Disclosure Statement Dr. Kadish has no relevant financial relationships with any commercial interests mentioned in this talk.
Head Trauma Evaluation Primary and secondary injury Disposition Sports related concussion
What is most predictive of an intracranial injury? 1) Vomiting 2) Loss of consciousness 3) Immediate or impact seizure 4) Headache 5) Skull fracture
PECARN Head Injury Study Kupperman et al, Lancet 2009 Prospective multicenter study 6/04-9/06 Less the 18 years of age with nontrivial head trauma evaluated in the E.D. Exclusion Standing, walking, or running at ground level, then striking stationary object or falling to ground and No signs or symptoms of head trauma (except abrasion or laceration) or GCS < 14 Inclusion 42,000 patients
Prediction rule for Children < 2 Normal mental status No scalp hematoma (except frontal) No loss of consciousness Non-severe injury mechanism No palpable skull fracture Acting normal to the parents
Results for Children < 2 years Negative predictive value for citbi TN / (TN + FN) 1176/1176 100.0% (95% CI 99.7-100.0) Sensitivity TP / (TP + FN) 25/25 (100%, 86.3-100.0)
Prediction rule for Children > 2 Normal mental status No loss of consciousness No vomiting Non-severe injury mechanism No signs of basilar skull fracture No severe headache
Results for Children > 2 years Negative predictive value for citbi TN / (TN + FN) 3798/3800 99.95% (95% CI 99.81-99.99) Sensitivity TP / (TP + FN) 61/63 (96.8%, 89.0-99.6) 2 patients missed did not require neurosurgery
Scalp Abnormalities The presence of a scalp abnormality is sensitive for an associated skull fracture Skull fracture is one of the best predictors of intracranial injury in children < 2 years
Basilar Skull Fracture The incidence of intracranial pathology associated with basilar skull fracture is estimated at 20% In the well appearing child
Basilar Skull Fracture
High risk group: CT scan indicated Depressed mental status Focal neurologic findings Signs of depressed or BSF Acute skull fracture Bulging fontanel Children with PE findings of skull fracture Witnessed LOC > 5 minute duration History of amnesia (antegrade or retrograde of > 5 minute duration
Low risk group: Observation Low energy mechanisms with no signs or symptoms
Intermediate risk group: Imaging or observation Vomiting Transient loss of consciousness Impact seizure History of lethargy or irritability
CT scans 2013
Why not scan all patients? Radiation exposure Location of CT scanner Cost Sedation
Primary Injury Injury immediately caused by the trauma Ischemia induced ionic derangement Decrease in electrical activity and suppression of neurotransmission Complete energy failure and anoxic depolarization Neurodegeneration
Preventing Secondary Injuries Progression of primary injury caused by: Hypoxia Hypercarbia Hypotension Hypertension Seizures Expansile lesions Intracranial pressure (ICP) Hypoglycemia Anemia
Hypotension Traumatic Coma Data Bank (TCDB) Hypotension and hypoxia are among the five most powerful predictors of outcome A single episode of hypotension was associated with a doubling of mortality and increased morbidity CPP = MAP - ICP If CPP increases, then CBF should increase
Early resuscitation of children with moderate-to-severe traumatic brain injury (Zebrack et al Peds) Children who did not receive an attempt to treat hypotension Increased odds of death 3.4 Increased odds of disability 3.7
Disposition of the Head Injured Patient Skull fracture Basilar skull fracture Concussion GCS 15 Vomiting Headache
Can patients with a skull fracture be safely sent home? Combining 6 studies 349 patients Incidence of clinical deterioration for children with an isolated skull fracture was zero (95% CI = 0, 0.9%)
Can patients with a BSF be safely discharged to home? Combining 3 studies 421 BSF patients with GCS 15 Normal neurological exam Normal head CT excepts for the BSF No cases of delayed intracranial hemorrhage (95% CI = 0, 1.0%)
Can patients with a concussion be safely discharged to home? 3 studies over 1700 patients All patients GCS 13 Normal neurological exams Normal head CT No cases of delayed intracranial hemorrhage
CT scan as a triage tool
Discharge criteria No intracranial injuries (normal head CT) Normal neurological examination No suspicion of abuse or neglect Reliable caretakers Simple skull fracture Single fracture Age > 3 months? Basilar skull fracture Symptoms are not getting worse
Sport Related Concussion Meehan et al (Peds 2009) Caused by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head Rapid onset of short lived impairment of neurologic function that resolves spontaneously Results in a graded set of clinical syndromes that may or may not involve loss of consciousness Associated with grossly normal structural neuroimaging studies
Epidemiology 26% of closed head injuries in children occur during athletics Numbers probably higher Incidence of concussion in high school and college football players Between 4% and 5% Numbers probably higher (15% - 45%)
Long-term and Cumulative Effects Lack of long-term prospective studies in high school and younger athletes with concussion High school athletes with 2+ concussions showed higher ratings of concussion-related symptoms at baseline than with athletes with < 2 (Moser, 2011) Many studies have shown longer recovery of full cognitive function in younger athletes compared to college-age (often 7-10 days)
On the field assessment ABC Cervical spine Neurologic evaluation Questions to test recent memory Ability to perform simple tasks Postural stability
Physical Cognitive Emotional Sleep Headache Mentally foggy Irritability Drowsiness Nausea Slowed down Sadness Sleeping more than usual Vomiting Balance problems Visual problems Fatigue Difficulty concentrating Difficulty remembering Forgetful of recent information Confused about recent events More emotional Nervousness Sleeping less than usual Difficulty falling asleep Sensitivity to light Sensitivity to noise Dazed Stunned Answers questions slowly Repeats questions
What about loss of consciousness and amnesia In the past concussion severity was determined based on presence and duration of LOC and amnesia at the time of injury We now know that cerebral dysfunction may be present without classic indicators of mild traumatic brain injury (LOC, amnesia) Avoid using the term ding or bell rung
Natural History of Concussion Most severe symptoms are exhibited immediately following concussion, with gradual recovery over 5-7 days 10-20% of athletes require > 7 days for complete recovery
Post-Concussive Syndrome Presence of cognitive, physical, or emotional symptoms of concussion (at least 2-3) lasting longer then 2 weeks Poor concentration, irritability, decreased school performance, depression, headache, disordered sleep
Management Each concussion should be managed individually by using multiple means of assessment No player should be returned to play until the symptoms of concussion have resolved completely, both at rest and during exercise
Utah HB 204 Requires amateur sports organizations to: Adopt and enforce a concussion / head injury policy Distribute policy to parents and obtain parental signatures to abide by the policy Immediately remove from sports any child suspected of sustaining a concussion Obtain a written signed statement from a qualifies health care provider, with adequate CME training within past 3 years, clearing child to resume participation in sporting event
Concussion Assessment Tools Sports Concussion Assessment Tool (SCAT) Standardized Assessment of Concussion (SAC) Balance Error Scoring System King-Devick Test Neuropsychological testing
Concussion Management: Rest Physical Cognitive
Rehabilitation Stage No activity Light aerobic activity Sport specific exercise Noncontact training drills Full-contact practice Return to play Functional Exercise Complete physical and cognitive rest Walking, swimming, stationary cycling Specific sport-related drills, but no head impact More complex drills, may start light resistance training After medical clearance, participate in normal training Normal game play
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