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

2. Outline Definitions Epidemiology Evaluation Evidence Summary

3. Definitions Traumatic Brain Injury – Any blow or jolt to the head or acceleration/ deceleration of the head which may cause an injury Closed Head Injury – An example of a TBI without any penetrating injury into the brain

4. Minor Closed Head Trauma An example of a Closed Head Injury with: – Normal mental status – Normal neurological exam – Normal fundoscopic exam – No physical signs of skull fracture “Mgmt of minor closed head injury in children.” Committee on QI, AAP, Commission on Clinical Policies & Research, AAFP. Pediatrics 1999

5. Epidemiology of Pediatric Head Injury

6. Children’s Health Act of 2000 Big financial backing by Congress for research in pediatrics. Mandated the CDC to report on incidence and prevalence of traumatic brain injuries.

7. Head Injuries: The numbers! Trauma- #1 cause of mortality and morbidity > 6 mo. Head injury is the #1 cause of death in these traumas

9. Traumatic Brain Injury- all ages 1.4 million in the US per year – 835,000 - male – 561,000 - female 50,000 deaths 235,000 hospitalizations 1.1 million treated and discharged from ER National Center for Injury Prevention and Control, CDC, 1995-2000

10. Pediatric TBI 2,685 deaths 37,000 hospitalizations 435,000 emergency department visits (Langlois et al. 2004). Approximately 75% of TBIs that occur each year are concussions or other forms of mild TBI. (CDC 2003).

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

13. Evaluation

14. MCHI: Evaluation ABC’s Stabilize cervical spine if necessary Secondary survey Stabilize other injuries if necessary Obtain appropriate HPI and PMH

15. Evaluation IMAGE!!!??? – CT – Skull X-ray – MRI Observe ??????????????????????????

16. Considerations Prevalence of TBI The % that need intervention Efficacy of treatment Poor outcome if delay diagnosis and Risk associated with imaging

17. Risks of Imaging Head CT approx 150-600x more radiation exposure then a CXR. Brenner, et al, determined the estimated lifetime cancer mortality risks attributed to the radiation exposure from a single head CT in a one year old is 0.07% (1 in 1400) Brenner, DJ, Elliston, CD, Hall, EJ, and Berdon, WE. Estimated Risks of Radiation-Induced Fatal Cancer from Pediatric CT. American Journal of Roentgenology. 2001. 176: 289-296.

18. Risk of imaging Risk of sedation, if needed Risk of pursuing false positive

19. The Evidence Show me the money!!!

20. AAP Guidelines Technical Report: Minor Head Injury in Children Pediatrics, Dec. 1999 Conclusion- “The literature on mild head trauma does not provide a sufficient scientific basis for evidence-based recommendations about most of the key issues in the clinical management.”

21. Problems There were no large pediatric trauma studies which address the major management issues in minor head trauma Most were small and retrospective

22. AAP Guidelines The Management of Minor Closed Head Injury in Children Pediatrics Dec, 1999 Literature Review- 64 articles Inclusion: – 2-20 y/o – Isolated minor head trauma

23. AAP Guidelines: Case 1 MCHI and no LOC – Obtain thorough history and physical – Observation in clinic, office, ER or home Reliability of family essential for dispo – No radiological studies recommended (Remember: MCHI= nl mental status, nl neurological exam, nl fundoscopic exam, no physical signs of skull fracture)

24. AAP Guidelines: Case 2 MCHI with brief LOC (<1 min) – Thorough history and physical – Observation optional – CT optional – Skull radiographs not recommended

25. Data Wide variability of inclusion criteria of studies. Children with hx of LOC, amnesia, HA or vomiting at time of evaluation have a 0-7% prevelance of ICI. 2-5% of children with MCHI with LOC may require neurosurgical intervention.

26. Data Limited predictive value of HA, vomiting or lethargy. Conflicting data on the urgency for diagnosis subdural or epidural.

