Clarifying Murky Waters: Head Injuries in Children

Transcription

1 Clarifying Murky Waters: Head Injuries in Children Judith R. Klein, MD, FACEP Assistant Professor of Emergency Medicine UCSF-SFGH Emergency Services 1 Case #1: Newborn Leo 2 month old dropped 4 feet onto sidewalk during removal from car seat Cried/fed since PE: small frontal hematoma To image or not to image, that is the question 2

2 Objectives Ø Ø Ø Ø Ø Is observation enough? Whom to image? How to image? Skull films vs. CT Role for ultrasound? Whom to admit? Return to play? 3 Pediatric head trauma: what s the big deal? #1 cause of death age 1-14 years 70% of fatal child injuries >7K deaths 60K hospitalizations, >600K ED visits per year 4

3 Why worry? 3 to 6% incidence of TBI post minor head trauma Up to 20% of kids < 2 years old with TBI are asymptomatic! Second impact syndrome 5 Who gets imaged? 40-50% with CHI to ED get imaged!! Higher CT rates: white race older general vs pediatric hospital emergent triage status attending treated 6

4 Implications of imaging Cognitive development Lifetime cancer risk from 1 head CT (3mSv): 1:1500 (1 yr old) 1:5000 (10 yr old) < 10% of CT s have any TBI 0.5% of CT s with clinically important (CI) TBI 7 GCS>14: To CT or not To CT?? Reduce # of CT s performed Cancer/brain dev Sedation $$$$ Identify all TBI or just CI TBI? NSU intervention Hospital >2 nights/intubation>24 hrs Death/long term neurological sequelae Identify TBI 8 IQ Cancer $$$ Sedation

5 The Science Several CDRs available Only 2 included infants PECARN rule the best: Largest, 25 centers Lots of young kids Clear reference standard for CI TBI Best validation 9 PECARN Minor Head Trauma Decision Rule 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% Kuppermann, Lancet

6 Under 2 years old Why identify all TBI: implications for sports/other activities? Kuppermann et al. Lancet 2009 Over 2 years old Why identify all TBI: implications for sports/other activities? Kuppermann et al. Lancet 2009

7 Severe Mechanism MVA with ejection, rollover or death of another occupant Pedestrian or bike w/o helmet vs. car Fall >3 ft (<2 yr) or >5 ft (>2 yr) High impact object to head 13 Back to Baby Leo Imaging? A good idea.. Imaging for <3 months with scalp hematoma + >3 ft fall Thin skull easily fractured strong correlation with TBI 14

8 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 15 Ultrasound and skull fracture? Skull fx 4-20x likelihood of TBI 15-30% with skull fx TBI Prospective study*: 55 patients 100% sensitivity 95% specificity Include in CDR for low risk? If US +, then CT? If US -, observe? *Parri, J Emerg Med

9 Baby Leo gets a CT How do I keep him still? Swaddle Dextrose H 2 0 Acetaminophen CT shows a skull fracture over posterior fossa Admit? YES 17 Admit criteria for skull fracture Depressed or basilar Widely diastatic Very young-->higher bleeding risk High energy mechanism High risk location (sutures, posterior fossa, dural sinus) Poor home situation NOT ALL NEED ADMISSION* *Mannix et al

10 Case #2: Wild Bill 20 month old rolls down 12 stairs Few seconds of LOC Cried. Ate. Physical Exam: GCS? Talk his language 3 cm temporal hematoma To CT or not to CT? 19 Wild Bill: CT or Observation? Rule: CT or 6 hour obs for all < 2 years with non-frontal scalp hematoma Location, location : Temporal > parietooccipital > frontal Severe mechanism?: Stairs vs. straight fall LOC too brief to count but... Verdict: Very careful observation or CT 20

11 Keeping Bill Still Sedation choices: Ketamine is OK Rectal methohexital Dexmedetomidine IV/IM pentobarbital Etomidate Avoid versed CT (+) epidural: Admit Brutane 21 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? 22

