2. Minor Head Injury In Children Larry Kleiner Medical Director, Dept of Neurosurgery The Children's Medical Center

3. Head Trauma

4. Definition of Mild head injury Glasgow Coma Scale 13-15 simple reproducible functional valid predicteur Prejudice against children doesn’t account for asymetry prejudice against facial injury/intubation doesn’t account for brainstem reflexes

5. Eye opening: spontaneous 4 to sound 3 to pain 2 none 1 Modification of the GCS

6. Modification of the GCS Verbalization Appropriate for age5 –fixes and follows –social smile cries but consolable 4 persistent irritability3 restless,lethargy2 none1

7. Modification of the GCS Motor Response Spontaneous6 localizes to pain5 withdraws4 decorticate3 decerebrate2 none1

8. Modification of GCS Glasgow-Liege Scale –includes brainstem reflexes –increases prediction of outcome from 76% to 90% with a.9 confidence level

9. Modification of the GCS Brainstem reflexes/scoring the GLCS fronto-orbicluar 5 vertical-oculocephalics 4 pupillary reaction to light 3 horizontal-oculocephalics 2 oculo-cardiac 1 none 0

10. Epidemiology 7-8 million “head injuries”/year 1.5-2.0 million/year with LOC/amnesia - 80% considered minor

11. Trauma: leading cause of death age 1-19 head injury direct cause in 30-50% major factor in 75% in MVA’s: 75% have head injuries 20% have spinal cord injuries

12. Epidemiology Head injury overview: 1:10 has loss of consciousness 250-500,00 hospitalizations/year 4,000 deaths/year 15-20,000 prolonged hospitalizations/year

13. Compared to severe head injuries: generally younger higher frequency of students percentage of males is less alcohol less frequently involved Demographics

14. Pediatric head Injury higher death rate under the age of two bimodal distribution- bikes/cars 90% are closed, non-penetrating mortality; 1-5% but rises to 17% if coma >12hr. 10% of the deaths are < ten years of age

15. Demographics Children aren’t little adults Infants aren’t little children

16. Physiology Unique to Children Skull relation to spine deformability thickness open sutures open fontanel

17. Physiology Unique to Children Meninges wider subarachnoid space over convexity(shear/tear), over all smaller in proportion to brain (less buoyancy) dura adherently applied to bone

18. Physiology Unique to Children Brain Increased water content autoregulatory mechanisms pressure/volume compliance shifted left contracoup post traumatic unconsciousness

19. Pediatric post-concussive Syndrome Characteristics: Stunned/unresponsive pupils dilated,fixed or anisocoric bradycardia pallor perspiration vomiting Mechanism: 1. most likely vasovagal effect 2. some consider post-traumatic seizure effect

20. Treatment Efficacy of head trauma sheets 66% referred to the document 84% found it answered all questions

21. Sequellae; at 48 hours headaches 51% dizziness 14% sleepy 14% naus/vomit 12% behavioral changes 7% memory deficits 5% visual changes 3% hearing problems 2% pupillary change 1.5%

22. Sequellae At one week these signs and symptoms are approximately halved 27% yet to return to normal function at 48hr, 13% at by one week 50% with residual complaints at 3 months recovery from cognitive deficits;1-3months

23. Sequellae 10-15% have surgical lesions EDH, SDH, ICH, Depressed skull Fx <1% demonstrate talk and die phenomena

26. sequellae Post Traumatic Seizures In isolation; impact or early sz (<1 week); –not indicative of severe head injury –not indicative of inc. risk for epilepsy –50% occurred in mild group with normal CT –No role for anticonvulsants

27. Classification of Injury Primary scalp: laceration, avulsion skull Fx: “ping-pong” linear, depressed open/closed, comminuted, basilar neck: soft tissue, bone, vascular brain: focal, diffuse

28. Primary Head Injuries Skull fractures of concern: open,depressed crosses suture lines crosses known vascular channels –arterial –dural sinuses enters into sinuses basilar

30. Metabolic hypoxia/hypercarbia hypo/hypernatremia hyperglycemia hormonal dysregulation dysautonomia nutritional Classification of Head Injury Secondary swelling hemorrhage edema vasospasm seizures hypotension ischemia

