1. 2008/12/30 PED MM三部曲之EBM
R3陳莉瑋

2. This case…
5 Y/O boy with delay brain abscess related with prior undiagnosed occipital skull open fracture
Come to ER due to fever and headache three weeks later
During admission, he receive partial cranioectomy twice and intravenous antibiotics use

3. 你一定會遇到
叔叔 我撞到頭了
頭不知道有沒有破掉
醫生 腦有沒有傷到
要不要照個電光 或是電腦斷層
會不會有後遺症？要注意什麼？

4. Background- Skull fractures in children
The incidence of skull fractures in children with head trauma :2 to 20 percent
Area: parietal bone > occipital> frontal>temporal bones
Cause
Falls — 35 percent
Recreational activities — 29 percent
Motor vehicle crashes — 24 percent
Skull fractures that have an overlying laceration, also called compound fractures
Skull fractures that disrupt the paranasal sinuses or middle ear and may be associated with CSF rhinorrhea or otorrhea. The evaluation of suspected CSF rhinorrhea is discussed separately

5. Background – Skull fractures in children
Type: Linear fractures are most common (75%) , followed by depressed and basilar fractures.
This case => compound fx(open fx+laceration)

6. Questions:
Q1:Which finding indicate the presence of intra-cranial injury?

7. Arch Dis Child 2004 Jul;89(7):653-9.
A meta-analysis of variables that predict significant intracranial injury in minor head trauma.
Arch Dis Child 2004 Jul;89(7):  

8. Review 16 papers for meta-analysis
Children with head injury who had skull radiography, recording of common symptoms and sign, and head CT were selected
Conclusion :significant correlation between intracranial hemorrhage and skull fracture, focal neurology, loss of consciousness, and abnormality
Headache and vomiting
 BACKGROUND: Previous studies have presented conflicting results regarding the predictive effect of various clinical symptoms, signs, and plain imaging for intracranial pathology in children with minor head injury. AIMS: To perform a meta-analysis of the literature in order to assess the significance of these factors and intracranial haemorrhage (ICH) in the paediatric population.
METHODS: The literature was searched using Medline, Embase, Experts, and the grey literature. Reference lists of major guidelines were crosschecked. Control or nested case-control studies of children with head injury who had skull radiography, recording of common symptoms and signs, and head computed tomography (CT) were selected. Outcome variable: CT presence or absence of ICH.
RESULTS: Sixteen papers were identified as satisfying criteria for inclusion in the meta-analysis, although not every paper contained data on every correlate. Available evidence gave pooled patient numbers from 1136 to Skull fracture gave a relative risk ratio of 6.13 (95% CI 3.35 to 11.2), headache 1.02 (95% CI 0.62 to 1.69), vomiting 0.88 (95% CI 0.67 to 1.15), focal neurology 9.43 (2.89 to 30.8), seizures 2.82 (95% CI 0.89 to 9.00), LOC 2.23 (95% CI 1.20 to 4.16), and Glasgow Coma Scale (GCS) <15 of 5.51 (95% CI 1.59 to 19.0).
CONCLUSIONS: There was a statistically significant correlation between intracranial haemorrhage and skull fracture, focal neurology, loss of consciousness, and GCS abnormality. Headache and vomiting were not found to be predictive and there was great variability in the predictive ability of seizures. More information is required about the current predictor variables so that more refined guidelines can be developed. Further research is currently underway by three large study groups.  

9. Other research..
History : penetrating trauma, intentional injury, or injury associated with loss of consciousness, localized pain and swelling. (older child)
PE: soft-tissue swelling, hematoma, palpable fracture or skull defect, crepitus, or signs of basilar skull fracture

11. Questions:
Q2: Are image study necessary in approaching minor head trauma children?

12. P(patient): children with acute head injury
I(intervention):brain CT or skull x-ray
C(comparsion): not done
O(outcome): diagnosis and patient outcome

13. Diagnostic testing for acute head injury in children: when are head computed tomography and skull radiographs indicated?
Pediatrics 1997;99;e11

14. 8%intracranial injury,16% skull fracture
331 children , prospective; mechanism of injury, symptom, CT, skull view, PE recorded
Amazing result:
8%intracranial injury,16% skull fracture
59%intracranial injury child=>normal GCS, no focal sign
Findings not significantly associated with intracranial
injury were scalp contusion, laceration, hematoma, abrasion,
headache, vomiting, seizure, drowsiness, amnesia,
and loss of consciousness for less than 5 minutes.

