Peds symposium pediatric head trauma 2011 -howard final

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Pediatric Head Injury presentation from 4/16/11

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Peds symposium pediatric head trauma 2011 -howard final

  1. 1. Management of Pediatric Head Trauma in the Emergency Department: Intracranial and Other Issues John M. Howard, DO Assistant Director, Emergikids Alexian Brothers Hospital Network April 16, 2011Wednesday, April 20, 2011
  2. 2. Disclosure • I have had no relevant financial relationships with any proprietary entities producing health care goods or services in the past 12 monthsWednesday, April 20, 2011
  3. 3. ObjectivesWednesday, April 20, 2011
  4. 4. Objectives • Discuss emergency department recognition of intracranial injury via history and physical examWednesday, April 20, 2011
  5. 5. Objectives • Discuss emergency department recognition of intracranial injury via history and physical exam • Discuss indications for neuroimagingWednesday, April 20, 2011
  6. 6. Objectives • Discuss emergency department recognition of intracranial injury via history and physical exam • Discuss indications for neuroimaging • Review management of head trauma cases in the ED: vital sign stabilization, maintenance of respiratory and circulatory parameters, preparation for neurosurgical interventionWednesday, April 20, 2011
  7. 7. WELCOME TOWednesday, April 20, 2011 EMERGIKIDS
  8. 8. ROOM AWednesday, April 20, 2011
  9. 9. ROOM A CC: UNRESPONSIVE, POOR RESPWednesday, April 20, 2011
  10. 10. ROOM A CC: UNRESPONSIVE, POOR RESP HPI: 7 MO FELL OFF BED EARLIER IN DAY ~1.5 FT,Wednesday, April 20, 2011
  11. 11. ROOM A CC: UNRESPONSIVE, POOR RESP HPI: 7 MO FELL OFF BED EARLIER IN DAY ~1.5 FT, “DIDN’T HIT HEAD,” NO LOC, “RECENTLY STARTED CRAWLING”Wednesday, April 20, 2011
  12. 12. ROOM A CC: UNRESPONSIVE, POOR RESP HPI: 7 MO FELL OFF BED EARLIER IN DAY ~1.5 FT, “DIDN’T HIT HEAD,” NO LOC, “RECENTLY STARTED CRAWLING” WAS “FINE” EARLIER IN THE DAY...Wednesday, April 20, 2011
  13. 13. ROOM BWednesday, April 20, 2011
  14. 14. ROOM B C/C: MVCWednesday, April 20, 2011
  15. 15. ROOM B C/C: MVC HPI: 3 YR MALE IN CARSEAT WITH SNOWBLOWER IN ADJACENT SEATWednesday, April 20, 2011
  16. 16. ROOM B C/C: MVC HPI: 3 YR MALE IN CARSEAT WITH SNOWBLOWER IN ADJACENT SEAT T-BONED BY ONCOMING CAR, LAUNCHING SNOWBLOWER INTO PTWednesday, April 20, 2011
  17. 17. ROOM B C/C: MVC HPI: 3 YR MALE IN CARSEAT WITH SNOWBLOWER IN ADJACENT SEAT T-BONED BY ONCOMING CAR, LAUNCHING SNOWBLOWER INTO PT SLEEPY, BUT AROUSES TO VOICEWednesday, April 20, 2011
  18. 18. ROOM B C/C: MVC HPI: 3 YR MALE IN CARSEAT WITH SNOWBLOWER IN ADJACENT SEAT T-BONED BY ONCOMING CAR, LAUNCHING SNOWBLOWER INTO PT SLEEPY, BUT AROUSES TO VOICE EAR LACERATION EXTENDING IN TO EAC, HEMORRHAGIC OTORRHEAWednesday, April 20, 2011
  19. 19. ROOM B C/C: MVC HPI: 3 YR MALE IN CARSEAT WITH SNOWBLOWER IN ADJACENT SEAT T-BONED BY ONCOMING CAR, LAUNCHING SNOWBLOWER INTO PT SLEEPY, BUT AROUSES TO VOICE EAR LACERATION EXTENDING IN TO EAC, HEMORRHAGIC OTORRHEAWednesday, April 20, 2011
  20. 20. IntroductionWednesday, April 20, 2011
  21. 21. Introduction • What is the leading cause of death in children and adolescents in US?Wednesday, April 20, 2011
  22. 22. Introduction • What is the leading cause of death in children and adolescents in US? • What % of these are due to traumatic brain injuries (TBI)? (40%)Wednesday, April 20, 2011
  23. 23. Introduction • What is the leading cause of death in children and adolescents in US? • What % of these are due to traumatic brain injuries (TBI)? (40%) • Remember! These are often associated with cervical spine injuriesWednesday, April 20, 2011
  24. 24. IntroductionWednesday, April 20, 2011
  25. 25. Introduction • Goals:Wednesday, April 20, 2011
  26. 26. Introduction • Goals: • Identify and stabilize pts with TBIWednesday, April 20, 2011
  27. 27. Introduction • Goals: • Identify and stabilize pts with TBI • Minimize factors that contribute to secondary brain injuryWednesday, April 20, 2011
  28. 28. Introduction • Goals: • Identify and stabilize pts with TBI • Minimize factors that contribute to secondary brain injury • HypoxiaWednesday, April 20, 2011
  29. 29. Introduction • Goals: • Identify and stabilize pts with TBI • Minimize factors that contribute to secondary brain injury • Hypoxia • HypotensionWednesday, April 20, 2011
