head injury in children - uw health€¦ · injuries after head trauma: a prospective cohort study....

Head injury in children

Michael Kim, MD

Department of Emergency Medicine University of Wisconsin- Madison

#1 cause of death and disability

Bimodal distribution

2,685 deaths

62,000 hospitalization

564,000 ED visits

1,300 by NAT

Objectives

• Background

• Case based working diagnosis

• What not to miss

• Intervention principles

• ED diagnostics and management

Anatomy

4

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%

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%

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%

Case 1

• 9 mo ran into a door

• Emesis x1

• Facial bruise

• Sleepy

A. Skull Fracture

B. Intracranial bleed

C. Concussion

D. Non-accidental

Trauma

Case 1

• 9 mo ran into a door

• Emesis x1

• Facial bruise

• Sleepy

A. Skull Fracture

B. Intracranial bleed

C. Concussion

D. Non-accidental

Trauma

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

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

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

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

Evaluation and Intervention approach

on’t

ever

orget

lucose

D

E

F

G

Taking focused history

Consistency Previous injuries Underlying risks

Critical exam findings

• VS abnormality

• Mental status

• Head integrity

• Pupils

• Blood/fluid

• Neuro deficits

2 year old fell from 2nd floor window with R=12, P=64, BP=145/74

Perfuse the brain

Cerebral Perfusion Pressure

• Pressure needed for adequate blood flow to brain

• CPP=MBP-ICP

• CPP: 50-70 mmHg

• ICP: 10-20 mm Hg

Keep brain perfusedCerebral Perfusion Pressure (CPP)

MBP ICP CPP

Normal 80 10 70

Cerebral edema

Shock

Edema and shock

Keep brain perfusedCerebral Perfusion Pressure (CPP)

MBP ICP CPP

Normal 90 10 70

Cerebral edema 90 40 50

Shock

Edema and shock

Keep brain perfusedCerebral Perfusion Pressure (CPP)

MBP ICP CPP

Normal 80 10 70

Cerebral edema 90 40 50

Shock 60 10 50

Edema and shock

Keep brain perfusedCerebral Perfusion Pressure (CPP)

MBP ICP CPP

Normal 90 10 80

Cerebral edema 90 40 50

Shock 60 10 50

Edema and shock 60 40 20

Keep brain perfusedCerebral Perfusion Pressure (CPP)

MBP ICP CPP

Normal 80 10 70

Cerebral edema 90 40 50

Shock 60 10 50

Edema and shock 60 40 20

Increase MBP• Fluid resuscitation

Keep brain perfusedCerebral Perfusion Pressure (CPP)

MBP ICP CPP

Normal 90 10 80

Cerebral edema 90 40 50

Shock 60 10 50

Edema and shock 60 40 20

Increase MBP• Fluid resuscitation

Methods to decrease ICP• Avoid hyperventilation• Mannitol• Surgical intervention

Intervention Priorities

• Maintain Airway, Breathing and Circulation

• EMS: Field triage guideline

• ED: Transfer to Level 1 Pediatric Trauma center ASAP

ED Evaluation

Best ED diagnostic modality

Typical organ radiation doses US FDA 2006

Procedure Effective dose (mSv)

# of CXR equivalent

Days of natural exp

CXR 0.02 1 2.4 days

Skull XR

L spine

IV urogram

UGI

BE

HCT

ACT

Typical organ radiation doses US FDA 2006

Procedure Effective dose (mSv)

# of CXR equivalent

Days of natural exp

CXR 0.02 1 2.4 days

Skull XR 0.07 4 8.5 days

L spine 1.3 65 158 days

IV urogram 2.5 125 304 days

UGI 3.0 150 1.0 year

BE 7.0 350 2.3 years

HCT 2.0 100 243 days

ACT 10.0 500 3.3 years

Copyright © 2007 by the American Roentgen Ray Society

Brenner, D. J. et al. Am. J. Roentgenol. 2001;176:289-296

--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

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

< 2 YOKuppermann 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%

< 2 YOKuppermann 2009

> 2 YOKuppermann 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%

> 2 YOKuppermann 2009

Who needs CT scan?

Kuppermann et al. (PECARN). Lancet. 2009 Oct

What can you do?

• “may need further evaluation”

• Know evidence in CT use

• Consider alternatives

Take home points

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. 2009 Oct 3;374(9696):1160-70. doi: 10.1016/S0140-6736(09)61558-0. Epub 2009 Sep 14.

2. 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. 2001 Nov;28(11):2387-8.

3. Brenner D. et al. Computed Tomography-An Increasing Source of Radiation Exposure N EnglJ Med 2007;357:2277-84.

Contusion/scalp hamatoma

Concussion

Skull fracture

(Epidural)

Case 3

• 16 YO with 10 sec LOC

• Headache

• Nausea

• Emesis x 1

• Photo/phono phobia

• Retrograde amnesia

A. Skull Fracture

B. Intracranial bleed

C. Concussion

D. Non-accidental

Trauma

Examination elements

Cases with answer options

A. Skull fracture

B. Intracranial bleed

C. Concussion

D. Non-accidental Trauma

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%)