Clarifying Murky Waters: Head and Cervical Spine Injuries in Children

Transcription

1 Clarifying Murky Waters: Head and Cervical Spine Injuries in Children Judith R. Klein, MD, FACEP Assistant Professor of Emergency Medicine UCSF-SFGH Emergency Services Case #1: Newborn Leo 2 month old dropped 4 feet onto sidewalk during removal from car seat Cried/fed since Physical exam: small frontal hematoma To image or not to image, that is the question 1 2 Ø Ø Objectives Whom to image? How to image? Skull films vs. CT Plain c-spine x-rays vs. CT Ø How to read those Rorschach tests called c- spine films? Ø Whom to admit? Ø How to manage injuries? Pediatric head trauma: what s the big deal? #1 cause of death age 1-14 years >7K deaths, 60K hospitalizations, >600K ED visits per year 3 to 6% incidence of TBI post minor head trauma Up to 20% of TBI pts < 2 years old asymptomatic! 3 4 1

2 Who gets imaged? GCS>14: To CT or not To CT?? 40-50% to ED get imaged!! Higher CT rates: white race older general vs pediatric hospital more emergent triage status attending treated Lifetime cancer risk from 1 head CT: 1:2000 (infant) to 1:5000 (older child) < 10% of CT s have TBI/0.5% with Reduce # of CT s performed Radiation Sedation $$$$ Identify all TBI or just CI TBI? NSU intervention Hospital >2 nights/intubation>24 hrs Death/long term neurological sequelae Identify TBI clinically important (CI) TBI 5 6 Cancer PECARN Minor Head Trauma Decision Rule Under 2 years old Derivation and validation study 42K kids GCS>14: >10K under 2 yrs <2 years: 100% NPV for CI TBI and all TBI >2 years: 99.9% NPV for CI TBI 98.4% NPV for all TBI CT by 20-25% 7 Why identify all TBI: implications for sports/other activities? Kuppermann et al. Lancet

3 Over 2 years old Severe Mechanism Why identify all TBI: implications for sports/other activities? MVA with ejection, rollover or death of another Ped or bike w/o helmet vs. car Fall >3 ft (<2 yr) or >5 ft (>2 yr) High impact object to head Kuppermann et al. Lancet Imaging? A good idea.. Back to Baby Leo Imaging for <3 months with scalp hematoma + >3 ft fall Thin skull easily fractured strong correlation with TBI Well, can I just do a skull x-ray? Skull film cons: Hard to read Not sensitive/specific enough If (+) still need to do CT CT cons: Radiation Cost Transport from ED Sedation Survey says: CT

4 Baby Leo gets a CT Case #2: Wild Bill How do I keep him still Swaddle/dextrose H 2 0 Acetaminophen CT shows a skull fracture Admit? YES Admit criteria skull fx: Very young bleeding Depressed Wide diastasis High energy High risk location Poor home situation month old rolls down 8 stairs Few seconds of LOC Cried. Ate. Physical Exam: GCS? Talk his language 3 cm temporal hematoma To CT or not to CT? 14 Wild Bill: CT or Observation? Keeping Bill Still CT or 6 hour obs for all < 2 yrs with non-frontal scalp hematoma Location, location : Temporal > parietooccipital > frontal Severe mechanism?: 8 stairs=fall>3 feet?? LOC too brief to count but... My call CT Sedation choices: Ketamine is OK Rectal methohexital IV/IM pentobarbital Etomidate Avoid versed CT (+) epidural: Admit Brutane

5 Case #3: The Car s a Mess... 5 year old helmeted bike vs low speed MV No LOC V x 3 en route Mild headache PE: Playing Small parietal scalp hematoma To CT or not to CT? Let s talk observation > 2 years Isolated vomiting Non-severe mechanism Mild headache Consider observation if parents comfortable Criteria: Normal MS Discharge home? Vomiting controlled No abuse suspected Responsible home/ reliable transportation Normal head CT* Holmes, Annals EM, Case #4: Tell me again what happened to Jane? 18 mo old BIB father Vomiting x 3 days Tripped at daycare 4 days ago PE: somnolent CT by criteria: +SAH! What do you do? Neurosurgery Admit Child Protective Services (CPS) 20 5

6 Epidemic: Non-accidental trauma (NAT) 6-10% of pediatric trauma: NAT #1 NAT mortality: head injury Suspect NAT: (+) CT: minor/no reported trauma Delayed presentation Changing history Other injuries inconsistent with reported mechanism Retinal hemorrhages* 21 Nutshell: Whom to CT after trauma? <2 years: AMS Sx skull fracture Non frontal scalp hematoma >5 seconds LOC Not acting ly per parent Severe mechanism > 2 years: AMS Sx basilar skull fracture Vomiting Severe HA LOC Severe mechanism 22 Nutshell (cont): Return to sports post concussion Whom to admit?: All TBI High risk skull fractures Depressed Wide diastasis Very young High energy mechanism High bleeding risk Poor social/transport situation Suspected abuse Neurosurgery discretion 23 Grading systems not useful Stepwise return to play based on sx: No activity Light aerobic Sports specific exercise Non contact drills Contact practice Return to play 24 6