  30. 30. Definitions Mild 13-15* (Concussion) • Defined by GCS Moderate 9-12 Severe <9Wednesday, April 20, 2011
  31. 31. DefinitionsWednesday, April 20, 2011
  32. 32. Definitions • *Minor head trauma (GCS 15):Wednesday, April 20, 2011
  33. 33. Definitions • *Minor head trauma (GCS 15): • Chidren < 2 yrs: H+P blunt trauma to scalp/skull/brain and is alert to voice/ touchWednesday, April 20, 2011
  34. 34. Definitions • *Minor head trauma (GCS 15): • Chidren < 2 yrs: H+P blunt trauma to scalp/skull/brain and is alert to voice/ touch • Children >/= 2 yrs: normal MS on initial exam, no focal neuro findings, no exam findings for skull fxWednesday, April 20, 2011
  35. 35. DefinitionsWednesday, April 20, 2011
  36. 36. Definitions • Mild Traumatic Brain Injury (GCS 13-15): brief LOC, disorientation, vomitingWednesday, April 20, 2011
  37. 37. Definitions • Mild Traumatic Brain Injury (GCS 13-15): brief LOC, disorientation, vomiting • Concussion: Trauma-induced disturbance of neuro fxn and MS, +/- LOC.Wednesday, April 20, 2011
  38. 38. Definitions • Mild Traumatic Brain Injury (GCS 13-15): brief LOC, disorientation, vomiting • Concussion: Trauma-induced disturbance of neuro fxn and MS, +/- LOC. • Associated sx’s: HA, vomiting, amnesia, AMSWednesday, April 20, 2011
  39. 39. EpidemiologyWednesday, April 20, 2011
  40. 40. Epidemiology • Children 0-14 years in US, TBI accounts for:Wednesday, April 20, 2011
  41. 41. Epidemiology • Children 0-14 years in US, TBI accounts for: • 475,000 ED visits/yrWednesday, April 20, 2011
  42. 42. Epidemiology • Children 0-14 years in US, TBI accounts for: • 475,000 ED visits/yr • 50,000 hospital admissions/yr < 17 yrs(2000)Wednesday, April 20, 2011
  43. 43. Epidemiology • Children 0-14 years in US, TBI accounts for: • 475,000 ED visits/yr • 50,000 hospital admissions/yr < 17 yrs(2000) • 29% < 4 yrs oldWednesday, April 20, 2011
  44. 44. Epidemiology • Children 0-14 years in US, TBI accounts for: • 475,000 ED visits/yr • 50,000 hospital admissions/yr < 17 yrs(2000) • 29% < 4 yrs old • 52% 10-17 yrs oldWednesday, April 20, 2011
  45. 45. EpidemiologyWednesday, April 20, 2011
  46. 46. Epidemiology • In developed countries: TBI most common cause of death and disability in childhoodWednesday, April 20, 2011
  47. 47. Epidemiology • In developed countries: TBI most common cause of death and disability in childhood • 3,000 children die each year in US from head injuriesWednesday, April 20, 2011
  48. 48. Epidemiology • In developed countries: TBI most common cause of death and disability in childhood • 3,000 children die each year in US from head injuries • Overall mortality among children with TBI seen in ED or requiring hospitalizationWednesday, April 20, 2011
  49. 49. Epidemiology • In developed countries: TBI most common cause of death and disability in childhood • 3,000 children die each year in US from head injuries • Overall mortality among children with TBI seen in ED or requiring hospitalization • 4.5%Wednesday, April 20, 2011
  50. 50. Epidemiology • In developed countries: TBI most common cause of death and disability in childhood • 3,000 children die each year in US from head injuries • Overall mortality among children with TBI seen in ED or requiring hospitalization • 4.5% • 10.4% adultsWednesday, April 20, 2011
  51. 51. Epidemiology: Mechanism • Falls • Assaults • MVC • Sports-related • Pedestrian/ bicycle • Inflicted head injuries accidents • Unknown? • ProjectilesWednesday, April 20, 2011
  52. 52. EpidemiologyWednesday, April 20, 2011
  53. 53. Epidemiology • Highest morbidity/mortality:Wednesday, April 20, 2011
  54. 54. Epidemiology • Highest morbidity/mortality: • < 4 yrsWednesday, April 20, 2011
  55. 55. Epidemiology • Highest morbidity/mortality: • < 4 yrs • Low GCS initiallyWednesday, April 20, 2011
  56. 56. Epidemiology • Highest morbidity/mortality: • < 4 yrs • Low GCS initially • CoagulopathyWednesday, April 20, 2011
  57. 57. Epidemiology • Highest morbidity/mortality: • < 4 yrs • Low GCS initially • Coagulopathy • HyperglycemiaWednesday, April 20, 2011
  58. 58. Epidemiology • Highest morbidity/mortality: • < 4 yrs • Low GCS initially • Coagulopathy • Hyperglycemia • HypotensionWednesday, April 20, 2011
  59. 59. IncidenceWednesday, April 20, 2011
  60. 60. Incidence • True incidence: ...?Wednesday, April 20, 2011
  61. 61. Incidence • True incidence: ...? • > 2 yrs w/ minor head trauma + normal neuro examWednesday, April 20, 2011