31. CT Scans of Intracranial Hemorrhage

34. Mechanism of Injury Translational linear focal Acceleration- deceleration rotational concussive-shearing forces

35. Mechanisms of injury Age Related birth injury; skull fx via canal vs forceps, CN posterior fossa SDH infant/toddler; falls, abuse children falls, bikes, pedestrian-MVA, bike-MVA teens; falls, MVA, assaults

37. Triage Approach/attitude apparent stability DOES NOT= insignificant injury stay directed, utilize protocols- avoid inertia repeat neurologic exam looking for change consider the mechanism of injury-think broadly alcohol level <.2 doesn’t alter neurologic much, but consider drug effect

38. Triage History mechanism of injury (should “fit” what you see) neurologic- recent, remote; baseline, SZ, HI general-medical, drugs psychological/educational

39. Triage Physical Exam CGLCS pupils respiratory pattern sensory modalities SEARCH FOR FOCALITY! reflexes – –DTR – –cutaneous mental status

42. Signs of Rostro-caudal deterioration decreased LOC headache vomiting visual changes pupilary change Cushing Triad loss of function – –motor/sensory respiratory pattern change

44. Triage As A Rule Any pupillary inequality> 1 mm in a head injured child must be attributed to an intracranial injury until proven otherwise

45. Pathophysiology Monroe-Kellie doctrine three compartments blood brain CSF change in one requires reciprocal change in the others

46. Clinical Findings in 4500 pediatric head injuries Initial LOC % normal56.0 confused30.2 major impairment13.8 Vomiting30.3 Skull Fx 26.6 linear 72.8 depressed 27.2 compound 19.7 Seizures7.4 paralysis3.8 pupil abn3.6 retinal hem2.6 subdural hem5.2 epidural hem0.9 major sequellae5.9 mortality5.4

47. Clinical Profile from 937 Pediatric Head Injuries 84% CGCS 13-15 Mean age 5.5 Males>females 2:1 Falls>pedestrian/MVA 75% “alert” on admission 13% had surgical lesions 0.3% with CGCS died avg. length of stay ; 2.8 days

48. Clinical profile Presence of Mass lesions Glasgow Coma Scale 15: 7.1 % Glasgow Coma Scale 14: 9.7 % Glasgow Coma Scale 13: 13.6 %

49. Identifying Risk Facteurs LOC >16 minutes =>45X>risk of poor outcome small punctate hem/ contusion on CT did not adversely effect outcome compared to normal CT. Linear,basilar,depressed skull Fxs did Not effect outcome Diastatic and compound depressed skull Fxs had poor outcomes respectively 50% vs 14%

50. Identifying Risk Facteurs GCGS and the patient’s MENTAL STATUS were the best predicteurs of potential deterioration or the presence of a mass lesion

51. Identifying risk facteurs Skull X-ray; what role if any?? Not essential for decision making process HOWEVER –presence=>inc risk of lesion\deterioration – useful in penetrating injuries – useful in Non-accidental trauma – useful in following growing Fx of childhood

52. Etiologies of delayed detoriation Mass lesions: EDH/SDH/ICH electrolyte imbalance cerebral edema seizures

53. Recommendations Glasgow Coma Scale 13-14: CT scan and admit for observation Glasgow Coma Scale 15 with normal neurologic exam/mental status, and normal CT; discharge with home observation. CT optional? Relevance of duration/presence of LOC- varied opinion.

54. Recommendations;Concussion and Sports Confusion w/o amnesia/LOC asymptomatic; observation 1/2 hr confusion with amnesia, no LOC observe 24 hr, asymptomatic return to activity after one week LOC; formal medical evaluation asymptomatic return to activity in 2-4 wks

55. Fail-Safe vs the Doomsday EDH Small percentage(<1%) will develop a delayed lesion with Normal original CT –In patients with abnormal CT scans: 30% of patients: develop a delayed lesion not present on first CT or worsening of original lesion Most will occur within the first 24-36 hrs

56. Bicycle Facts 400,000 Rx/yr 1/3 HI 300deaths/yr 80% HI annual cost:$8 billion 2200/yr sustain permanent disability, helmets would prevent 1700 helmets reduce risk of injury85% Helmet laws have reduced mortality 80% Bikes are assoc with more childhood injury than any other consumer product operated by children Universal use of helmets would prevent one HI every 4 min and save a life DAILY

57. Is it a crap shoot? KNOWLEDGE IS POWER