Head injury in children
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1 Head injury in children Michael Kim, MD Department of Emergency Medicine University of Wisconsin- Madison
2 #1 cause of death and disability Bimodal distribution 62,000 hospitalization 564,000 ED visits 2,685 deaths 1,300 by NAT
3 Objectives Background Case based working diagnosis What not to miss Intervention principles ED diagnostics and management
4 4 Anatomy
5 mechanism of head injury Kuppermann 2009 Fall from height: 27% Fall from ground level: 17% MVC: 9% Struck by object: 7% Assault: 7% Sports related: 7% Fall down stairs: 7% Bike collision or fall: 4% Pedestrian struck: 3% Wheeled transport crash: 2% Bike versus car: 1%
6 mechanism of head injury Kuppermann 2009 Fall from height: 27% Fall from ground level: 17% MVC: 9% Struck by object: 7% Assault: 7% Sports related: 7% Fall down stairs: 7% Bike collision or fall: 4% Pedestrian struck: 3% Wheeled transport crash: 2% Bike versus car: 1%
7 mechanism of head injury Kuppermann 2009 Fall from height: 27% Fall from ground level: 17% MVC: 9% Struck by object: 7% Assault: 7% Sports related: 7% Fall down stairs: 7% Bike collision or fall: 4% Pedestrian struck: 3% Wheeled transport crash: 2% Bike versus car: 1%
8 9 mo ran into a door Emesis x1 Facial bruise Sleepy Case 1 A. Skull Fracture B. Intracranial bleed C. Concussion D. Non-accidental Trauma
9 9 mo ran into a door Emesis x1 Facial bruise Sleepy Case 1 A. Skull Fracture B. Intracranial bleed C. Concussion D. Non-accidental Trauma
10 Case 2 10 YO struck by baseball bat LOC for 10 seconds Sleepy Headache GCS 14 Frontal hematoma Bony step-off A. Skull Fracture B. Intracranial bleed C. Concussion D. Non-accidental Trauma
11 Case 2 10 YO struck by baseball bat LOC for 10 seconds Sleepy Headache GCS 14 Frontal hematoma Bony step-off A. Skull Fracture B. Intracranial bleed C. Concussion D. Non-accidental Trauma
12 Case 3 17 YO driver struck a tree at 60 mph LOC at the scene VSS GCS 12 Large forehead laceration A. Skull Fracture B. Intracranial bleed C. Concussion D. Non-accidental Trauma
13 Case 3 17 YO driver struck a tree at 60 mph LOC at the scene VSS GCS 12 Large forehead laceration A. Skull Fracture B. Intracranial bleed C. Concussion D. Non-accidental Trauma
14 Evaluation and Intervention approach D E F G on t ever orget lucose
15 Taking focused history Consistency Previous injuries Underlying risks
16 Critical exam findings VS abnormality Mental status Head integrity Pupils Blood/fluid Neuro deficits
17 2 year old fell from 2 nd floor window with R=12, P=64, BP=145/74
18 Perfuse the brain
19 Cerebral Perfusion Pressure Pressure needed for adequate blood flow to brain CPP=MBP-ICP CPP: mmhg ICP: mm Hg
20 Keep brain perfused Cerebral Perfusion Pressure (CPP) MBP ICP CPP Normal Cerebral edema Shock Edema and shock
21 Keep brain perfused Cerebral Perfusion Pressure (CPP) MBP ICP CPP Normal Cerebral edema Shock Edema and shock
22 Keep brain perfused Cerebral Perfusion Pressure (CPP) MBP ICP CPP Normal Cerebral edema Shock Edema and shock
23 Keep brain perfused Cerebral Perfusion Pressure (CPP) MBP ICP CPP Normal Cerebral edema Shock Edema and shock
24 Keep brain perfused Cerebral Perfusion Pressure (CPP) MBP ICP CPP Normal Cerebral edema Shock Edema and shock Increase MBP Fluid resuscitation
25 Keep brain perfused Cerebral Perfusion Pressure (CPP) MBP ICP CPP Normal Cerebral edema Shock Edema and shock Increase MBP Fluid resuscitation Methods to decrease ICP Avoid hyperventilation Mannitol Surgical intervention
