1. Minor Head Trauma: What a headache! Joshua Rocker, MD Director of Education, PEM Dept Cohen Children’s Medical Center/LIJ

2. Disclosure: Joshua Rocker, MD I have no relevant financial relationships or conflicts of interest to disclose This presentation will not involve discussion of unapproved or off-label, experimental or investigational use medications or devices.

3. Minor Head Trauma Definition: –A patient who experiences an impulsive force to the head from a direct or indirect blow, but is currently conscious and responsive. –A GCS of (13) 14 or 15.

4. Not this…

5. But this…

6. And don ’ t forget this…

7. Objectives What are the stats? Review the literature. – Where we have been and where we are now Other concerns

8. Why do we care? Just look at the numbers!!

9. Why do we care? Traumatic Brain Injury (TBI) –leading cause of pediatric death/disability – > 7000 deaths – > 60k hospitalizations – > 600,000 ED visits

10. Sports Related National Electronic Injury Surveillance System--All Injury Program (NEISS-AIP) –Overall, >200k EM visits for SR- TBI –Highest rates for 10-14 y/o –Extrapolation: 1.6 - 3.8M SR-TBIs annually

11. TBI: common and serious…what we also know In Canada: PEDs CT use for minor head traumas increased from 15% in 1995 to 53% in 2005. US similar increase Why?

12. Why not? Its simple, just CT everyone!!!

13. Why not? Its simple, just CT everyone!!! NIKHIL????

14. How did this happen? What motivated this drastic increase? Yes, CT technology improved –Faster –More detailed –More accessible BUT….

15. Let’s look at the literature?

16. Some early studies Risks of acute traumatic intracranial haematoma in children and adults: implications for managing head injuries. BMJ, Teasdale, et al, 1990 –If skull fx on Xray and no AMS- 80 fold increase risk of intracranial hematoma 80 fold increase risk of intracranial hematoma

17. Early studies Predictive value of skull radiography for intracranial injury in children with blunt head injury. Lloyd, et al. Lancet, 1997. –If skull fracture on Xray: Sensitivity: 65% ICI NPV: 83% –If neurological abnormalities: Sensitivity: 91% NPV: 97%

18. Lloyd, et al, Lancet, 1997 Conclusion: –Skull radiography is not a reliable predictor of intracranial injury –Clinical neurological abnormalities are a reliable predictor of intracranial injury –If imaging is required, it should be with CT and not skull radiography. Ohhhh….here we go! Ohhhh….here we go!

19. Dietrich, et al, Ann Emerg Med, 1993 Pediatric head injuries: can clinical factors reliably predict an abnormality on computed tomography? –12% with ICI –LOC, amnesia, neuro deficits, GCS<15 increased risk for ICI –GCS 15: 5% with ICI

20. Dietrich, et al, Ann Emerg Med, 1993 Pediatric head injuries: can clinical factors reliably predict an abnormality on computed tomography? –12% with ICI (90% isolated skull fx) –LOC, amnesia, neuro deficits, GCS<15 increased risk for ICI –GCS 15: 5% with ICI That is worrisome!!! 1 out of 20!!!

21. Greenes and Schutzman, Pediatrics, 1999 Clinical Indicators of ICI in Head-Injured Infants (<2yrs) –608 subjects –5% with ICI 13% if 0-2 months 6% if 3-11 months 2% if 1-2 yrs –48% with ICI were asymptomatic (but 93% had scalp hematoma)

22. Greenes and Schutzman, Pediatrics, 1999 Conclusion: –Clinical signs of brain injury are insensitive markers of ICI in infants. CT recommended. Are you seeing where we are going yet… 1 in 8 infants <2months of age with ICI

23. AAP: Technical Report: Minor Head Injury in Children, 1999 Risk of ICI –0-7% if GCS 15 –4-10% if GCS 15 with hx of LOC or amnesia –Conslusion: True prevalence not clearly known If GCS 15 and no issues, risk <1% ICI If GCS 15 but hx of LOC, amnesia, vomiting, or seizure, risk 1-5%