  62. 62. Incidence • True incidence: ...? • > 2 yrs w/ minor head trauma + normal neuro exam • 3-7% with intracranial injury (ICI)Wednesday, April 20, 2011
  63. 63. Incidence • True incidence: ...? • > 2 yrs w/ minor head trauma + normal neuro exam • 3-7% with intracranial injury (ICI) • < 2 yrs w/ minor head trauma + normal neuro examWednesday, April 20, 2011
  64. 64. Incidence • True incidence: ...? • > 2 yrs w/ minor head trauma + normal neuro exam • 3-7% with intracranial injury (ICI) • < 2 yrs w/ minor head trauma + normal neuro exam • 3-10% with ICIWednesday, April 20, 2011
  65. 65. Incidence • True incidence: ...? • > 2 yrs w/ minor head trauma + normal neuro exam • 3-7% with intracranial injury (ICI) • < 2 yrs w/ minor head trauma + normal neuro exam • 3-10% with ICI • Many of these pts have no clinical symptomsWednesday, April 20, 2011
  66. 66. Incidence • True incidence: ...? • > 2 yrs w/ minor head trauma + normal neuro exam • 3-7% with intracranial injury (ICI) • < 2 yrs w/ minor head trauma + normal neuro exam • 3-10% with ICI • Many of these pts have no clinical symptoms • Most have scalp hematomasWednesday, April 20, 2011
  67. 67. Clinical Features Symptom Percentage Comment Longer duration of LOC 5% (< 2), 13% (>2) LOC assoc with CITBI* Preverbal children HA 45% = irritable Assoc w/ slight risk Vomiting 14% of TBI Smaller studies Sz 0.6% report larger % Mostly linear when Skull Fx 15-30% assoc w/ ICI *Clinically Important TBIWednesday, April 20, 2011
  68. 68. Clinical FeaturesWednesday, April 20, 2011
  69. 69. Clinical Features • Scalp hematomas:Wednesday, April 20, 2011
  70. 70. Clinical Features • Scalp hematomas: • When < 1 yr, large size or location (parietal or temporal) may be assoc w/ fxWednesday, April 20, 2011
  71. 71. Clinical Features • Scalp hematomas: • When < 1 yr, large size or location (parietal or temporal) may be assoc w/ fx • Others:Wednesday, April 20, 2011
  72. 72. Clinical Features • Scalp hematomas: • When < 1 yr, large size or location (parietal or temporal) may be assoc w/ fx • Others: • Transient cortical blindness or confusional statesWednesday, April 20, 2011
  73. 73. Types of Brain InjuryWednesday, April 20, 2011
  74. 74. Types of Brain Injury • Diffuse brain injury (DBI): most common type of severe TBIWednesday, April 20, 2011
  75. 75. Types of Brain Injury • Diffuse brain injury (DBI): most common type of severe TBI • acceleration or decelerationWednesday, April 20, 2011
  76. 76. Types of Brain Injury • Diffuse brain injury (DBI): most common type of severe TBI • acceleration or deceleration • mildest form = ConcussionWednesday, April 20, 2011
  77. 77. Types of Brain InjuryWednesday, April 20, 2011
  78. 78. Types of Brain Injury • Diffuse axonal injury (DAI): more severe formWednesday, April 20, 2011
  79. 79. Types of Brain Injury • Diffuse axonal injury (DAI): more severe form • Tissue shearing at interface of grey- white matterWednesday, April 20, 2011
  80. 80. Types of Brain Injury • Diffuse axonal injury (DAI): more severe form • Tissue shearing at interface of grey- white matter • Associated with focal injuries:Wednesday, April 20, 2011
  81. 81. Types of Brain Injury • Diffuse axonal injury (DAI): more severe form • Tissue shearing at interface of grey- white matter • Associated with focal injuries: • Cerebral ContusionsWednesday, April 20, 2011
  82. 82. Types of Brain Injury • Diffuse axonal injury (DAI): more severe form • Tissue shearing at interface of grey- white matter • Associated with focal injuries: • Cerebral Contusions • Intracranial HemorrhageWednesday, April 20, 2011
  83. 83. Types of Brain Injury http://www.braininjury.com/children.htmlWednesday, April 20, 2011
  84. 84. Types of Brain Injury • Focal injuries: Cerebral contusion: http://www.braininjury.com/children.htmlWednesday, April 20, 2011
  85. 85. Types of Brain Injury • Focal injuries: Cerebral contusion: • Usually due to acceleration/ deceleration injury http://www.braininjury.com/children.htmlWednesday, April 20, 2011
  86. 86. Types of Brain Injury • Focal injuries: Cerebral contusion: • Usually due to acceleration/ deceleration injury • Coup, contracoup, or both http://www.braininjury.com/children.htmlWednesday, April 20, 2011
  87. 87. Types of Brain InjuryWednesday, April 20, 2011
  88. 88. Types of Brain Injury • Focal injuries: Intracranial hemorrhageWednesday, April 20, 2011
