Catastrophically Injured Children

Transcription

1 Catastrophically Injured Children The Challenges of Assessment, Treatment & Evaluation Through Development Dr. P. Rumney September 2011

2 Catastrophic Injury Legal & Not Medical definition Adult tools used GCS<9, GOS, AMA Guidelines 4 th Edition where the insured person is less than 16 years of age at the time of the accident, for the purposes of clauses (e), (f) and (g), a catastrophic impairment shall be an impairment that is sustained by the child which is deemed to be the most analogous to the impairments as presently described in those sections, taking into account the developmental consequences as they may reasonably be anticipated. 2

3 Proposed Definition Proposed definition: 3. Paediatric Traumatic Brain Injury (prior to age 18) i. A child who sustains a traumatic brain injury is automatically deemed to have sustained a catastrophic impairment automatically provided that either one of the following criteria (a orb) is met on the basis of traumatic brain injury sustained in the accident in question: 3

4 a. In-patient admission to a Level I trauma centre with positive findings on CT/MRI scan indicating intracranial pathology that is the result of the accident, including but not limited to intracranial contusions or haemorrhages, diffuse axonal injury, cerebral edema, midline shift, or pneumocephaly; or b. Inpatient admission to a publically funded rehabilitation facility (i.e. an Ontario Association of Children Rehabilitation Facility or equivalent) for a program ofbrain injury rehabilitation or Ontario Association of Children Rehab Facilities);

5 Proposed Definition Part2 Paediatric catastrophic impairment on the basis of traumatic brain injury is any one of the following criteria: ii. At any time after the first 3 months, the child s level of neurological function does not exceed the KOSCHI Category of Vegetative (Crouchman M et al., A practical outcome scale for paediatric head injury. Archives of Disease in Childhood. 2001; 84:1204)18: The child is breathing spontaneously and may have sleep/wake cycles. He may have non-purposeful or reflex movements of limbs or eyes. There is no evidence of ability to communicate verbally or non-verbally or to respond to commands. 5

6 iii. At any time after the first 6 months, the child s level of function does not exceed the KOSCHI Category of Severe (Crouchman M et al., A practical outcome scale for paediatric head injury. Archives of Disease in Childhood. 2001; 84:1204)18: (1) The child is at least intermittently able to move part of the body/eyes to command or make purposeful spontaneous movements; for example, a confused child pulling at nasogastric tube, lashing out at caregivers, or rolling over in bed.

7 (2) May be fully conscious and able to communicate but not yet able to carry out any self care activities such as feeding. (3) Severe Impairment implies a continuing high level of dependency, but the child can assist in daily activities; for 23 example, can feed self or walk with assistance or help to place items of clothing. (4) Such a child is fully conscious but may still have a degree of post-traumatic amnesia. iv. At any time after the first 9 months,, the child s level of function remains seriously altered such that the child is for the most part not age appropriately independent and requires supervision/actual help for physical, cognitive and/or behavioural impairments for the majority of his/her waking day

8 Clearer Approach Severely Injured Children Acquired Brain Injury GCS 8 0r less Post Traumatic Amnesia > 24 hr. Multiple complications infection, anoxia,shock, CNS foreign Body 8

9 Challenges of Assessment and Prognosticating in Paediatrics Growth & development is not lock step Wide variation in individual capabilities and function Trouble in assessment of undeveloped functions in early childhood Frontal Lobes undeveloped in early childhood Nature <-> Nurture interplay 9

10 Variability in Recovery in Children & Adults Children recover differently after TBI/ABI than adults. Literature shows the arc of outcomes that relate to age at time of injury Younger = Worse from Cognitive & Behavioural standpoint. 10

11 Literature Review Klonoff et al J. of Neurology,Neurosurgery & Psychiatry 5 year Follow up of two groups 131 < 9 yrs & 100 > 9 yr. 4 domains assessed, neuropsychologic f(x), neurologic status, EEG status, school progress found differential recoveries over time greater educational problems in younger group 23.9% with Neurologic sequelae 11

