparent Often with persistent neurological changes Recovery correlates with acute injury characteristics: LOC, GCS, PTA Mild TBI: Symptoms not always apparent Symptom severity does not correlate with acute injury characteristics (LOC, GCS) McCrea (2008) Symptoms Delayed, recurrent, worsen mtbi Most severe symptoms? Initial: Fatigue 7 10 days: Falling asleep (Blinman, et al, 2009) Longe recovery: Children (4 9 yrs) Adolescents (10 19 yrs) (Lovell, et al, 2004) Cognitive Physical Emotional Sleep Difficulty processing Difficulty concentrating Difficulty remembering Headache Blurred vision Dizziness Nausea Vomiting Light / noise sensitivity Balance problems Fatigue Irritable More emotional Sadness Nervous Sleeping more Sleeping less Drowsy Difficulty falling asleep 4

5 Severity of Concussion Concussion grading scales: Cantu (1986), AAAN (1997), Colorado Medical Society (1991): Grade 1: Transient confusion, no loss of consciousness (LOC), all symptoms resolve within 15 min. Grade 2: Transient confusion, no LOC, but symptoms or mental status abnormalities persist longer than 15 min. Grade 3: Any LOC, either brief or prolonged Simple vs complex concussion History: Mechanism?? LOC Associated s / s Physical Head Musculoskeletal Examination Neurologic: Cranial nerves Cervical spine Cognition / language screen Sensory / Motor: Pronator drift, asymmetrical weakness, & reflexes Balance / Coordination Imaging Need for CT? 2 3 CTs triples risk of tumor CCHMC Neurosurgery Minor Head Injury Flow Diagram Specific Criteria Recommend CT GCS Non-specific Criteria Consider CT Adnormal Mental Status Exam Scoring Scale Reverse side LOC>5 minutes GCS <13 Any Time Since Injury Headache, amnesia, GCS hours After Injury Behavioral Change All Children <3 months of age All Children <2 years of age Asymmetric Neurological Exam Suspected Basilar Skull FX Indeterminant Criteria High Velocity Injury Decision for Vomiting Unwitnessed Injury CT per ER Post-Contact Seizure Suspected Non-accidental Trauma CT Findings. Appreciate the term minor or mild. is misleading Abnormal CT Scan High Risk Epidural (>2 mms) /subdural hemtoma Intraparenchymal hematoma Petechial contusions or shear injuries (>3 in number) Ventricular enlargement Ischemia, focal edema Abnormal brain attenuation Diffuse brain swelling Complex comminuted depressed fxs ER Neurosurgical Consult Rehabilitation Consult in AM Must have at least one repeat CT within 12 hours Worse CT Abnormal CT Scan Low Risk Epidural blood (>2 mm thick) SAH (Fisher Grade 1-2) Intraventricular hemorrhage without ventriculomegaly Petechial contusions or shear injuries (>3 in number) Pneumocephalus Notify on-call neurosurgery provider Of admission and request: Morning Neurosurgical and Rehabilitation Consult May request Neurosurgery resident Review images via Web PACS Clinically Stable -No Repeat CT CT Findings Resolved Clinically Stable Normal Intracranial CT Absent extra-axial or parenchymal lesions Linear Non-depressed Fxs Facial/Orbital Fractures Soft Tissue Injury No Neurosurgical Consult Refer to EPIC Mild TBI Order set Potential ER Discharge CT Unchanged Clinically Stable OR if indicated Jjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjj Discharge Criteria and Followup: Glasgow 15 No vomiting, Tolerating p.o ICU then 5

6 Clinical Decision Rules CDRs: Derived from original research Incorporate 3 or more variables from: History Clinical exam Diagnostic tests Optimize clinical decision making Minimizes second guessing self Decrease variability in care CHALICE Children s Head Injury Algorithm for Prediction of Important Clinical Events MOI: Exam: High speed accident GCS < 14; < 15 infant Fall > 3 m Suspicion skull fx: High speed projectile Penetrating Depressed History: Basilar signs Witnessed LOC / amnesia Neuro deficit > 5 min Bruise/lac > 5 cm Drowsiness >3 emesis (Dunning, et al, 2006) R/O NAT Seizure NICE: National Institute NICE for Clinical Excellence 6

7 CATCH Obtain CT if any 1 variable Sensitivity: 100% (95% CI) Sensitivity: 98.1% (95% CI) Osmond, et al, 2010 PECARN Head CT <2 yrs PECARN Head CT > 2 yrs 7

8 Management ED observation vs inpatient admission CT findings Clinical exam Supportive care: IVF Zofran Tylenol Avoid NSAIDs Patient / family education DC criteria: GCS 15 No focal neuro deficit(s) Tolerating po No functional impairment High Risk Epidural > 2 mms Subdural hematoma Intraparenchymal hematoma Petechial contusions or shear (>3 in number) Ventricular enlargement Ischemia, focal edema Abnormal brain attenuation Diffuse brain swelling Complex depressed fxs Criteria for Re-Imaging Neurosurgery consult Inpatient admission Repeat CT w/in 12 hours Stable: DC criteria Worse: Repeat CT OR if indicated DC criteria Recovery Symptom resolution: Days to weeks No association: LOC & symptom duration Length of PTA: Predictive of symptom severity & neuro-cognitive deficits Concussion: Professional athlete: ~ 3 days College athlete: ~ 7 days High school athlete: ~ > 7 days Intracranial injury: Controversial (McCrea, 2008) 8

