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Pediatric Traumatic Brain Injury

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Presentation on theme: "Pediatric Traumatic Brain Injury"— Presentation transcript:

1 Pediatric Traumatic Brain Injury
Janice L. Cockrell MD Medical Director, Pediatric Rehabilitation Legacy Emanuel Children’s Hospital

2 Incidence Annual incidence 180/100,000 in 1-15 year olds (Kraus, 1995)
Most common cause of mortality

3 Pediatric TBI 81% mild 8% moderate 6% severe 5% fatal

4 Injury Severity Mild – unconscious <15 min; GCS 13-15
Mod – unconscious >15 min; GCS 9-12 Severe – unconscious >6hr; GCS 3-8

5 Etiology Non-accidental trauma in infants Falls in toddlers
Ped vs. MVA in school-age children MVA in >16 year olds

6 Types of Injuries Trauma Focal Diffuse Stroke Hypoxia

7 Trauma Focal injuries Prefrontal regions Intracranial hematomas

8 Anatomy of the Skull

9 Trauma Focal injuries Diffuse injuries Prefrontal regions
Intracranial hematomas Diffuse injuries Diffuse axonal injury (DAI) Hypoperfusion Excitatory cascades of neurotransmitters producing free radicals

10 Risk Factors Age Previous TBI Socioeconomic deprivation
Premorbid behavior problems only a minor risk factor (Demellweek et al, 2002)

11 Effect of AANS Trauma Protocols
Implementation of the AANS protocols for TBI resulted in a 9.13 times higher odds ratio of a good outcome compared to prior outcomes in a community hospital. Hospital charges increased by more than $97,000 per patient (Palmer, Bader, Qureshi et al, 2001)

12 Most Common Physical Problems (Hawley, 2003)
Headache Blurred vision Difficulty sleeping Fatigue Clumsiness Seizures Hearing problems Change in appetite

13 Sensory Problems Blurry vision Visual field cuts Cortical blindness
Diplopia Hearing loss/central auditory processing problems Loss of smell

14 Motor Problems Spasticity Ataxia Clumsiness
Tend to improve markedly over time

15 Outcomes measurement Glasgow Outcome Score IQ Academic achievement
Motor skills Adaptive skills Problem solving Executive function

16 Glasgow Outcome Score 1 - Expired 2 - Vegetative 3 - Severe disability
4 - Moderate disability 5 - Good outcome

17 Most Common Sequelae Intellectual Academic Personality/behavioral

18 Cognitive Outcomes Declines in IQ Attention and concentration Memory
Language Non-verbal skills Executive functions

19 Behavioral Outcomes Impulsivity Irritability
Agitation (overstimulation) Apathy Emotional lability

20 Academic Outcomes Declines in achievement
Declines in school performance Decreased adaptability

21 Problems Which Resolve Mild TBI
Clumsiness Speech Hearing

22 Problems Which Resolve Mod-Severe TBI
Sleep Epilepsy

23 Problems Which Persist Mild
Attitude to siblings Nightmares Lost hobbies Personality change Temper

24 Problems Which Persist Moderate/Severe
Attitude toward siblings Clumsiness Concentration Hearing Mood fluctuations Temper

25 Adult Outcomes Difficulty maintaining employment Marital problems
Social isolation (adults described as less likable, less interesting, less socially skilled) Involvement with criminal justice system

26 Long-term Neuropsychological Outcomes
Family factors influence behavior and academic outcomes Family factors did not moderate neuropsychological outcomes (Yeates, Taylor, Wade, et al 2002)

27 Intellectual & Emotional Functioning in College Students with Hx of Mild TBI
Intellectually unimpaired Significantly higher level of emotional distress (Marschark et al, 2000)

28 Executive Functions Modulated by frontal lobe and prefrontal circuits
Involve both monitoring and controlling behavior Interact with declarative memory and processing speed but are distinct abilities

29 Anatomy of the Skull

30 Outcomes of Frontal Lesions
Children with unilateral frontal lesions regardless of severity had a higher frequency of maladaptive behaviors than those without, even if there was no difference in cognition (Levin, Zhang, Dennis et al 2004)

31 Mediating Factors Age Severity SEC Premorbid personality
Family functioning Education Economic resources Premorbid personality

32 Predictors of Social Outcome (Yeates, Swift, Taylor, et al, 2004)
Executive function Social Problem Solving Social Outcome Pragmatic language

33 SADHD Omission vs commission errors
Omission errors immediately after TBI predicted SADHD Children with ADHD have a high number of commission errors SADHD is likely fundamentally different than ADHD (Wassenberg, Max, Lindgren et al, 2004)

34 What can the treating physician do?
Follow patient closely for the first few months Evaluate hearing and vision Monitor growth, nutrition Monitor and treat sleep disorders Educate patient and family regarding TBI Refer family for counseling if needed

35 Resources Brain Injury Association of Oregon 1-800-544-5243
Brain Injury Support Group of Portland Brain Injury Assoc of the US Teaching Research, Western Oregon University

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