  89. 89. Types of Brain Injury • Focal injuries: Intracranial hemorrhage • Epidermal hematoma: arise from middle meningeal artery or othersWednesday, April 20, 2011
  90. 90. Types of Brain Injury • Focal injuries: Intracranial hemorrhage • Epidermal hematoma: arise from middle meningeal artery or others • Subdural hematoma: rupture of bridging veinsWednesday, April 20, 2011
  91. 91. Types of Brain Injury • Focal injuries: Intracranial hemorrhage • Epidermal hematoma: arise from middle meningeal artery or others • Subdural hematoma: rupture of bridging veins • Subarachnoid hematoma: tearing of small vessels in pia materWednesday, April 20, 2011
  92. 92. Associated Injuries • Multiple trauma • Cervical spine injuryWednesday, April 20, 2011
  93. 93. PathophysiologyWednesday, April 20, 2011
  94. 94. Pathophysiology • Two insult model:Wednesday, April 20, 2011
  95. 95. Pathophysiology • Two insult model: • Primary event--direct injury to brain parenchymaWednesday, April 20, 2011
  96. 96. Pathophysiology • Two insult model: • Primary event--direct injury to brain parenchyma • Impaired Autoregulation -->Wednesday, April 20, 2011
  97. 97. Pathophysiology • Two insult model: • Primary event--direct injury to brain parenchyma • Impaired Autoregulation --> • Cerebral hypoperfusion -->Wednesday, April 20, 2011
  98. 98. Pathophysiology • Two insult model: • Primary event--direct injury to brain parenchyma • Impaired Autoregulation --> • Cerebral hypoperfusion --> • increased metabolic demand...Wednesday, April 20, 2011
  99. 99. Pathophysiology • Two insult model: • Primary event--direct injury to brain parenchyma • Impaired Autoregulation --> • Cerebral hypoperfusion --> • increased metabolic demand... • Secondary event--result of exogenous insults: hypoxia and hypotensionWednesday, April 20, 2011
  100. 100. EvaluationWednesday, April 20, 2011
  101. 101. Evaluation • Prompt recognition: Interventions, Follow up, NeuroimagingWednesday, April 20, 2011
  102. 102. Evaluation • Prompt recognition: Interventions, Follow up, Neuroimaging • Emergent stabilizationWednesday, April 20, 2011
  103. 103. Evaluation • Prompt recognition: Interventions, Follow up, Neuroimaging • Emergent stabilization • Primary survey: A, B, C’s, and identification of life-threatening conditionsWednesday, April 20, 2011
  104. 104. Evaluation • Prompt recognition: Interventions, Follow up, Neuroimaging • Emergent stabilization • Primary survey: A, B, C’s, and identification of life-threatening conditions • Secondary survey: Head-to-toe exam with thorough neurological evaluationWednesday, April 20, 2011
  105. 105. Evaluation: HistoryWednesday, April 20, 2011
  106. 106. Evaluation: History • Obvious vs. Subtle:Wednesday, April 20, 2011
  107. 107. Evaluation: History • Obvious vs. Subtle: • Prolonged LOC or AMSWednesday, April 20, 2011
  108. 108. Evaluation: History • Obvious vs. Subtle: • Prolonged LOC or AMS • Persistent vomitingWednesday, April 20, 2011
  109. 109. Evaluation: History • Obvious vs. Subtle: • Prolonged LOC or AMS • Persistent vomiting • Severe HAWednesday, April 20, 2011
  110. 110. Evaluation: History • Obvious vs. Subtle: • Prolonged LOC or AMS • Persistent vomiting • Severe HA • Progression of symptomsWednesday, April 20, 2011
  111. 111. Evaluation: History • Obvious vs. Subtle: • Prolonged LOC or AMS • Persistent vomiting • Severe HA • Progression of symptoms • Occult: Inflicted head injuryWednesday, April 20, 2011
  112. 112. Wednesday, April 20, 2011
  113. 113. Evaluation: Physical ExamWednesday, April 20, 2011
  114. 114. Evaluation: Physical Exam • General assessmentWednesday, April 20, 2011
  115. 115. Evaluation: Physical Exam • General assessment • Vitals + Pulseox:Wednesday, April 20, 2011
  116. 116. Evaluation: Physical Exam • General assessment • Vitals + Pulseox: • Hypoxia, hypotensionWednesday, April 20, 2011
  117. 117. Evaluation: Physical Exam • General assessment • Vitals + Pulseox: • Hypoxia, hypotension • Irregular respirations, bradycardia, hypertension...Wednesday, April 20, 2011
  118. 118. Evaluation: Physical Exam • General assessment • Vitals + Pulseox: • Hypoxia, hypotension • Irregular respirations, bradycardia, hypertension... • Cervical spine immobilization!Wednesday, April 20, 2011
  119. 119. Evaluation: Physical Exam • General assessment • Vitals + Pulseox: • Hypoxia, hypotension • Irregular respirations, bradycardia, hypertension... • Cervical spine immobilization!Wednesday, April 20, 2011