24. AAP: Technical Report: Minor Head Injury in Children, 1999 Conclusion: –Literature- not sufficient evidence for clinical decision rule –Nonetheless a small percentage of children with minimal to minor head injury will have significant ICI “CT scan is the most sensitive, specific and clinically safe modality of identifying ICI”

26. 4 month old presents after falling off the couch, from dad’s sleeping arms, onto a hard wood floor…

27. Patient at high risk for ICI, right? Looks well… but may be asymptomatic!

28. Play it safe!!!!

29. This is also why CT rates skyrocketed?

30. Timeline AAP Technical Report- 1999 AM J Roetgen, Feb 2001 (BAM!!!!!!) –Estimated risks of radiation-induced fatal cancer from pediatric CT. Brenner, et al. –Helical CT of the Body: Are Settings Adjusted for Pediatric Patients? Paterson, et al. –Perspective. Minimizing Radiation Dose for Pediatric Body Applications of Single- Detector Helical CT: Strategies at a Large Children's Hospital. Donnelly, et al.

31. People recognized the risk and things are out of control

32. Head CTs The CT numbers were dramatically increasing but were we reducing morbidity and mortality? Or were we just finding radiological abnormalities in clinically well kids? All at the expense of irradiating them

33. Schutzman, et al, Pediatrics, May, 2001 Evaluation and management of children younger than 2 years old with apparent minor head trauma: Proposed guidelines. –“We sought to develop guidelines…to identify children with complications of head trauma and reduce imaging procedures.”

34. Schutzman, 2001: Management Strategy Stratify patients into 4 groups –High risk –Some risk because of concerning symptoms –Some risk without symptoms –Low risk

35. Schutzman, 2001 High risk –CT indicated! –Qualifications: AMS, focal neuro deficit, signs of depressed or 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)

36. Schutzman, 2001 Intermediate Risk –Group 1 CT/ observation –3-4 episodes of emesis –Transient LOC –Hx of lethargy or irritability –Behavior not baseline –Nonacute SF (>24hrs) Intermediate Risk –Group 2 (Unknown or concerning mechanism) CT/ Skull Xray –Higher force mechanism –Fall onto hard surface –Scalp hematoma –Suspect intentional injury

37. Schutzman Low Risk –Observation/ Discharge Minimal mechanism and clinically well

38. More studies trying to figure this issue out – the search for the low risk patients

39. Palchak, et al, Annals of Emerg Med, 2003 A Decision Rule for Identifying Children at Low Risk for Brain Injuries After Blunt Head Trauma University of California, Davis 2043 subjects

40. Palchak, 2003 Outcome variables: (1) TBI on CT (2) TBI requiring acute intervention NS procedure, antiepileptics >7d, persistent neuro deficits until d/c, >2 days for inpatient tx for symptoms related to head injury

41. Palchak, 2003 TBI requiring acute intervention – –We sought to define an outcome that was meaningful to clinical decision making, independent of the sensitivity of neuroimaging technology, and independent of physician accuracy in recognition of subtle traumatic brain injuries on CT. Translation: It is not the CT we care about… it is the patient!!!!!

42. Palchak, 2003 Predictor variable –Amnesia –LOC –HA –Sz –Vomiting –Clinical SF –Focal ND –Scalp hematoma <2 yr –AMS Relative Risk of ICI on CT 2.1 2.6 1.5 2.4 2.3 5.5 5.3 2.6 6.8

43. Palchak, 2003 Predictor variable –Amnesia –LOC –HA –Sz –Vomiting –Clinical SF –Focal ND –Scalp hematoma <2 yr –AMS RR of acute intervention 4.7 7.6 4.5 5.3 3.5 11.3 10.6 1.2 21.7

44. Palchak, 2003 Decision tree for predicting for predicting TBI with acute TBI with acuteintervention

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

46. Palchak, 2004 Same dataset – –42% with hx of LOC and/or amnesia – –Risk of TBI increased if LOC (3.7% v 9.7%) – –Risk of TBI if with LOC or amnesia and absence of other findings was _____?