7 Case #5: Do you have neck pain?? 6 month old rear carseat passenger MVArear-ended Car-seat/patient in place PE: VS nl. Happy, no signs of trauma How do I clear the c- spine? Some background on pediatric c-spine injuries Uncommon injury More common in older kids (> 8 years) Leading causes: MVA (<8 yrs) Sports (>8 yrs) PVA Kids aren t just little adults Unique anatomy: Large head high fulcrum Higher injuries more common in < 8 year old Horizontal facets slippage/dislocation More cartilage tough to read x-rays More pre-vertebral soft tissue > 8 years more like adult NEXUS: 3065 kids Clearing little c-spines 30 CS injuries: Only 4 injuries 2-8 years None < 2 years Criteria: (100% sens) No neck tenderness No focal neuro sx No distracting injury Normal MS No intoxication

8 Applying NEXUS criteria 187 kids with c-spine injury-->nexus rules applied: 32 kids < 8 yrs: 94% sensitivity 155 kids > 8 yrs: 100% sensitivity *Garton, Neurosurgery, PECARN: Risk factors for CSI 540 CSI cases/1060 controls Risk factors: AMS/focal neuro sx Neck pain/torticollis Significant torso injury High risk condition Diving/high risk MVA 98% sensitive CT use by 25% 29 Leonard, Annals EM, Modified NEXUS: Clearing younger c-spines Age appropriate MS/no LOC/no focal neuro sx No distracting injury/significant torso injury No neck tenderness or pain/muscle spasm Low force mechanism... Case # 6: Johnny Walker 5 yr old 20 mph PVA BIBA with (+) LOC Now awake/alert No c/o of neck pain or neurological sx Open leg fracture Image: YES LOC Distracting injury High force mechanism Let them look around

9 Pediatric Cervical Spine Clearance Bad CNS status yes Very positive history or physical Positive or inadequate plain films Full Cervical Spine CT Pediatric Cervical Spine Clearance Bad CNS status Very positive history or physical Positive or inadequate plain films yes Full Cervical Spine CT <3 years Attempt clinical clearance: -Age appropriate mental status -No history of LOC -No neck pain or tenderness -Normal neurological exam -No distracting injury -Low force mechanism THEN let them look around left/right/flex/extend 3-8 years: Use NEXUS criteria (as in >8 years) to clinically clear ab clinically clear >8 years Attempt clinical clearance with NEXUS criteria -Normal mental status/no intoxication -No neck pain or tenderness -Normal neurological exam -No distracting injury ab <8 years Attempt clinical clearance: -Age appropriate mental status -No history of LOC -No neck pain or tenderness -Normal neurological exam -No distracting injury -Low force mechanism THEN let them look around left/right/flex/extend >8 years Attempt clinical clearance with NEXUS criteria -Normal mental status/no intoxication -No neck pain or tenderness -Normal neurological exam -No distracting injury ab ab Start with 3 view plain X-rays clinically clear ab Start with 3 view plain X-rays clinically clear clinically clear Consider AP/Lat plain XR PLUS Occiput to C3 CT ab or inadequate clinically clear Consider AP/Lat plain XR PLUS Occiput to C3 CT ab or inadequate ab or inadequate attempt clinical clearance ab or inadequate attempt clinical clearance attempt clinical clearance Fails attempt clinical clearance Fails Fails Full cervical spine CT Fails Full cervical spine CT *Low force mechanism: -Fall <3-5 feet vertical -Lower speed MVA where patient/car-seat all stay in place MRI Persistent pain/tenderness/neuro sx *Low force mechanism: -Fall <3-5 feet vertical -Lower speed MVA where patient/car-seat all stay in place MRI Persistent pain/tenderness/neuro sx Rorschach tests: reading pediatric c-spine x-rays ABC S Alignment Bones Cartilage/Physes Spaces Pre-dental Child: < 4 mm Adolescent: < 2-3 mm Pre-C2 Child: < 7 mm Adolescent: < 5 mm Pre-C6 Child: < 14 mm Adolescent: < 21 mm 35 More on pediatric c-spine films Psuedo-subluxation: < 4-5 mm of C2 on C3 Up to 40% < 8 yrs C1-3 spinolaminar line alignment SCIWORA: Injury visible on MRI NL CT does not = clinical clearance If neuro sx/guarding/ pain and (-) CT get MRI/call neurosurgery 36 9

10 Final case: Suzy Q 8 year old diving from board Struck head on bottom of pool C/O neck pain and hand paresthesias BIBA in full C-spine precautions PE: tender, mild hand weakness Start with CT Suzy s got a fracture High pretest probability Vertebral burst C5 Image whole spine Management: Strict immobilization: highly unstable Steroids? No data on kids 30 mg/kg solumedrol bolus 5.4 mg/kg/hr x 24 to 48 hours Nutshell: Nutshell (cont): Whom to image? Neck pain or tenderness Focal neurological symptoms /signs Distracting injury/significant torso injury AMS/LOC/intoxication High force mechanism Unwilling to look around/ guarding neck 39 Try to avoid reflex CT in kids How to image? CT first if: Very positive history/pe Significant AMS Otherwise: Consider AP/Lat XR plus occiput to C3 CT if <8 yrs 3 view XR alone if >8 yrs If one fracture, image whole spine How to manage? Immobilization/NSU Steroids-your call 40 10

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