12 Levin & Eisenberg Neuropsych Outcome in Children & Adolescents - Child s Brain children, all TBI Three levels of severity Mild, Moderate, Severe Three age groups(0-5),(6-12),(13-18) Relationship between severity & age at time of injury 12

13 Kreil, Krach & Panser CHI: A Comparison of Children Younger & Older Than 6 Yr, - Paed. Neurology children with severe CHI Older children had better outcomes Worse outcomes seen in relationship to distance of referral from trauma/rehab. centre SCAN survivors had worse outcomes over other TBI survivors 13

14 Inger Thomsen Do young patients have worse outcomes after severe blunt head trauma? - Brain Injury patients, PTA > 1 month follow up at 2-5, yrs post trauma The younger at the time of injury, the higher the risk of late behavioural & emotional sequelae 14

15 Costeff, Groswasser & Goldstein Long Term Follow up of 31 children with severe C.H.I. - J. Neurosurgery 1990 Ages 3-15 yr., 5 to 11 yr F/U Median duration of 3 weeks One fatality at 9 yr. In P.V.S. 30 recovered consciousness & D.C. 24 with Long Term Disability - Signif. 26 had independent mobility, 7 epileptic 14 dysarthric, 10 had cognit ~ return to school but none into post secondary education 15

16 Tomkins, Holland et. al Predicting Cognitive Recovery from C.H.I. In Children & Adolesc. Brain & Cogn children followed, 3 evaluations in first yr. post injury Evaluated lang., memory, visuomotor & speeded performance. Injury severity & preinjury intellectual challenges were best predictors at time of D.C. in older >9 yr. Younger children - parental marital status was best predictor of cognitive performance early on At 6/12 & 12/12 - older children, those performing most poorly remained most impaired Younger - parental marital status still best predictor of cogn. F(x) 16

17 Boyer & Edwards Outcome 1 to 3 yr. After severe T.B.I. In children & adolescents - Injury children admitted to ABI rehab prog. Assessed mobility, ADL, education & cogn. F(x) Physical recovery most rapid in first yrs. Cognitive & Lang F(x) improved up to 3 yr. Post injury Consciousness upon admission a good predictor Persistent coma x 6 mon. - 72% remained so 14% returned to regular education, 25% unable to benefit from any education 17

18 Jaffe, Fay, Polissar et. al Severity of Paed. T.B.I. & early Neurobehavioural Outcome Cohort study, 98 children, 6-15 yr., matched to age controls Neuropsych. testing at 3 wk upon awakening (mild,mod.,severe) Mod. & Severe TBI preformed normally related to peers I.Q. Pattern of decreasing performance relating to severity of the T.B.I. 18

19 Jaffe, Fay, Polissar et. al -2 Severity of Paed. TBI & Neurobehavioral Recovery at 1 yr. - Arch. Phys. Med Rehab children in cohort with paired controls Dose response correlation of performance to severity of TBI in neurobehav. F(x) Strongest correlates - severity with intelligence, academic performance & physical f(x) Mild TBI recovery appeared complete Mod. & Severely injured scores significantly different than age matched controls 19

20 Klonoff, Clark & Klonoff Long Term outcome of Head Injuries -A 23 yr. F/U Study of Children - J. Neur. Neuros. & Psych individuals, mean age = 31.4 yr. 91% admitted to hosp. with mild TBI I.Q. at discharge a good predictor of long term outcome 32.7% had physical complaints, 17.6% psychologic/ psychiatric problems The severity of the head injury was the primary contributory factor in affecting long term outcome. 20

21 Michaud, Rivara, Grady, Reay Predictors of Survival & Severity in Disability after Severe B.I. In Children - Neurosurgery 1992 Seventy Five children 1-16 yr., in Level one unit, CHI no penetrating ABI. Survival = 67%, 31% had good recovery, 12% mod. disability, 19% severe disability, 5% P.V.S. Clinical status in field & E.R. relates to survival GCS at 72 hr. better predictor of survival Severity of TBI & extra cranial injurys relates to QOL Level of oxygenation in the E.R. Highly predictive of disability. 21

