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

2. Management of Severe TBI
Children are small adults (with minor exceptions)
ABC’s
Intubate if clinically required
Maintain PaCO2 at 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
cc/kg 3% hypertonic saline (3-5 cc/kg often used)
1 g/kg mannitol
Consider hyperventilation (PaCO mm Hg)

3. 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**

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

7. 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

8. Risk of skull fracture in young children
CMAJ 187(16): (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

9. CMAJ 187(16): (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%

10. Concussions Rates have doubled in last decade
~ 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

11. Treatment of Concussive Headache
Migraine Cocktail
Hypertonic Saline

12. Migraine Therapy for Concussive Headache

13. 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%

14. 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)

15. Pediatric Emergency Care 30:139-145 (2014)

16. Pediatric Emergency Care 30:139-145 (2014)

17. 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

26. 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): (2001)
Seminars in Pediatric Neurology 21: (2014)

27. 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