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