27. Data Point: no real consistency in evidence.

28. Evidence: Baseline to compare Masters SJ, et al. Skull radiograph examinations after head trauma: N Engl J Med 1987; 316:84-91 Prospective study 7035 patients- from 31 ERs 5252 categorized as low risk for ICI – asymptomatic or with one or more of the following: HA, dizziness, scalp hematoma, lac, contusion or abrasion. – No LOC. 0 had ICI Conclusion: Radiographic studies in low risk patients can be avoided.

29. Evidence in Pediatrics No large prospective studies: Limited data. Dietrich, et al, Ann Emer Med, 1993 322 consecutive head CTs on trauma patients –5% of patients with GCS of 15 had evidence of ICI –Loss of consciousness, amnesia for the event, a Glasgow Coma Scale (GCS) of less than 15, or the presence of a neurologic deficit were more common in children with intracranial injury (P <.05). –Vomiting, seizures, and headache were not discriminating clinical features. –No single characteristic consistently identified the children with an intracranial injury

30. Evidence in Pediatrics Dacey, RG, et al, J Neurosurg, 1986 – 610 children with NCHI with GCS >12 11% had skull fractures 3% required NS intervention 2 pts (0.3%) of the patients with GCS of 15 with nl skull Xray required NS Hennes, et al, Am J Dis Child, 1988 – 55 patients 3 with moderate injury and 8 with mild injury= all with normal CT Chen, et al, Neurosur, 1993 – 74 patients with epidurals and a GCS >11 After the 3-day period, in the absence of neurological symptoms, the presence of the EDH may not be an indication for surgical evacuation or hospitalization beyond 7 days

31. More Studies

32. Dunning, et al A meta-analysis of variables that predict significant injury in minor head trauma Archives of Disease in Childhood, 2003 16 studies pooled 22,420 patients

33. Dunning Increased relative risk of ICI: – Reduced level of consciousness (5.5) – Focal neuro deficit (9.4) – Skull fracture (6.1) – LOC (2.2) No increased risk of ICI (less reliable data) – HA – Seizure – Vomiting

34. Palchak, et al (#1) A Decision Rule for Identifying Children at Low Risk for Brain Injuries After Blunt Head Trauma Annals of Emerg Med, Oct, 2003 University of California, Davis

35. Palchak #1 Prospective- 3 year study <18 y/o All severities Excluded trivial traumas – Fall from ground level – Walking/running into stationary objects if only PE is scalp lac/abrasion.

36. Palchak (#1) Outcome variables: – TBI on CT – TBI requiring acute intervention

37. Palchak (#1) 2,640 eligible, 2043 (77%) enrolled Mean age- 8.3 CT scans on 1271 (62.2%) 98 (7.7%) with TBI on CT 75/98 required intervention (76.5%) 29 (27.6%) of the patients with TBI requiring acute intervention didn’t have +CT for TBI

38. Palchak (#1) Predictor variable – Amnesia – LOC – HA – Sz – Vomiting – Clinical SF – Focal ND – Scalp hematoma <2 – AMS Relative Risk of +CT – 2.1 – 2.6 – 1.5 – 2.4 – 2.3 – 5.5 – 5.3 – 2.6 – 6.8

39. Palchak (#1) Predictor variable – Amnesia – LOC – HA – Sz – Vomiting – Clinical SF – Focal ND – Scalp hematoma <2 – AMS RR of acute intervent – 4.7 – 7.6 – 4.5 – 5.3 – 3.5 – 11.3 – 10.6 – 1.2 – 21.7

40. Palchak (#1) Decision tree for predicting +CT

41. Palchak (#1) Decision tree for predicting intervention

42. Palchak (#1) Decision tree for predicting +CT with GCS 14-15

43. Palchak (#1) Decision tree for predicting +CT in children <2

44. Palchak, et al (#2) Does an Isolated History of LOC or Amnesia Predict Brain Injuries in Children After Blunt Head Trauma? PEDIATRICS, June 2004 University of California, Davis

45. Palchak (#2) 2043 patients in ER for trauma eval over a 3 year period (same data set) – <18 y/o, mean 8.3 yrs 62% underwent CT 7.7% with CT + for TBI – 23% of that 7.7% did not require intervention 42% with hx of LOC and/or amnesia

46. Palchak (#2) Risk of TBI increased if LOC – (3.7% v 9.7%) Risk of TBI with LOC or amnesia and absence of other findings was ZERO. Follow up in 88%- no patients had missed TBI.

