Traumatic Brain Injuries in Children PALS Update April 25, 2017 Credit: P. Enarson

Management of Severe TBI Children are small adults (with minor exceptions) ABC’s Intubate if clinically required Maintain PaCO2 at 35-45 mm Hg Keep SBP > 75th percentile (age appropriate) 20 cc/kg NS bolus X 3 Pressor if required (norepi, epi, dopamine, phenylephrine) Treat herniation if present 6.5-10 cc/kg 3% hypertonic saline (3-5 cc/kg often used) 1 g/kg mannitol Consider hyperventilation (PaCO2 30-35 mm Hg)

Management of Severe TBI Avoid hypoxia Maintain normocapnia Blood if Hb < 70 Aim for normotensive, but do not treat hypertension pharmacologically Avoid hyperthermia ** Always consider non-accidental injury**

Outline Clinical Decision Rules for Head CT Skull x-rays in infants Management of Concussions ED Treatment Counseling

Risk of skull fracture in young children 6-30% of children < 2 years old with head trauma have a skull fracture Risk of intracranial hematoma increased 12 times in presence of fracture Complications: leptomeningeal cyst, growing fracture, displaced fracture

Risk of skull fracture in young children CMAJ 187(16):1202-1208 (2015) Prospective cohort study in 3 Canadian EDs Children < 2 years old with non-high risk head trauma (e.g. GCS 15, normal LOC, no palpable skull fracture, no concern for NAI, no imaging at another site Imaging at the physician’s discretion

CMAJ 187(16):1202-1208 (2015) 811 patients (49 skull fractures) in derivation phase 856 patients (44 skull fractures) in validation phase 2 predictors: parietal or occipital swelling or hematoma and age less than 2 months Derivation phase: sensitivity of 94% and specificity of 86% Validation phase: sensitivity of 89% and specificity of 87%

Concussions Rates have doubled in last decade ~750 000 pediatric acute concussion visits to ED annually in the US Most symptoms resolve within 2 weeks ~33% experience longer symptoms – somatic, cognitive, psychological behavioral Postconcussion symptoms = symptoms > 28 days

Treatment of Concussive Headache Migraine Cocktail Hypertonic Saline

Migraine Therapy for Concussive Headache

Am J Emerg Med 33:635-639 (2015) Medication Group Treatment success Ketorolac only (n=55) 80% Metoclopramide or prochlorperazine only (n=30) 93% Ketorolac plus metoclopramide or prochlorperazine (n=132) 89% Ondansetron only (n=37) 78%

Migraine Therapy Bolus of 0.9% NS (20 cc/kg) Diphenhydramine 1 mg/kg (maximum 25 mg) followed in 15 minutes by metoclopramide 0.2 mg/kg (maximum 10 mg) Ketorolac 0.5 mg/kg (maximum 30 mg) www.pedmed.org

Pediatric Emergency Care 30:139-145 (2014)

Pediatric Emergency Care 30:139-145 (2014)

ED Counselling for Concussions Analgesic Management Return to ED Reasons Concussion Management Graduated return to play better than strict rest Some physical activity important within the first week

Second impact syndrome Rapid brain swelling and herniation Occurs when a second head injury occurs while recovering from a concussion All reported cases in people less than 20 years old Journal of Athletic Training 36(3):312-315 (2001) Seminars in Pediatric Neurology 21:275-283 (2014)

Conclusions Head injuries in children are common Treat severe head injuries the same as you would in adults Use a clinical decision rule for need for head CT in MHI Treat the headache, counsel on concussion treatment