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  1. 1. Minor Head Trauma inMinor Head Trauma in Children and AdolescentsChildren and Adolescents Bill AhrensBill Ahrens The University of Illinois atThe University of Illinois at ChicagoChicago
  2. 2. MHTMHT ►An extraordinarily common problemAn extraordinarily common problem ►Obvious sequelae are uncommonObvious sequelae are uncommon ►Recommendations characterized byRecommendations characterized by  lack of standard definitionlack of standard definition  lack of prospective studieslack of prospective studies
  3. 3. MHTMHT ►For the purposes of this lecture MHT will beFor the purposes of this lecture MHT will be considered to involve:considered to involve:  a relatively trivial mechanism of injurya relatively trivial mechanism of injury  a patient with a GCS of 15 on arrival to the EDa patient with a GCS of 15 on arrival to the ED  no evidence of skull fractureno evidence of skull fracture  Retrograde/posttraumatic amnesiaRetrograde/posttraumatic amnesia  ??? Brief LOC ?????? Brief LOC ???
  4. 4. MHTMHT ►Key questions for the evaluating physicianKey questions for the evaluating physician include:include:  What is the appropriate evaluation?What is the appropriate evaluation?  What radiographic studies are necessary?What radiographic studies are necessary?  What is the disposition of the patient?What is the disposition of the patient?  When can the patient resume activity?When can the patient resume activity?  Are there sequelaeAre there sequelae
  5. 5. MHTMHT ►Radioimaging in the ED: the goal is toRadioimaging in the ED: the goal is to diagnose neurosurgical emergenciesdiagnose neurosurgical emergencies  Skull FilmsSkull Films  CT ScanningCT Scanning
  6. 6. MHTMHT ►What is known (more or less)What is known (more or less)  Intracranial lesions ( per CT scanning) are notIntracranial lesions ( per CT scanning) are not rare in pediatric patients with MHTrare in pediatric patients with MHT  A normal neurologic exam does not exclude anA normal neurologic exam does not exclude an injury—especially in infantsinjury—especially in infants  The overwhelming majority of intracranialThe overwhelming majority of intracranial lesions in children with MHT are nonoperativelesions in children with MHT are nonoperative
  7. 7. MHTMHT ►Skull X-Rays:Skull X-Rays:  Intracranial injuries are associated with skullIntracranial injuries are associated with skull fracturesfractures  Skull fractures are usually associated withSkull fractures are usually associated with swellingswelling  The parietal bone is the most common site of aThe parietal bone is the most common site of a skull fractureskull fracture  Whether skull films can be used as a screeningWhether skull films can be used as a screening tool is controversialtool is controversial
  8. 8. MHTMHT ►Infants are different:Infants are different:  Both skull fractures and intracranial injuries areBoth skull fractures and intracranial injuries are more common in patients less than 2 years oldmore common in patients less than 2 years old  Infants less than 6 months of age are probablyInfants less than 6 months of age are probably exceptionally vulnerable to injuryexceptionally vulnerable to injury
  9. 9. MHTMHT ►Indications for CT scanning:Indications for CT scanning:  Any patient with altered mental status or anAny patient with altered mental status or an abnormal neurological examabnormal neurological exam  Patients less than 2 years of age withPatients less than 2 years of age with symptoms such as vomiting or irritabilitysymptoms such as vomiting or irritability  Patients less than 2 years old with large scalpPatients less than 2 years old with large scalp hematomas, especially non-frontal swellinghematomas, especially non-frontal swelling  Infants less than 3 months—especially if aInfants less than 3 months—especially if a scalp hematoma is presentscalp hematoma is present
  10. 10. MHTMHT ►Disposition: Patients with minor headDisposition: Patients with minor head trauma and a normal CT scan may be safelytrauma and a normal CT scan may be safely discharged– delayed bleeds are extremelydischarged– delayed bleeds are extremely rarerare
  11. 11. MHT: ConcussionMHT: Concussion ►““a clinical syndrome characterized by thea clinical syndrome characterized by the immediate and transient post-traumaticimmediate and transient post-traumatic impairment of neural function such asimpairment of neural function such as alteration of consciousness, disturbance ofalteration of consciousness, disturbance of vision or equilibrium etc. due to brainstemvision or equilibrium etc. due to brainstem involvement”involvement”
  12. 12. MHT: ConcussionMHT: Concussion ►Results from acceleration-decelerationResults from acceleration-deceleration forces applied to a moving brainforces applied to a moving brain ►Shearing forces disrupt normal neurologicalShearing forces disrupt normal neurological elementselements ►Axonal injury, biochemical abnormalities, orAxonal injury, biochemical abnormalities, or microvascular injury may resultmicrovascular injury may result
  13. 13. MHT: ConcussionMHT: Concussion ►Prospectively Validated Signs andProspectively Validated Signs and Symptoms:Symptoms:  Loss of Consciousness ( less than 10%)Loss of Consciousness ( less than 10%)  Amnesia (Retrograde---Posttraumatic)Amnesia (Retrograde---Posttraumatic)  Attention DeficitAttention Deficit  Headache, Dizziness, Blurred VisionHeadache, Dizziness, Blurred Vision
  14. 14. MHT: ConcussionMHT: Concussion ►Subjective findings:Subjective findings:  Vacant Stare, Impaired CoordinationVacant Stare, Impaired Coordination  Emotional Lability, Sleep DisturbanceEmotional Lability, Sleep Disturbance  Lethargy, Behavioral DisturbanceLethargy, Behavioral Disturbance  Altered Sense of Taste or SmellAltered Sense of Taste or Smell