15. signs of a basilar skull fracture
loss of consciousness for more than 5 minutes,
altered mental status
focal neurologic abnormality
scalp contusion, laceration, hematoma, abrasion
headache, vomiting, seizure, drowsiness, amnesia,
loss of consciousness for less than 5 minutes.
和intra-cranial injury有相關的factor

16. Other research .. Delayed diagnosis can lead to poor outcomes
Skull radiographs can be used to identify and classify skull fractures
CT is the preferred modality to identify skull fractures and intracranial injuries
MRI has not been shown to provide any advantage over CT in the acute imaging of head trauma
Delayed diagnosis and evacuation can lead to poor outcomes [37,38] .
Skull radiographs can be used to identify and classify skull fractures
Computed tomography (CT) is the preferred modality to identify skull fractures and intracranial injuries [39] .
Magnetic resonance imaging (MRI) has not been shown to provide any advantage over CT in the acute imaging of head trauma

17. Patients who are at high risk for intracranial injury are candidates for CT scanning, and plain radiography is of no added value
Skull radiographs may be indicated when the history of trauma is uncertain (eg, skeletal survey in the evaluation of suspected abuse), or to rule out the presence of a foreign body
patients who are at high risk for intracranial injury are candidates for CT scanning, and plain radiography is of no added value [8,42-44] .
Skull radiographs may be indicated when the history of trauma is uncertain (eg, skeletal survey in the evaluation of suspected abuse), or to rule out the presence of a foreign body [45]

19. Background: brain abscess therapy: aspiration or operation?
Needle aspiration > surgical excision
Surgical drainage generally is required for both diagnosis and treatment.
Surgical excision is a more radical approach that generally results in greater neurologic deficits and now is infrequently performed.

20. Questions:
Q3:Approach to post-trauma brain abscess, which operation or drainage more suitable?

21. Post-traumatic brain abscess: experience of 36 patients
British Journal of Neurosurgery, Volume 9, Number 1, 1 March 1995 , pp (8)

22. 20/36 external compound fracture in 20
The mean interval between the time of injury to presentation with an abscess was 113 days
Close/compound head injury;
wound sepsis/clean wound
沒有顯著的差別

23. Other research: 什麼時候一開始就要切..
Traumatic brain abscesses (to remove bone chips and foreign material)
Encapsulated fungal brain abscesses
Multiloculated abscesses

24. Other research: 什麼時候drainage完,還是要開進去?
No clinical improvement within one week
Depressed sensorium
Signs of increased intracranial pressure
Progressive increase in the ring diameter of the abscess
In addition, the following are indications for excision after initial aspiration and drainage [6] :
No clinical improvement within one week
Depressed sensorium
Signs of increased intracranial pressure
Progressive increase in the ring diameter of the abscess

25. Reference
Extradural haematoma--earlier detection, better results [editorial]. Brain Inj 1988; 2:83.
Extradural haematomas: an analysis of the changing characteristics of patients admitted from 1980 to Diagnostic and therapeutic implications in 158 cases. Brain Inj 1988; 2:87.
The management of minor closed head injury in children. Committee on Quality Improvement, American Academy of Pediatrics. Commission on Clinical Policies and Research, American Academy of Family Physicians. Pediatrics 1999;104:1407.
Evaluation and management of children younger than two years old with apparently minor head trauma: proposed guidelines. Pediatrics 2001; 107:983.
A meta-analysis of variables that predict significant intracranial injury in minor head trauma. Arch Dis Child 2004; 89:653.
Skull x-ray examinations after head trauma. Recommendations by a multidisciplinary panel and validation study. N Engl J Med 1987; 316:84.