  120. 120. Evaluation: Physical Exam • Calculation of GCS! • Scalp abnormalities: AF, hematoma, depression? • Basilar skull fx? periorbital ecchymosis, Battle’s sign, hemotympanum, CSF otorrhea/rhinorrheaWednesday, April 20, 2011
  121. 121. Evaluation: PhysicalWednesday, April 20, 2011
  122. 122. Evaluation: Physical • Focused neuro exam: LOC, pupils, EOM, fundoscopic eval, brainstem reflexes (gag, cornea), DTR’s, response to pain?Wednesday, April 20, 2011
  123. 123. Evaluation: Physical • Focused neuro exam: LOC, pupils, EOM, fundoscopic eval, brainstem reflexes (gag, cornea), DTR’s, response to pain? • Any Abnormalities noted may signal in increase in ICP or possible herniation...!Wednesday, April 20, 2011
  124. 124. HerniationWednesday, April 20, 2011
  125. 125. Evaluation: Physical ExamWednesday, April 20, 2011
  126. 126. Evaluation: Physical Exam • Signs of herniation: • Uncal herniation --> CN III palsy --> hemiplegia • Changes in respiratory patterns, pupil size, vestibuloocular reflexes, posture • Cushing’s triadWednesday, April 20, 2011
  127. 127. Evaluation: Laboratory Studies • Trauma labs: Hct, Type + Screen, UA • Blood glucose*, serum electrolytes, osmolarity • Coagulation studies* • * = abnormality associated with poor outcome in TBIWednesday, April 20, 2011
  128. 128. Evaluation: Imaging • Mild TBI: Skull radiographs for: • Unclear hx, • R/O FB, • Screen for fx in asymptomatic pts 3-24 mos with scalp hematomasWednesday, April 20, 2011
  129. 129. Medline ® Abstract for Reference 39 of Minor head trauma in infants and children39TISkull radiograph interpretation of children younger than two years: how good are pediatric emergency physicians?AUChung S, Schamban N, Wypij D, Cleveland R, Schutzman SASOAnn Emerg Med. 2004;43(6):718.STUDY OBJECTIVE: We determine pediatric emergency physicians accuracy in interpreting skull radiographs of children younger than 2 years and determine thecharacteristics of misidentified skull radiographs.METHODS: A set of 31 skull radiographs (16 with fractures, 15 normal) was compiled from children younger than 2years who were evaluated for head trauma in a pediatric emergency department from March 3, 1997, to March 3, 1998. A pediatric radiologist reinterpreted the filmsand agreed with all of the original readings in the final set. Participants (attending level physicians) were asked to identify the presence, location, and pattern of anyfracture. Skull radiograph interpretation was considered radiographically correct if the presence, location, and pattern of fracture were correctly identified and wasconsidered diagnostically correct if the presence of a fracture was recognized.RESULTS: Twenty-five of 26 eligible pediatric emergency physicians completed the study.The mean of each participants radiographically correct interpretation was 65%+/-10% (mean+/-SD), and diagnostically correct interpretation was 80%+/-9%. The groups mean sensitivity for diagnostically correct interpretation was 76%+/-15%, and specificity was 84%+/-14%. Shorter fractures were identifiedcorrectly less often (63%<or =5 cm versus 93%>5 cm; mean difference 30%; 95% confidence interval 21% to 39%). Diagnostically correct rates did not differaccording to age of patient, physician practice location, years in practice, or practice in ordering skull radiographs.CONCLUSION: Pediatric emergency physicians havelimited accuracy in interpreting skull radiographs of children younger than 2 years. Shorter fractures are more commonly misinterpreted.ADDivision of Emergency Medicine, Childrens Hospital, Harvard Medical School, Boston, MA 02115, USA. sarita.chung@tch.harvard.eduPMID15159702 Wednesday, April 20, 2011
  130. 130. Evaluation: ImagingWednesday, April 20, 2011
  131. 131. Evaluation: Imaging • Head CT preferred initial modality for children with severe TBIWednesday, April 20, 2011
  132. 132. Evaluation: Imaging • Head CT preferred initial modality for children with severe TBI • By definition, all children with moderate to severe TBI have an abnormal neuro evaluation and should have head CTWednesday, April 20, 2011
  133. 133. Evaluation: Imaging • Head CT preferred initial modality for children with severe TBI • By definition, all children with moderate to severe TBI have an abnormal neuro evaluation and should have head CT • Imaging for mild TBI is more complex...Wednesday, April 20, 2011
  134. 134. THE CT DEBATE...Wednesday, April 20, 2011
  135. 135. THE CT DEBATE...Wednesday, April 20, 2011