  15. 15. MHT: ConcussionMHT: Concussion ►Grading the Severity of Injury:Grading the Severity of Injury:  There are 25 published injury severity scales;There are 25 published injury severity scales; many are “sport-specific”many are “sport-specific”  Many rely on history of and duration of LOC andMany rely on history of and duration of LOC and duration of Posttraumatic Amnesiaduration of Posttraumatic Amnesia  More severe injuries would not qualify as MHTMore severe injuries would not qualify as MHT and would mandate aggressive evaluationand would mandate aggressive evaluation
  16. 16. MHT: ConcussionMHT: Concussion ►““Mild Concussion:”Mild Concussion:”  No Standardized Definition butNo Standardized Definition but  1) Usually characterized by no LOC1) Usually characterized by no LOC  2) Normal neurological examination2) Normal neurological examination  3) Normal “sideline tests” evaluating3) Normal “sideline tests” evaluating orientation, memory, concentrationorientation, memory, concentration
  17. 17. MHT: ConcussionMHT: Concussion ►Sequelae of “Mild” Concussion:Sequelae of “Mild” Concussion:  There is evidence for neuropsychiatric deficitsThere is evidence for neuropsychiatric deficits during the first week following mild concussiveduring the first week following mild concussive injury in some patientsinjury in some patients  After one week there is no consensus regardingAfter one week there is no consensus regarding time frame for full neurologic recoverytime frame for full neurologic recovery  Risk of Second Impact Syndrome (SIS)Risk of Second Impact Syndrome (SIS)
  18. 18. MHT: ConcussionMHT: Concussion ►Second Impact SyndromeSecond Impact Syndrome  Thought to occur when an athlete sustains aThought to occur when an athlete sustains a second head injury prior to recovery from ansecond head injury prior to recovery from an initial head injury, usually a mild concussioninitial head injury, usually a mild concussion  Severe cerebral swelling occurs, which hasSevere cerebral swelling occurs, which has been reported to be fatalbeen reported to be fatal  May be similar in pathology to “malignant brainMay be similar in pathology to “malignant brain edema” that is know to occur in children andedema” that is know to occur in children and adolescents after mild head traumaadolescents after mild head trauma
  19. 19. MHT: ConcussionMHT: Concussion ►Second Impact Syndrome (cont)Second Impact Syndrome (cont)  The pathology of malignant brain edema isThe pathology of malignant brain edema is though to involve disordered cerebralthough to involve disordered cerebral autoregulationautoregulation  Fear of SSI guides current recommendationsFear of SSI guides current recommendations regarding the management of concussionregarding the management of concussion  In fact the role of repeated concussion as aIn fact the role of repeated concussion as a cause of SSI is questionablecause of SSI is questionable
  20. 20. MHT: ConcussionMHT: Concussion ►Postconcussion SyndromePostconcussion Syndrome  Clinically characterized by multiple physical andClinically characterized by multiple physical and cognitive complaintscognitive complaints  Etiology is controversial: physical damage vsEtiology is controversial: physical damage vs emotional sequelae– also possible geneticemotional sequelae– also possible genetic vulnerabilityvulnerability  Cannot be predicted in the immediateCannot be predicted in the immediate postconcussion periodpostconcussion period
  21. 21. MHT: ConcussionMHT: Concussion ►Sequelae of Multiple Concussions:Sequelae of Multiple Concussions:  There is evidence that there is cumulativeThere is evidence that there is cumulative impairment from repeated mild head trauma,impairment from repeated mild head trauma, especially in cognitive functionespecially in cognitive function  Damage may be subtle and can involve deficitsDamage may be subtle and can involve deficits in verbal skills, memory processing, and spatialin verbal skills, memory processing, and spatial relationships, coordinationrelationships, coordination  Do some patients have a predestined traumaDo some patients have a predestined trauma reserve?reserve?
  22. 22. MHT: ConcussionMHT: Concussion ►There is a growing trend towardThere is a growing trend toward neuropsychologic testing in the evaluationneuropsychologic testing in the evaluation of concussion in athletesof concussion in athletes  There are many different types of examsThere are many different types of exams  Knowing a baseline is crucialKnowing a baseline is crucial  The primary goal is to prevent the return toThe primary goal is to prevent the return to competition before the brain has healedcompetition before the brain has healed
  23. 23. MHT: ConcussionMHT: Concussion ►New Radiologic Modalities in ConcussionNew Radiologic Modalities in Concussion  The CT scan is rarely a useful toolThe CT scan is rarely a useful tool  Promising Modalities includePromising Modalities include 1) Functional MRI1) Functional MRI 2) Spect Scanning2) Spect Scanning
  24. 24. MHT: CasesMHT: Cases ►A 6 month old boy with a chief complaint ofA 6 month old boy with a chief complaint of fever, and by the way he hit his headfever, and by the way he hit his head against the coffee table.against the coffee table.  PE remarkable for:PE remarkable for: 1) left parietal swelling– no palpable fx1) left parietal swelling– no palpable fx 2) normal neurological exam2) normal neurological exam
  25. 25. MHT: CasesMHT: Cases ►A 3 year old boy presents with foreheadA 3 year old boy presents with forehead swelling after a fall sustained when heswelling after a fall sustained when he tripped; no loc; vomited x one.tripped; no loc; vomited x one.  PE remarkable forPE remarkable for 1) An alert happy child1) An alert happy child 2) A forehead contusion2) A forehead contusion 3) A normal neurological exam3) A normal neurological exam
  26. 26. MHT: CasesMHT: Cases ►A 17yo male presents because he needs aA 17yo male presents because he needs a note to return to baseball; he had anote to return to baseball; he had a concussion one week prior.concussion one week prior.  PE remarkable forPE remarkable for 1) An alert oriented patient1) An alert oriented patient 2) Normal neurological exam2) Normal neurological exam

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