minor head trauma in children and adolescents william ahrens the university of illinois at chicago

Minor Head Trauma in Minor Head Trauma in Children and Children and AdolescentsAdolescents

William AhrensWilliam Ahrens

The University of Illinois at The University of Illinois at ChicagoChicago

MHTMHT

►An extraordinarily common problemAn extraordinarily common problem►Obvious sequelae are uncommonObvious sequelae are uncommon►All it takes is oneAll it takes is one►Recommendations characterized byRecommendations characterized by

lack of standard definitionlack of standard definition lack of prospective studies lack of prospective studies

MHTMHT

►For the purposes of this lecture MHT For the purposes of this lecture MHT will be considered to involve:will be considered to involve: a relatively trivial mechanism of injurya relatively trivial mechanism of injury a patient with a GCS of 15 on arrival to a patient with a GCS of 15 on arrival to

the EDthe ED no evidence of skull fracture no evidence of skull fracture May be retrograde/posttraumatic amnesiaMay be retrograde/posttraumatic amnesia ??? Brief LOC ??? ??? Brief LOC ???

MHTMHT

►Key questions for the physician Key questions for the 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 sequelae?Are there sequelae?

MHTMHT

►Radioimaging in the ED: the goal is to Radioimaging in the ED: the goal is to diagnose neurosurgical emergenciesdiagnose neurosurgical emergencies Skull FilmsSkull Films CT ScanningCT Scanning

MHT: CasesMHT: Cases

►A 6 month old boy with a chief A 6 month old boy with a chief complaint of fever, and by the way he complaint of fever, and by the way he hit his head against the coffee table.hit his head 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


►A 3 year old boy presents with A 3 year old boy presents with forehead swelling after a fall sustained forehead swelling after a fall sustained when he tripped; no loc; vomited x when he tripped; no loc; vomited x one.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

MHTMHT

►What is known (more or less)What is known (more or less)

Intracranial lesions ( per CT scanning) are not Intracranial lesions ( per CT scanning) are not rare in pediatric patients with MHTrare in pediatric patients with MHT

A normal neurologic exam does not exclude A normal neurologic exam does not exclude an injury—especially in infantsan injury—especially in infants

The overwhelming majority of intracranial The overwhelming majority of intracranial lesions in children with MHT are lesions in children with MHT are nonoperativenonoperative

MHTMHT

► Infants are different:Infants are different: Both skull fractures and intracranial Both skull fractures and intracranial

injuries are more common in patients less injuries are more common in patients less than 2 years oldthan 2 years old

Infants less than 12 months of age are Infants less than 12 months of age are probably exceptionally vulnerable to probably exceptionally vulnerable to injuryinjury

Babies’ bones breakBabies’ bones break

MHTMHT

►Skull X-Rays:Skull X-Rays: Intracranial injuries are associated with Intracranial injuries are associated with

skull fracturesskull fractures Skull fractures are usually associated with Skull fractures are usually associated with

swellingswelling The parietal bone is the most common The parietal bone is the most common

site of a skull fracture in infantssite of a skull fracture in infants Whether skull films can be used as a Whether skull films can be used as a

screening tool is controversialscreening tool is controversial

MHTMHT

► Indications for CT scanning:Indications for CT scanning: Any patient with altered mental status or Any patient with altered mental status or

an abnormal neurological examan abnormal neurological exam Patients less than 2 years of age with Patients 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 Patients less than 2 years old with large

scalp hematomas, especially non-frontal scalp hematomas, especially non-frontal swellingswelling

Infants less than 3 months—especially if a Infants less than 3 months—especially if a scalp hematoma is presentscalp hematoma is present

MHTMHT

►Disposition: Patients with minor head Disposition: Patients with minor head trauma and a normal CT scan may be trauma and a normal CT scan may be safely discharged– delayed bleeds are safely discharged– delayed bleeds are extremely rareextremely rare

►What to do with patients with linear What to do with patients with linear skull fractures?skull fractures?

►Remember it only takes oneRemember it only takes one


►A 6 month old boy with a chief A 6 month old boy with a chief complaint of fever, and by the way he complaint of fever, and by the way he hit his head against the coffee table.hit his head 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


►A 3 year old boy presents with A 3 year old boy presents with forehead swelling after a fall sustained forehead swelling after a fall sustained when he tripped; no loc; vomited x when he tripped; no loc; vomited x one.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


►A 17yo male presents because he A 17yo male presents because he needs a note to return to baseball; he needs a note to return to baseball; he had a concussion one week prior.had a 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

MHT: ConcussionMHT: Concussion

►““a clinical syndrome characterized by a clinical syndrome characterized by the immediate and transient post-the immediate and transient post-traumatic impairment of neural traumatic impairment of neural function such as alteration of function such as alteration of consciousness, disturbance of vision or consciousness, disturbance of vision or equilibrium etc. due to brainstem equilibrium etc. due to brainstem involvement”involvement”


►Results from acceleration-deceleration Results from acceleration-deceleration forces applied to a moving brainforces applied to a moving brain

►Shearing forces disrupt normal Shearing forces disrupt normal neurological elementsneurological elements

►Axonal injury, biochemical Axonal injury, biochemical abnormalities, or microvascular injury abnormalities, or microvascular injury may resultmay result


►Prospectively Validated Signs and Prospectively 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


►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


►Grading the Severity of Injury:Grading the Severity of Injury: There are over 25 published injury There are over 25 published injury

severity scales; many are “sport-specific”severity scales; many are “sport-specific” Many rely on history of and duration of Many rely on history of and duration of

LOC and duration of Posttraumatic LOC and duration of Posttraumatic AmnesiaAmnesia

Current recommendations disregard these Current recommendations disregard these grading scales and divide concussion intograding scales and divide concussion into

simple and complexsimple and complex


►Simple concussion: symptoms resolve Simple concussion: symptoms resolve in 7-10 daysin 7-10 days

►Complex concussion:Complex concussion:

Symptoms persistSymptoms persist

Symptoms may be specificSymptoms may be specific

May include athletes with multiple May include athletes with multiple concussionconcussion


►Sequelae of Concussion:Sequelae of Concussion: There is evidence for neuropsychiatric There is evidence for neuropsychiatric

deficits during the first week following deficits during the first week following mild concussive injury in some patientsmild concussive injury in some patients

After one week there is no consensus After one week there is no consensus regarding time frame for full neurologic regarding time frame for full neurologic recovery: each patient is differentrecovery: each patient is different

Risk of Second Impact Syndrome (SIS) ?Risk of Second Impact Syndrome (SIS) ?