9 Zemek, et al, 2013: Risk Factors Older children with: Loss of consciousness Headache Nausea or vomiting Premorbid conditions: Prior head injury Learning difficulties Behavioral problems Dizziness Complications Delayed recovery Post concussion syndrome: Concussive symptoms beyond 3 months Incidence: 35% of children with TBI (Yeates et al., 1999) Symptoms may persist for as long as 1 year (Catale, Marique, Closset, & Meulemans, 2009) Second impact syndrome: 2nd concussion while symptomatic from previous concussion Rapid & progressive brain edema: Herniation High mortality Return to..? What guides return to activities? Controversial: No gold standard Limited research CT findings Current symptoms School: Symptoms manageable Sports: Sports Medicine Physical Medicine Neurosurgery 9

10 Treatment Guidelines Factors influencing management: Military Sport related concussion Emphasis: Prevention Surveillance / baseline exam Symptom assessment Physical & vestibular exam Diagnosis / treatment Reintegration Early mtbi Recovery Education Evaluation Intervention & referral Social/Family support Care Considerations Clinicians do not routinely provide TBI education: Follow-up instructions Safe return to: Exertional activities: School Recreational activities: Biking, non-organized sports Organized sports (Bazarian, Veenema, Brayer, & Lee, 2001) Nance, Polk- Williams, Collins, & Wiebe, 2009) 10

11 Care Considerations Standardized assessment: Supports care interventions Discharge education Appropriate activity restrictions (Blinman, et al, 2009; Goia, et al, 2009) Monitor symptom progression / resolution Discharge education significantly reduces: Symptom reporting Behavioral changes (Ponsford, et al, 2001) Acute Concussion Evaluation: ACE Assessment Tools CDC Heads Up toolkit: Systematic Evidenced based Children & adults ACE 11

12 ACE ACE SAC Standardized Assessment of Concussion: Severity of concussion Neuropsychological measures: Orientation Immediate memory Concentration Delayed recall Score: 0-30 Exertional maneuvers & neurologic exam not incorporated 12

13 SCAT 3 Sport Concussion Assessment Tool Age: 5 12 yrs Symptoms Not validated Rivermead 16 symptoms: 0 4 RPQ 3: Headache, dizziness, nausea Higher score: Monitor RPQ 13: 13 PCS scored Higher score: > severity of symptoms > impact ADLs 13

14 PCSS Post Concussion Symptom Score: Range: Normal score: Boys: 0-6 Girls: 0-8 Abnormal score 7 10 days refer: Sports Med Neurology Peds Rehab Symptom Assessment When should symptom assessment be performed? ED Acute hospitalization prior to dc 7 10 days At ongoing follow-up Allows to monitor trajectory & severity of symptoms Should not be used in isolation Guides specialty referral Symptom Assessment Barriers Young: Inability to communicate Cannot describe symptoms Older: Invulnerable, honest? Subjective Standardized tools: Not typically utilized in acute setting Most validated children >10 years Should not be used in isolation 14

15 Optimizing Recovery Cognitive & physical rest: Facilitate symptom resolution and recovery Don t strain the brain Cognitive & physical rest Sleep Hydration; no caffeine Limited screen time : 15 minute intervals up to 4x / day TV, texting, & video games Optimizing Recovery Objective: Minimize cerebral glucose demands & avoid additional strain on CBF Exertion: Risk of increase or emergence of symptoms: Physical activity: Recreation, sports Cognitive: Homework Reading Return to school 15

16 Symptom Management Sleep hygiene Establish consistent routine Avoid caffeine, stimulants Melatonin Trazodone Headaches: Hydration Tylenol, ibuprofen: Limit, if at all AANN & ARN, 2011 Case Study 15 yo s/p basketball injury Collided w/ another player Hyperextension of neck Dazed; no LOC Presented to ED: Headache, neck pain GCS 15 Cspine films: Negative Head CT: Deferred Released to home in collar 16

17 Case Study F/U Trauma Clinic: Cspine: Clinically cleared Symptom assessment: 17 Referral Sports Medicine F/U Sports Medicine: Symptom assessment: 10 Headache: Hydration, abort meds Sleep hygiene Graded Return to Play: OK for aerobic condition Restrictions: Contact sports Follow up: 2 weeks Case Study 6 yo s/p fall from bed of non-moving truck No LOC, cried Next day: Emesis at daycare, somnolent ED: GCS 14 (- 1 eye) No focal deficits Small right temporal scalp hematoma Headache Somnolent, easily aroused Persisting emesis Imaging indicated? To OR: Emergent evacuation PICU / Floor: Stable neuro exams Symptom score: 5 DC home Activity restrictions F/U PMR pending Case Study 17

18 Questions? 18