1. Pediatric Head Trauma Joshua Rocker, MD Pediatric Emergency Medicine Schneider Children’s Hospital

2. Parents present a 10 month old male to ER stating he fell down while walking and he is currently not himself.

3. Epidemiology of Pediatric Head Injury

4. Head Injuries: The numbers! Trauma- #1 cause of mortality and morbidity >1y/o. Head injury is the #1 cause of death in these traumas

5. Head injuries: The numbers!! 600,000 ER visits 100,000 hospitalizations 7,000 deaths 29,000 permanent disability

6. Head Injuries: the mechanism! Falls- 37% MVA- 18% (most fatal) Pedestrian Struck- 17% Bicycle injuries- 10%

7. Head Injuries: the differences Age: Infants- fall or non-accidental vs. Adolescent- sports, MVAs Sex: males : females (2-4:1)

8. Pathophysiology Two phases – Primary – Secondary

9. Pathophysiology: The Box: Blood, Brain, CSF

10. Pathophysiology: Cerebral Perfusion Pressure (CPP)= Mean Arterial Pressure (MAP) – Intracranial Pressure (ICP).

11. Pathophysiology- lastly … Axonal Injury- – Primary pathological feature of traumatic head injury. – Traumatic forces exert strain and/or torque on axons which may reversibly or irreversibly damage them.

12. Location, Location, Location (Anatomy, Anatomy, Anatomy)

13. Case #1 Parents present with a 3 day old male who was a product of a NSVD without any complications. His birth weight was 9lb 4oz. He now appears to be yellow tinged and has a swelling to the right side of the occiput.

14. Case #1 Parents present with a 3 day old male who was a product of a NSVD without any complications. His birth weight was 9lb 4oz. He now appears to be yellow tinged and has a swelling to the right side of the occiput. Amita?? What’ya think?

15. Scalp 5 Layers: – Skin – Subcutaneous tissue – Galea aponeurosis – Loose areola tissue – pericranium

16. Skull- Skull fractures Types: – linear, diastatic, depressed compound, basilar Linear – 75-90% – Location key

17. Signs of Basilar Skull Fracture Yes, this is a question to you Nikhil?

18. Basilar Skull Fracture Fx of petrous portion of temporal bone: hemotympanum, hemorrhagic or CSF otorrhea, Battle sign Fx of anterior skull base: CSF rhinorrhea, raccoon eyes

19. Intracranial Injury Functional derangements Hemorrhagic Edema Penetrating

20. Functional Derangements Concussion Posttraumatic Seizures

21. Hemorrhage Cerebral Contusion Epidural Subdural Subarachnoid Intracerebral Hematoma

22. Cerebral Contusion

23. Epidural Hemorrhage Likely skull fracture Lucid interval

24. Subdural Hemorrhage Direct trauma or accel-decel Bridging veins Often with underlying brain injury Seizures

25. Subdural Hemorrhage

26. Subdural Hemorrhage

27. Subarachnoid Hemorrhage

28. Cerebral Edema

29. Clinical Approach History Symptoms Primary Survey – ABCD (GCS) Secondary Survey Spinal Injury? Suspect Child Abuse?

30. Glasgow Coma Scale Do you remember?

31. GCS

32. Modified GCS Eye Opening Motor – Spontaneous Normal – To speech W/D to touch – To pain W/D to pain – None Decorticate Decerebrate Verbal None – Coos, Babbles – Cries to Pain – Moans to Pain – None

33. Management Following lecture…to be continued… But….

34. Before we end …

35. Non-accidental head injuries (aka- child abuse) In 2000 child abuse and neglect was responsible for 1200 deaths. 44% under 1 y/o. Head injury #1 cause of death.

36. Child abuse- numbers Victims – Median age 4.6 months – Range 7 d to 58 months Perpetrators – 50% fathers, 20% male partner, 12% mothers

37. Child Abuse- Risk factors Perpetrators – Young and/or single parent – Lower level of education – Unstable family structure – Stress in family – DV – Alcohol/drug abuse – depression Victims – Multiple birth – Young age – Prematurity – Chronic illness – Difficult temperament

38. Child abuse- LOOK OUT 60% with history or clinical evidence of previous abuse Retinal Hemorrhages – Not pathognomonic (50-100% will have) – Seen in: Birth trauma, accidental injuries, bleeding d/o, glutaric aciduria, infections, etc Skeletal Fracture – 20-50% – Classic metaphyseal avulsion lesions (CML) – Posterior Rib Cutaneous bruising – From autopsy- only 21%

39. JOSH, Please stop!!!!!! NO….

40. Last case! A 9 month old male with CF presents with sleepiness after falling off the sofa (onto a hard wood floor) where the parents placed the child to sleep for the night. The family lives in a crowded one bedroom apartment with grandparents. The father smells of alcohol. Its 2 AM.

41. Case cont … The child is sleeping. Vitals normal. Small hematoma over the temporal region. What do you do?

42. CT results …

43. THE END!!!!!!!!