  136. 136. THE CT DEBATE...Wednesday, April 20, 2011
  137. 137. THE CT DEBATE...Wednesday, April 20, 2011
  138. 138. Evaluation: ImagingWednesday, April 20, 2011
  139. 139. Evaluation: Imaging • Increased use of CT in USWednesday, April 20, 2011
  140. 140. Evaluation: Imaging • Increased use of CT in US • 13% to 22% b/t 1995 and 2003Wednesday, April 20, 2011
  141. 141. Evaluation: Imaging • Increased use of CT in US • 13% to 22% b/t 1995 and 2003 • Goal: eliminate pediatric pts receiving head CT in minor head traumaWednesday, April 20, 2011
  142. 142. Evaluation: Imaging • Increased use of CT in US • 13% to 22% b/t 1995 and 2003 • Goal: eliminate pediatric pts receiving head CT in minor head trauma • More likely to occur in community hospitalsWednesday, April 20, 2011
  143. 143. Evaluation: Imaging • Increased use of CT in US • 13% to 22% b/t 1995 and 2003 • Goal: eliminate pediatric pts receiving head CT in minor head trauma • More likely to occur in community hospitals • Rare, significant injuries vs risks of CTWednesday, April 20, 2011
  144. 144. Evaluation: ImagingWednesday, April 20, 2011
  145. 145. Evaluation: Imaging • Lifetime risk for cancer in pediatric pts with head CT? (1:1500 HEAD CT)Wednesday, April 20, 2011
  146. 146. Evaluation: Imaging • Lifetime risk for cancer in pediatric pts with head CT? (1:1500 HEAD CT) • Worse for children vs. adultsWednesday, April 20, 2011
  147. 147. Evaluation: Imaging • Lifetime risk for cancer in pediatric pts with head CT? (1:1500 HEAD CT) • Worse for children vs. adults • Longer subsequent lifetimeWednesday, April 20, 2011
  148. 148. Evaluation: Imaging • Lifetime risk for cancer in pediatric pts with head CT? (1:1500 HEAD CT) • Worse for children vs. adults • Longer subsequent lifetime • Greater sensitivity to radiation in some developing organsWednesday, April 20, 2011
  149. 149. Evaluation: Imaging • Lifetime risk for cancer in pediatric pts with head CT? (1:1500 HEAD CT) • Worse for children vs. adults • Longer subsequent lifetime • Greater sensitivity to radiation in some developing organs • Sedation issuesWednesday, April 20, 2011
  150. 150. Evaluation: Imaging • Goal: identify pts with clinically important TBI: • neurosurgery, • ET intubation > 24 hrs, • hospitalized > 2 daysWednesday, April 20, 2011
  151. 151. Evaluation: ImagingWednesday, April 20, 2011
  152. 152. Evaluation: Imaging • Predictors of Intracranial Injury (ICI)Wednesday, April 20, 2011
  153. 153. Evaluation: Imaging • Predictors of Intracranial Injury (ICI) • Consistent: skull fx, focal neuro deficit, depressed MSWednesday, April 20, 2011
  154. 154. Evaluation: Imaging • Predictors of Intracranial Injury (ICI) • Consistent: skull fx, focal neuro deficit, depressed MS • Variable: sz, LOC, amnesia, vomiting, < 2 yrs, trauma mechanism, scalp swelling (pt < 1yr), HAWednesday, April 20, 2011
  155. 155. FOCUS! 2 MOST IMPORTANT SLIDES AHEAD!Wednesday, April 20, 2011
  156. 156. FOCUS! 2 MOST IMPORTANT SLIDES AHEAD!Wednesday, April 20, 2011
  157. 157. Wednesday, April 20, 2011
  158. 158. Wednesday, April 20, 2011
  159. 159. Management: TBIWednesday, April 20, 2011
  160. 160. Management: Airway and BreathingWednesday, April 20, 2011
  161. 161. Management: Airway and Breathing • Maintaining an oral airway, supplemental O2Wednesday, April 20, 2011
  162. 162. Management: Airway and Breathing • Maintaining an oral airway, supplemental O2 • Bag-valve-mask ventilationsWednesday, April 20, 2011
  163. 163. Management: Airway and Breathing • Maintaining an oral airway, supplemental O2 • Bag-valve-mask ventilations • Endotracheal intubation via Rapid sequence intubation (RSI) if:Wednesday, April 20, 2011
  164. 164. Management: Airway and Breathing • Maintaining an oral airway, supplemental O2 • Bag-valve-mask ventilations • Endotracheal intubation via Rapid sequence intubation (RSI) if: • Decreasing LOC (GCS < 9)Wednesday, April 20, 2011
  165. 165. Management: Airway and Breathing • Maintaining an oral airway, supplemental O2 • Bag-valve-mask ventilations • Endotracheal intubation via Rapid sequence intubation (RSI) if: • Decreasing LOC (GCS < 9) • Marked respiratory distressWednesday, April 20, 2011
  166. 166. Management: Airway and Breathing • Maintaining an oral airway, supplemental O2 • Bag-valve-mask ventilations • Endotracheal intubation via Rapid sequence intubation (RSI) if: • Decreasing LOC (GCS < 9) • Marked respiratory distress • Hemodynamic instabilityWednesday, April 20, 2011