22 Predicting Outcomes Prasad, Ewings-Cobb et al (2002) prospectively at 60 cases of childhood TBI. In those less than 6 years of age; the best predictors remained the modified Glasgow Coma Scale, the duration of impaired consciousness, and the number of lesions seen on neuroimaging. If the TBI was inflicted, as opposed to accidental there were poorer outcomes for the children measured by the Glasgow Outcome Scale and cognitive measures. Pupillary changes also predicted poorer motor outcomes. 22

23 CNS Imaging (Himanen et al, 2005). Relationship between long term cognitive effects & remote traumatic brain injury (TBI) which can be correlated to MRI findings & clinical evaluation of severity of injury. In 61 patients assessed on average 30 years after TBI of variable severity, there were reductions in hippocampal volumes and lateral ventricular enlargement; significantly associated with impaired memory functions, memory complaints and executive functions. 23

24 CNS Imaging - 2 The best predictor for cognitive outcome is felt to be the volume of the lateral ventricle. This would suggest that the degree of diffuse injury with atrophic changes is prognostically more important than the initial severity of the brain injury. 24

25 Family Function and Impact Yeates et al. (1997) family s pre-injury environment was a strong predictor of recovery of function in children post-tbi. High-functioning families (Anderson et al 2005) significantly moderated the effects of more severe TBI when compared to those who are low functioning. effect is seen controlling for socio-economic status, age at time of injury and family environment. 25

26 Age Differences Children < 5 years at injury are more likely: to receive school assistance to have problems with speech, language and cognition to have persisting physical limitations (i.e. ataxia, spasticity, and mobility problems) impairments in the social behavioral domain increased over time There is a linear trend in which older age at injury is positively associated with improvement on MPAI. 26

27 Additional Consequences Difficulties with anger, endurance, initiative, sleep, processing speed are reported. These difficulties are not associated with recovery, but persist long term despite severity. Approx. 50% of parents with children (< 10 yrs) reported significant concerns about their children s anger. 27

28 Additional Consequences (2) For children and adolescents over 10 yrs., reports of anger peaked 2 years postdischarge (23% - serious episode). Verbal anger was more common at first (4:1) but 4 years after discharge, reports of verbal and physical anger were equal. 28

29 Persisting Limitations Seen: Academic performance Pragmatic communication skills Social interactions Physical abilities 29

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31 Issue of Cognitive Stall Topics in Language Disorders: July/September Volume 29 - Issue 3 - p Strategic Learning in Youth With Traumatic Brain Injury: Evidence for Stall in Higher- Order Cognition Gamino, Jacquelyn F. PhD; Chapman, Sandra B. PhD; Cook, Lori G. MS December 21, 2010 Features The ASHA Leader 31

32 Executive Functions and Communication in Adolescents by Lyn S. Turkstra & Lindsey J. Byom The PreFrontal Cortex and its connections undergo significant changes during adolescence. These changes underlie important cognitive developments. The timeline for PFC development is variable across adolescents and even adults; some people never attain what might be called "mature" frontal lobes.

33 Current Research on Reliable Outcomes still Thin Current Validated tools are functionally concrete or not clearly functionally relevant WeeFIM acute rehab tool GMFM- PEDI excellent Physical Fx Assessments G.O.S. / KOSCHI I.Q. / NeuroPsych/ 33

34 Need for Time for Development and Evaluation Allow normal maturation to proceed along with the effects of injury Influences of Family Structure & Function are sizeable Psychopathology can disable despite normal cognition Current rehabilitation & compensation is being refined and improved. 34

35 Sorry! Unable to be more definitive at present Research is progressing Science is refining its assessment tools Neuroimaging, biomarkers Rehabilitation is evolving with the application of evidence and objective evaluation 35

36 Thank You Peter Rumney M.D., FRCPC Holland Bloorview Kids Rehabilitation Hospital 36