26 Intervention Priorities Maintain Airway, Breathing and Circulation EMS: Field triage guideline ED: Transfer to Level 1 Pediatric Trauma center ASAP
27
28 ED Evaluation
29 Best ED diagnostic modality
30
31 Procedure Typical organ radiation doses US FDA 2006 Effective dose (msv) # of CXR equivalent Days of natural exp CXR days Skull XR L spine IV urogram UGI BE HCT ACT
32 Procedure Typical organ radiation doses US FDA 2006 Effective dose (msv) # of CXR equivalent Days of natural exp CXR days Skull XR days L spine days IV urogram days UGI year BE years HCT days ACT years
33 --Graph shows estimated lifetime attributable cancer mortality risk as a function of age at examination for a single typical CT examination of head (broken dotted line) and of abdomen (broken solid line) 1 in 435 ACT 1 in 1250 HCT 1 in 10,000 HCT Brenner, D. J. et al. Am. J. Roentgenol. 2001;176: Copyright 2007 by the American Roentgen Ray Society
34
35 Methods Prospective cohort 25 EDs <18 YO with head injury w/in 24 hours citbi: death, neurosurgery, ETT>24 hrs., or admission for >1 night Injury mechanism: Severe: MVC, ejection, bike no helmet Mild: ground level fall, run into stationary object Moderate: other 2 groups: <2 years and >2 years
36 < 2 YO Kuppermann 2009 AMS or palpable skull fx risk of citbi = 4.4% Any one of non-frontal hematoma, LOC>5 sec, severe mechanism, or not acting normal risk citbi= 0.9% None of above 6 predictors Risk of citbi = <0.02%
37 < 2 YO Kuppermann 2009
38 > 2 YO Kuppermann 2009 AMS or signs of basilar skull fx Risk of citbi = 4.3% Any of h/o LOC, h/o vomiting, severe mechanism, or severe HA Risk of citbi = 0.9% None of the 6 predictors Risk of citbi = <0.05%
39 > 2 YO Kuppermann 2009
40 Who needs CT scan? Kuppermann et al. (PECARN). Lancet Oct
41 What can you do? may need further evaluation Know evidence in CT use Consider alternatives
42 Take home points
43 References 1. Kuppermann et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet Oct 3;374(9696): doi: /S (09) Epub 2009 Sep Brenner DJ et al. Estimates of the cancer risks from pediatric CT radiation are not merely theoretical: comment on "point/counterpoint: in x-ray computed tomography, technique factors should be selected appropriate to patient size against the proposition". Med Phys Nov;28(11): Brenner D. et al. Computed Tomography-An Increasing Source of Radiation Exposure N Engl J Med 2007;357:
44 Contusion/scalp hamatoma
45 Concussion
46 Skull fracture
47
48 (Epidural)
49 16 YO with 10 sec LOC Headache Nausea Emesis x 1 Photo/phono phobia Retrograde amnesia Case 3 A. Skull Fracture B. Intracranial bleed C. Concussion D. Non-accidental Trauma
50 Examination elements
51
52 Cases with answer options A. Skull fracture B. Intracranial bleed C. Concussion D. Non-accidental Trauma
53 Results Kuppermann 2009 N=42,412 <2 years: 10,718 >2 years: 31,694 Isolated head injury in (90%) GCS 15 in 41,071 (97%) CT performed in 14,969 (35.3%) TBI on CT in 780 (5.2%) citbi in 376 (0.9%) Neurosurgery in 60 (15.9%) Intubated >24 hrs. in 8 (2.1%) No death Admitted: 3821 (9.0%)
Disclosure Statement. Dr. Kadish has no relevant financial relationships with any commercial interests mentioned in this talk.
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Author Manuscript. Received Date : 27-Oct Revised Date : 09-Jan-2017 Accepted Date : 31-Jan-2017
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