  167. 167. Management: Airway and Breathing • Maintaining an oral airway, supplemental O2 • Bag-valve-mask ventilations • Endotracheal intubation via Rapid sequence intubation (RSI) if: • Decreasing LOC (GCS < 9) • Marked respiratory distress • Hemodynamic instability • Use cuffed tracheal tubes to protect airway from aspirationWednesday, April 20, 2011
  168. 168. Management: Airway and BreathingWednesday, April 20, 2011
  169. 169. Management: Airway and Breathing • RSI considerations:Wednesday, April 20, 2011
  170. 170. Management: Airway and Breathing • RSI considerations: • Pretreat with Lidocaine --> minimizes increase in ICP that can be associated with airway manipulationWednesday, April 20, 2011
  171. 171. Management: Airway and Breathing • RSI considerations: • Pretreat with Lidocaine --> minimizes increase in ICP that can be associated with airway manipulation • Sedation --> Etomidate and thiopental* = neuroprotectiveWednesday, April 20, 2011
  172. 172. Management: Airway and Breathing • RSI considerations: • Pretreat with Lidocaine --> minimizes increase in ICP that can be associated with airway manipulation • Sedation --> Etomidate and thiopental* = neuroprotective • Paralysis --> Succinylcholine (+/-) vs. RocuroniumWednesday, April 20, 2011
  173. 173. Management: Airway and Breathing • Role of Hyperventilation HYPERVENTILATION DECREASE PCO2 CEREBRAL VASOCONSTRICTION DECREASED CEREBRAL PERFUSION REDUCTION OF INTRACRANIAL PRESSUREWednesday, April 20, 2011
  174. 174. Management: Airway and Breathing • Role of Hyperventilation HYPERVENTILATION DECREASE PCO2 HYPOPERFUSION = CEREBRAL HYPOXIA? VASOCONSTRICTION DECREASED CEREBRAL PERFUSION REDUCTION OF INTRACRANIAL PRESSUREWednesday, April 20, 2011
  175. 175. Management: Airway and Breathing • Role of Hyperventilation HYPERVENTILATION DECREASE PCO2 HYPOPERFUSION = CEREBRAL VASOCONSTRICTION IDEAL PACO2 35-38...* HYPOXIA? DECREASED CEREBRAL PERFUSION REDUCTION OF INTRACRANIAL PRESSUREWednesday, April 20, 2011
  176. 176. Management: Fluid ManagmentWednesday, April 20, 2011
  177. 177. Management: Fluid Managment • Outcome is poor for pts with severe TBI and initial hypotensionWednesday, April 20, 2011
  178. 178. Management: Fluid Managment • Outcome is poor for pts with severe TBI and initial hypotension • Target blood pressure to maintain cerebral perfusion pressure is not clearly defined, but may be age- dependent.Wednesday, April 20, 2011
  179. 179. Management: Fluid Managment • Outcome is poor for pts with severe TBI and initial hypotension • Target blood pressure to maintain cerebral perfusion pressure is not clearly defined, but may be age- dependent. • Maintain SBP > 5th percentile, as a minimumWednesday, April 20, 2011
  180. 180. Management: Fluid Managment • Outcome is poor for pts with severe TBI and initial hypotension • Target blood pressure to maintain cerebral perfusion pressure is not clearly defined, but may be age- dependent. • Maintain SBP > 5th percentile, as a minimum • Isotonic fluids preferred (vs. hypertonic)Wednesday, April 20, 2011
  181. 181. Management: Other Head positioning Hyperventilation Sedation/paralysis AVOID HYPERGLYCEMIA Antiseizure Corticosteroids (?) Hyper-/Hypothermia Emergent surgery Hyperosmolar TxWednesday, April 20, 2011
  182. 182. Management: Monitoring • HR, BP, Pulse oximetry • Capnography: end-tidal CO2 • ICP monitoring if abn head CT or GCS 3-8Wednesday, April 20, 2011
  183. 183. ED Management DecisionsWednesday, April 20, 2011
  184. 184. ED Management Decisions • Immediate neurosurgical evaluation required for:Wednesday, April 20, 2011
  185. 185. ED Management Decisions • Immediate neurosurgical evaluation required for: • Focal injuries identified on CTWednesday, April 20, 2011
  186. 186. ED Management Decisions • Immediate neurosurgical evaluation required for: • Focal injuries identified on CT • Depressed, basilar, widely diastatic skull fxWednesday, April 20, 2011
  187. 187. ED Management Decisions • Immediate neurosurgical evaluation required for: • Focal injuries identified on CT • Depressed, basilar, widely diastatic skull fx • Increased ICPWednesday, April 20, 2011
  188. 188. ED Management Decisions • Immediate neurosurgical evaluation required for: • Focal injuries identified on CT • Depressed, basilar, widely diastatic skull fx • Increased ICP • Deteriorating clinical conditionWednesday, April 20, 2011
