Transcript Minor Head Injury In Children

Minor Head Injury In Children
Larry Kleiner
Medical Director, Dept of
Neurosurgery
The Children's Medical Center
Head Trauma
Definition of Mild head injury
Glasgow Coma Scale 13-15 • Prejudice against children
• doesn’t account for
• simple
asymetry
• reproducible
• prejudice against facial
• functional
injury/intubation
• valid predicteur
• doesn’t account for
brainstem reflexes
Modification of the GCS
• Eye opening:
spontaneous
to sound
to pain
none
4
3
2
1
Modification of the GCS
• Verbalization
• Appropriate for age
– fixes and follows
– social smile
• cries but consolable
• persistent irritability
• restless,lethargy
• none
5
4
3
2
1
Modification of the GCS
• Motor Response
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Spontaneous
localizes to pain
withdraws
decorticate
decerebrate
none
6
5
4
3
2
1
Modification of GCS
Glasgow-Liege Scale
– includes brainstem reflexes
– increases prediction of outcome
from 76% to 90% with a .9 confidence level
Modification of the GCS
Brainstem reflexes/scoring the GLCS
fronto-orbicluar
5
vertical-oculocephalics
4
pupillary reaction to light
3
horizontal-oculocephalics
2
oculo-cardiac
1
none
0
Epidemiology
• 7-8 million “head injuries”/year
• 1.5-2.0 million/year with LOC/amnesia
- 80% considered minor
Epidemiology
• Trauma: leading cause of death age 1-19
• head injury direct cause in 30-50%
• major factor in 75%
in MVA’s:
75% have head injuries
20% have spinal cord injuries
Epidemiology
Head injury overview:
• 1:10 has loss of consciousness
• 250-500,00 hospitalizations/year
• 4,000 deaths/year
• 15-20,000 prolonged hospitalizations/year
Demographics
Compared to severe head injuries:
generally younger
• higher frequency of students
• percentage of males is less
• alcohol less frequently involved
Demographics
Pediatric head Injury
• higher death rate under the age of two
• bimodal distribution- bikes/cars
• 90% are closed, non-penetrating
• mortality; 1-5%
but rises to 17% if coma >12hr.
• 10% of the deaths are < ten years of age
Demographics
• Children aren’t little adults
• Infants aren’t little children
Physiology Unique to Children
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Skull
relation to spine
deformability
thickness
open sutures
open fontanel
Physiology Unique to Children
Meninges
• wider subarachnoid space over
convexity(shear/tear), over all smaller
in proportion to brain (less buoyancy)
• dura adherently applied to bone
Physiology Unique to Children
Brain
• Increased water content
• autoregulatory mechanisms
• pressure/volume compliance shifted left
• contracoup
• post traumatic unconsciousness
Pediatric post-concussive
Syndrome
Characteristics:
• Stunned/unresponsive
• pupils dilated,fixed or
anisocoric
• bradycardia
• pallor
• perspiration
• vomiting
Mechanism:
1. most likely
vasovagal effect
2. some consider
post-traumatic
seizure effect
Treatment
Efficacy of head trauma sheets
• 66% referred to the document
• 84% found it answered all questions
Sequellae; at 48 hours
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headaches
dizziness
sleepy
naus/vomit
51%
14%
14%
12%
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behavioral changes
memory deficits
visual changes
hearing problems
pupillary change
7%
5%
3%
2%
1.5%
Sequellae
• At one week these signs and symptoms are
approximately halved
• 27% yet to return to normal function at
48hr, 13% at by one week
• 50% with residual complaints at 3 months
• recovery from cognitive deficits;1-3months
Sequellae
• 10-15% have surgical lesions
• EDH, SDH, ICH, Depressed skull Fx
• <1% demonstrate talk and die phenomena
sequellae
Post Traumatic Seizures
In isolation; impact or early sz (<1 week);
– not indicative of severe head injury
– not indicative of inc. risk for epilepsy
– 50% occurred in mild group with normal CT
– No role for anticonvulsants
Classification of Injury
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Primary
scalp: laceration, avulsion
skull Fx: “ping-pong” linear , depressed
open/closed, comminuted, basilar
neck: soft tissue, bone, vascular
brain: focal, diffuse
Primary Head Injuries
Skull fractures of concern:
• open,depressed
• crosses suture lines
• crosses known vascular channels
– arterial
– dural sinuses
• enters into sinuses
• basilar
Classification of Head Injury
Secondary
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swelling
hemorrhage
edema
vasospasm
seizures
hypotension
ischemia
• Metabolic
hypoxia/hypercarbia
hypo/hypernatremia
hyperglycemia
• hormonal dysregulation
• dysautonomia
• nutritional
CT Scans of Intracranial Hemorrhage
Mechanism of Injury
Translational
• linear
• focal
Accelerationdeceleration
• rotational
• concussive-shearing
forces
Mechanisms of injury
Age Related
• birth injury; skull fx via canal vs forceps, CN
posterior fossa SDH
• infant/toddler; falls, abuse
• children falls, bikes, pedestrian-MVA, bike-MVA
• teens; falls, MVA, assaults
Triage
Approach/attitude
• apparent stability DOES NOT=
insignificant injury
• stay directed, utilize protocols- avoid inertia
• repeat neurologic exam looking for change
• consider the mechanism of injury-think broadly
• alcohol level <.2 doesn’t alter neurologic much,
but consider drug effect
Triage
History
• mechanism of injury (should “fit” what you see)
• neurologic- recent, remote; baseline, SZ, HI
• general-medical, drugs
• psychological/educational
Triage
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Physical Exam
CGLCS
• reflexes
– DTR
pupils
– cutaneous
respiratory pattern
• mental status
sensory modalities
SEARCH FOR FOCALITY!