►Second Impact SyndromeSecond Impact Syndrome Thought to occur when an athlete sustains Thought to occur when an athlete sustains

a second head injury prior to recovery from a second head injury prior to recovery from an initial head injury, usually a mild an initial head injury, usually a mild concussionconcussion

Severe cerebral swelling occurs, which has Severe cerebral swelling occurs, which has been reported to be fatalbeen reported to be fatal

May be similar in pathology to “malignant May be similar in pathology to “malignant brain edema” that is know to occur in brain edema” that is know to occur in childrenchildren


►Second Impact Syndrome (cont)Second Impact Syndrome (cont) The pathology of malignant brain edema The pathology of malignant brain edema

is thought to involve disordered cerebral is thought to involve disordered cerebral autoregulationautoregulation

Fear of SIS used to guide Fear of SIS used to guide recommendations regarding the recommendations regarding the management of concussionmanagement of concussion

In fact the role of repeated concussion as In fact the role of repeated concussion as a cause of SIS is questionablea cause of SIS is questionable


►Post (complex) concussion SyndromePost (complex) concussion Syndrome Clinically characterized by multiple Clinically characterized by multiple

physical and cognitive complaintsphysical and cognitive complaints Etiology is controversial: physical damage Etiology is controversial: physical damage

vs emotional sequelae– also possible vs emotional sequelae– also possible genetic vulnerabilitygenetic vulnerability

Cannot be predicted in the immediate Cannot be predicted in the immediate postconcussion periodpostconcussion period

New data suggests headache is New data suggests headache is associated with incomplete recoveryassociated with incomplete recovery


►Sequelae of Multiple Concussions:Sequelae of Multiple Concussions: There is evidence that there is cumulative There is evidence that there is cumulative

impairment from repeated mild head impairment from repeated mild head trauma, especially in cognitive functiontrauma, especially in cognitive function

Damage may be subtle and can involve Damage may be subtle and can involve deficits in verbal skills, memory processing, deficits in verbal skills, memory processing, spatial relationships, and coordinationspatial relationships, and coordination

Do some patients have a predestined Do some patients have a predestined trauma reserve?trauma reserve?

ConcussionConcussion

► Is the recovery from concussion age-Is the recovery from concussion age-dependent? Gender dependent?dependent? Gender dependent?

►Recent data suggests that high school Recent data suggests that high school athletes recover more slowly from athletes recover more slowly from concussion than college studentsconcussion than college students

►The brain is a constantly evolving The brain is a constantly evolving organismorganism


►There is a growing trend toward There is a growing trend toward neuropsychologic testing in the neuropsychologic testing in the evaluation of concussion in athletesevaluation of concussion in athletes There are many different types of exams: There are many different types of exams:

several are commercially availableseveral are commercially available Knowing a baseline is crucialKnowing a baseline is crucial The primary goal is to prevent the return The primary goal is to prevent the return

to competition before the brain has healedto competition before the brain has healed More research is needed in this field, More research is needed in this field,

especially in children and adolescentsespecially in children and adolescents


►New Radiologic Modalities in New Radiologic Modalities in ConcussionConcussion 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


►A 17yo male presents because he A 17yo male presents because he needs a note to return to baseball; he needs a note to return to baseball; he had a concussion one week prior.had a 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

Current GuidelinesCurrent Guidelines

►Any player with signs or symptoms of Any player with signs or symptoms of a concussion should not be allowed a concussion should not be allowed return to the game or practice.return to the game or practice.

►Emphasis is on physical and cognitive Emphasis is on physical and cognitive rest until symptoms completely rest until symptoms completely resolve: in simple concussions this will resolve: in simple concussions this will be in about a week.be in about a week.

Concussion: Return to PlayConcussion: Return to Play

Once asymptomatic patients advance Once asymptomatic patients advance through a graduated level of activity:through a graduated level of activity:

1: light aerobic activity1: light aerobic activity2: sport specific exercise2: sport specific exercise3: noncontact training3: noncontact training4: contact training4: contact training

Concussion: complexConcussion: complex

►There is no consensus on managementThere is no consensus on management►Role of neuropsychiatric testing?Role of neuropsychiatric testing?►Long-term sequela are probably Long-term sequela are probably

patient specificpatient specific


►What happened to the 17 year old: What happened to the 17 year old: He’s done with contact sportsHe’s done with contact sports

►There is no consensus on when to quit There is no consensus on when to quit after repeated concussionsafter repeated concussions


►Advantage of new data: greater Advantage of new data: greater understanding of concussion.understanding of concussion.

►Disadvantages of new data:Disadvantages of new data:

Unnecessary sports restrictionsUnnecessary sports restrictions

Pre-existing condition in young Pre-existing condition in young people? people?

minor head trauma in children and adolescents william ahrens the university of illinois at chicago

Documents

mht infants

mht skull xrays

swelling skull fractures

mht disposition

mht intracranial lesions

mht indications

mht radioimaging

lecture mht