  189. 189. ED Management DecisionsWednesday, April 20, 2011
  190. 190. ED Management Decisions • Children with signs of herniation:Wednesday, April 20, 2011
  191. 191. ED Management Decisions • Children with signs of herniation: • O2, breathing, BPWednesday, April 20, 2011
  192. 192. ED Management Decisions • Children with signs of herniation: • O2, breathing, BP • Hyperosmolar Tx (Mannitol)Wednesday, April 20, 2011
  193. 193. ED Management Decisions • Children with signs of herniation: • O2, breathing, BP • Hyperosmolar Tx (Mannitol) • Mild hyperventilation (PaCO2 30-35)Wednesday, April 20, 2011
  194. 194. ED Management Decisions • Children with signs of herniation: • O2, breathing, BP • Hyperosmolar Tx (Mannitol) • Mild hyperventilation (PaCO2 30-35) • Immediate neurosurgical evaluationWednesday, April 20, 2011
  195. 195. Disposition: Minor Head TraumaWednesday, April 20, 2011
  196. 196. Disposition: Minor Head Trauma • May go home after observation period without deterioration and/or negative head CT --> F/U PCP IN 24 HRSWednesday, April 20, 2011
  197. 197. Disposition: Minor Head Trauma • May go home after observation period without deterioration and/or negative head CT --> F/U PCP IN 24 HRS • If home, f/u if worsening HA, persistent vomiting, AMS, gait/coordination issues, szWednesday, April 20, 2011
  198. 198. Disposition: Minor Head Trauma • May go home after observation period without deterioration and/or negative head CT --> F/U PCP IN 24 HRS • If home, f/u if worsening HA, persistent vomiting, AMS, gait/coordination issues, sz • Admit: brain injury, depressed/basilar skull fracture (with Neurosurg), AMS, persistent vomiting, suspected abuse, unreliable caretakersWednesday, April 20, 2011
  199. 199. Disposition: TBIWednesday, April 20, 2011
  200. 200. Disposition: TBI • Children in field with GCS < or = 12 should go directly to pediatric trauma center. • Once stabilized, pts should be transferred from community hospital to peds trauma center if: • GCS < or = 8 • GCS < or = 12 with associated major injuries • Deterioration in clinical condition / GCS dropWednesday, April 20, 2011
  201. 201. Return to Play GuidelinesWednesday, April 20, 2011
  202. 202. Return to Play Guidelines • Children/adolescents at increased risk for Second Impact Syndrome • Diffuse cerebral swelling after 2nd concussion -- rare, often FATAL. • Any LOC or symptoms of concussion > 15 minutes -- no sports until asymptomatic x 7 daysWednesday, April 20, 2011
  203. 203. NFL Players Association What is the cumulative effect of recurrent mild TBI?Wednesday, April 20, 2011
  204. 204. Some final words... http://www.cdc.gov/traumaticbraininjury/ prevention.htmlWednesday, April 20, 2011
  205. 205. ROOM A: 7 MO MALEWednesday, April 20, 2011
  206. 206. ROOM A: 7 MO MALE ACTIVE SZ INTUBATED, ANTICONVULSANTS URGENT NEUROSURG CONSULT MANNITOLWednesday, April 20, 2011
  207. 207. ROOM A: 7 MO MALE ACTIVE SZ INTUBATED, ANTICONVULSANTS URGENT NEUROSURG CONSULT MANNITOLWednesday, April 20, 2011
  208. 208. ROOM B: 3 YR MALEWednesday, April 20, 2011
  209. 209. ROOM B: 3 YR MALEWednesday, April 20, 2011
  210. 210. ROOM B: 3 YR MALEWednesday, April 20, 2011
  211. 211. bibliography Langlois, JA, Rutland-Brown, W, Thomas, KE. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta 2006. Schneier AJ, Shields BJ, Hostetler SG, et al. Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States. Pediatrics 2006; 118:483. White JR, Farukhi Z, Bull C, et al. Predictors of outcome in severely head-injured children. Crit Care Med 2001; 29:534. Luerssen TG, Klauber MR, Marshall LF. Outcome from head injury related to patients age. A longitudinal prospective study of adult and pediatric head injury. J Neurosurg 1988; 68:409. Vavilala MS, Muangman S, Tontisirin N, et al. Impaired cerebral autoregulation and 6-month outcome in children with severe traumatic brain injury: preliminary findings. Dev Neurosci 2006; 28:348. Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009; 374:1160. McCrory P. Does second impact syndrome exist? Clin J Sport Med 2001; 11:144. Kirkwood MW, Yeates KO, Wilson PE. Pediatric sport-related concussion: a review of the clinical management of an oft-neglected population. Pediatrics 2006; 117:1359.Wednesday, April 20, 2011
  212. 212. Questions? QUESTIONS?Wednesday, April 20, 2011
  213. 213. ROOM CWednesday, April 20, 2011

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