Signs of Rostro-caudal
deterioration
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decreased LOC
headache
vomiting
visual changes
pupilary change
• Cushing Triad
• loss of function
– motor/sensory
• respiratory pattern
change
Triage
As A Rule
Any pupillary inequality> 1 mm in a head
injured child must be attributed to an
intracranial injury until proven otherwise
Pathophysiology
Monroe-Kellie doctrine
• three compartments
blood
brain
CSF
• change in one requires reciprocal change in
the others
Clinical Findings in 4500
pediatric head injuries
• Initial LOC
normal
confused
%
56.0
30.2
major impairment
• Vomiting
• Skull Fx
linear
depressed
compound
13.8
30.3
26.6
72.8
27.2
19.7
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Seizures
paralysis
pupil abn
retinal hem
subdural hem
epidural hem
major sequellae
mortality
7.4
3.8
3.6
2.6
5.2
0.9
5.9
5.4
Clinical Profile from 937
Pediatric Head Injuries
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84% CGCS 13-15
Mean age 5.5
Males>females 2:1
Falls>pedestrian/MVA
75% “alert” on admission
13% had surgical lesions
0.3% with CGCS died
avg. length of stay ; 2.8 days
Clinical profile
Presence of Mass lesions
Glasgow Coma Scale 15: 7.1 %
Glasgow Coma Scale 14: 9.7 %
Glasgow Coma Scale 13: 13.6 %
Identifying Risk Facteurs
• LOC >16 minutes =>45X>risk of poor outcome
• small punctate hem/ contusion on CT did not
adversely effect outcome compared to normal CT.
• Linear,basilar,depressed skull Fxs did Not effect
outcome
• Diastatic and compound depressed skull Fxs had
poor outcomes respectively 50% vs 14%
Identifying Risk Facteurs
• GCGS and the patient’s MENTAL
STATUS were the best predicteurs of
potential deterioration or the presence
of a mass lesion
Identifying risk facteurs
Skull X-ray; what role if any??
• Not essential for decision making process
HOWEVER
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presence=>inc risk of lesion\deterioration
useful in penetrating injuries
useful in Non-accidental trauma
useful in following growing Fx of childhood
Etiologies of delayed detoriation
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Mass lesions: EDH/SDH/ICH
electrolyte imbalance
cerebral edema
seizures
Recommendations
• Glasgow Coma Scale 13-14:
CT scan and admit for observation
• Glasgow Coma Scale 15 with normal
neurologic exam/mental status, and
normal CT; discharge with home
observation . CT optional?
• Relevance of duration/presence of
LOC- varied opinion.
Recommendations;Concussion
and Sports
• Confusion w/o amnesia/LOC
asymptomatic; observation 1/2 hr
• confusion with amnesia , no LOC
observe 24 hr, asymptomatic
return to activity after one week
• LOC; formal medical evaluation
asymptomatic return to activity in 2-4 wks
Fail-Safe vs the Doomsday EDH
• Small percentage(<1%) will develop
a delayed lesion with Normal original CT
– In patients with abnormal CT scans:
30% of patients:
• develop a delayed lesion not present on
first CT or worsening of original lesion
• Most will occur within the first 24-36 hrs
Bicycle Facts
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400,000 Rx/yr 1/3 HI
300deaths/yr 80% HI
annual cost:$8 billion
2200/yr sustain
permanent disability,
helmets would
prevent 1700
• helmets reduce risk of
injury85%
• Helmet laws have
reduced mortality 80%
• Bikes are assoc with
more childhood injury
than any other
consumer product
operated by children
• Universal use of
helmets would prevent
one HI every 4 min
and save a life DAILY
Is it a crap shoot?
KNOWLEDGE
IS
POWER