47. Palchak (#2) Conclusion: – LOC and amnesia in isolation appear to carry no more risk of +CT or of requiring intervention. – Recommendation to eliminate isolated LOC and/or amnesia as indications for CT in pediatric trauma patients

48. Schutzman, et al Evaluation and Management of Children Younger than Two Years Old with Apparently Minor Head Trauma: Proposed Guidelines. Pediatrics, 2001 Used evidence and expert consensus

49. Schutzman Question #1: Indications for CT? – Incidence of ICI is 3-6%, with higher incidence in the younger children. – Clinical predictors: AMS, focal neuro deficit, scalp swelling, young age, inflicted injury and head injury no clear hx of trauma LOC and vomiting not risk factors – Occult ICI more prevalent in 0-6 month range

50. Schutzman Question #2 : Indications for skull films? – Skull fractures one of the strongest predictors for ICI – The incidence of scalp hematoma is 80- 100% sensitive for associated SF. Question #3: If fracture present should CT be obtained? – If SF present ICI in 15-30%.

51. Schutzman Question #4: If CT normal, dispo? – In 3 studies including 261 patients 0 had late deterioration. Question #5: If SF but normal CT, dispo? – In 6 studies including 349 patients 0 had late deterioration.

52. Schutzman: Management Strategy Stratify patients into 4 groups – High risk – Some risk because of concerning symptoms – Some risk without symptoms – Low risk

53. Schutzman High risk – CT indicated! – Qualifications: AMS, focal neuro deficit, signs of depressed of basilar SF, evidence of SF, irritability, bulging fontanel, LOC >1min and vomiting >5 times or lasting longer than 6 hours (but not evidence based) (maintain a low threshold for children <3 months)

54. Schutzman Intermediate Risk – Group 1 CT/observation –Qualifications 3-4 episodes of vomiting Transient LOC (<1 min) Hx of lethargy or irritability Behavior not baseline Nonacute SF (>24 hrs old Intermediate Risk – Group 2 (Unknown or concerning mechanism) CT/SR –Qualifications Higher force mechanism Fall onto hard surface Scalp hematoma Suspect intentional injury

55. Schutzman Intermediate Risk – Dispo If CT negative Observed for 4-6 hours post-injury and no concerning symptoms

56. Schutzman Low Risk – Observation Minimal mechanism

57. HEY!!!!!!!!!!! Just one more study so….. wake up!!!

58. Roddy, et al Minimal Head Trauma in Children Revisited: Is Routine Hospitalization Required PEDIATRICS, April 1998 Yale-New Haven Hospital

59. Roddy Methods: – Retrospective review over 3 years 1992-1995 – N-267…188 (GCS-15) … 62 (all criteria) – Inclusion: Admitted for trauma with: 0-16 y/o Had LOC or amnesia An initial Glasgow Coma Scale of 15 a normal neurologic exam a normal head CT scan – Exclusion: Children with associated injuries requiring admission

60. Roddy – Endpoint: Deterioration in CNS exam new CT findings The need for a prolonged hospital stay

61. Roddy Results: – The mean length of stay was 1.2 days (range, 1 to 3 days). Prolonged hospitalization occurred in 9 patients (15%). No child developed significant CNS sequelae warranting hospital admission. – The average patient charge was $2869 per hospital stay. Total charges for these hospitalizations were $177 874.

62. Roddy Conclusion: Children undergoing emergency department work-up of occult head injury, who have a normal CNS exam and a normal head CT scan, do not seem to be at risk for significant CNS sequelae.

63. SUMMARY Very difficult decision!!! No clear guidelines established by the AAP More larger studies need to be produced in pediatrics

64. SUMMARY KEY POINTS – AMS, focal neuro deficits and skull fractures very concerning. – HA, sz and vomiting alone less concerning – LOC and amnesia alone may be insignificant – With children under the age of 2 years (especially under 6 months) one should be conservative – If CT -, minimal risk for neuro sequele.

65. Confused? Questions?

66. Thank You Applaud now!!