12 Let s talk observation > 2 years Isolated vomiting No LOC Non-severe mechanism Mild headache Consider observation if parents comfortable -inform parents of malignancy risks 23 Discharge home? Criteria: Normal MS Vomiting controlled No abuse suspected Responsible home/ reliable transportation Normal head CT* Confused after normal CT? Observe x 4-6 hrs -->admit if still AMS Holmes, Annals EM,

13 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) 25 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* 26

14 Return to sports post concussion Second Impact Syndrome (SIS) Stepwise return to play based on sx: No activity Light aerobic Sports specific exercise Non contact drills Contact practice Return to play Halstead, Pediatrics Nutshell: Whom to CT after trauma? <2 years: AMS Sx skull fracture Non frontal scalp hematoma >5 seconds LOC Not acting normally per parent Severe mechanism > 2 years: AMS Sx basilar skull fracture Vomiting Severe HA LOC Severe mechanism 28

15 Nutshell (cont): Whom to admit?: All TBI* High risk skull fractures Depressed/basilar Wide diastasis Very young High energy mechanism High bleeding risk Persistent AMS after observation Poor social/transport situation Suspected abuse Neurosurgery discretion Advocate for kids brains!! 29 30

16 Klein 2014 Pediatric Head Trauma References Bar Joseph G, Guilburd Y, Tamir A, et al. Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension. J Neurosurg Pediatr 2009; 4(1): 37. Blackwell CD, Gorelick M, Holmes JF, et al. Pediatric head trauma: changes in use of computed tomography in emergency departments in the United States over time. Ann Emerg Med 2007; 49(3): 320. Boutis K, Cogollo W, Fischer J, et al. Parental Knowledge of potential cancer risks from exposure to computerized tomography. Pediatrics 2013; 132: Egloff AM, Kadom N, Vezina G, et al. Pediatric cervical spine trauma imaging: a practical approach. Pediatr Radiol 2009; 39(5): 447. Halstead ME Walter KD, et al. Clinical report-sport related concussion in children and adolescents. Pediatrics 2010; 126(3): 599. Hennelly KE, Nigrovic LE, Lee LK, et al. Pediatric traumatic brain injury and radiation risks: a clinical decision analysis. J Pediatr 2013; 162(2): 392. Holmes JF, Borgialli DA, Nadel FM, et al. Do children with blunt head trauma and normal cranial computed tomography results require hospitalization for neurologic observation? Ann Emerg Med 2011; 58(4): Hutchings L, Willet K. Cervical spine clearance in pediatric trauma: a review of current literature. J Trauma 2009; 67(4): 687. Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinicallyimportant brain injuries after head trauma: a prospective cohort study. Lancet 2009; 374: Kupperman N. Pediatric head trauma: the evidence regarding indications for emergent neuroimaging. Pediatr Radiol 2008; 38 (Suppl 4): S670. Mannix R, Bourgeois FT, Schutzman SA, et al. Neuroimaging for pediatric head trauma: do patient and hospital characteristics influence who gets imaged? Acad EM 2010; 17(7): 694. Mannix R, Monteaux MC, Schutzman SA, et al. Isolated skull fractures: trends in management in US pediatric emergency departments. Annals Emerg Med 2013; 62(4): Osmond MH, Klassen TP, Wells GA, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ 2010; 182(4): 341. Parri N, Crosby BJ, Glass C, et al. Ability of emergency ultrasonography to detect pediatric skull fractures: a prospective observational study. J Emerg Med 2013; 44(1): 135. Rabiner JE, Friedman LM, Khine H, et al. Accuracy of point-of-care ultrasound for diagnosis of skull fractures in children. Pediatrics 2013; 131: e Weinstein E, Turner M, Kuzma B, et al. Second impact syndrome in football: new imaging and insights into a rare and devastating condition. J Neurosurg Ped 2013; 11: