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