47. Palchak, 2004 Same dataset – –42% with hx of LOC and/or amnesia – –Risk of TBI increased if LOC (3.7% v 9.7%) – ZERO –Risk of TBI if with LOC or amnesia and absence of other findings was ZERO (0 of 164).

48. Palchak, 2004 Conclusion: –Recommendation to eliminate isolated LOC and/or amnesia as indications for CT in pediatric trauma patients

49. Maguire, et al, 2009 Should a Head-Injured Child Receive a Head CT Scan? A Systematic Review of Clinical Prediction Rules Pediatrics, July 2009

50. Maguire, 2009 “Given the potential harm of cranial CT, including the possible need for sedation…and lifetime estimated risk of cancer mortality of 1 per 1400 head CT scans, predicting which children can be safely managed without CT scanning is vitally important.”

51. Maguire, 2009 Conclusion: – –Eight clinical prediction-rule derivation studies were identified. They varied considerably in population, methodological quality and performance. – –Need for a larger study.

52. Osmond, et al, CMAJ, 2010 CATCH: A clinical decision rule for the use of CT in children with MHT –Pediatric Emergency Research Canada (PERC) –3866 patients enrolled –4.1% with ICI –0.6% requiring NS intervention

53. PERC, 2010 High risk factors (need for NS intervention) (100% sensitivty, 70% reduction of CT) –GCS <15 within 2 hours –Suspicion of open fracture –Worsening HA –Irritability Medium risk factors (ICI on CT) (98% sensitivity, 50% reduction of CT) –Large boggy scalp hematoma –Sign of basal skull fx –Dangerous mechanism

54. AND THEN…

55. …there is the BIG momma

56. Kupperman, et al, Lancet, 2009 Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study –PECARN- Pediatric Emergency Care Applied Research Network- 25 PEDs – 42,412 children enrolled

57. PECARN, 2009 Derived and validated a prediction rule ICI- 5.2% Clinical important TBI- 0.9 % –Death, NS intervention, intubation >24 hours, hospitalized for >2 nights because of non-surgical management of TBI Neurosurgical intervention- 0.1%

58. >2 yrs Potential 86% reduction in CT

59. <2 yrs Potential 86.1% reduction in CT

60. RE-visit: 4 month old presents after falling off the couch, from dad’s sleeping arms, onto a hard wood floor. On exam well, but with a small parietal hematoma.

61. Not so simple Pros –Excellent radiological modalities –Serious pathology with known and effective intervention –Fast and easy –Pressure from family –Answers a question –Medical Legal Fears Cons –Risk of radiation exposure –Increase medical costs –Increase LOS –Possible risk of sedation –What are we teaching the public? –What is our responsibility to the field of medicine?

62. Not so simple ProsCons –Parental concerns –Medical Legal

63. Almost the end…

64. How to dispo the CT- kids?

65. Schutzman, et al, Pediatrics, 2001 If CT normal, clinically well –0 had late deterioration If Skull fracture, but no ICI on CT –0 had late deterioration.

66. Concussion

67. Return to play recommendations AAP Policy: Clinical Report—Sport- Related Concussion inChildren and Adolescents 2010

68. Concussions Constellation of symptoms –Physical Fatigue, HA –Cognitive Memory and concentration dysfunction –Emotional Irritability, anxiety –Sleep disturbance Typically resolved in 7-10 days

69. Management Assessment with PE and Neuropsych testing Cognitive and Physical Rest Progressive Exercise Program – immediate return –No immediate return –A gradual and graded return Rest-> light aerobic activity-> sport-specific exercise-> full contact practice-> return to play

70. Second Impact Syndrome Debate Sustaining a head injury prior to resolution of a previous concussion Cerebral congestion -> diffuse cerebral swelling All case reports <20 yrs old

71. Postconcussion Syndrome WHO- no clear definition DSMIV- >3mo, >3 symptoms

72. Down the pipeline

73. Other Diagnostic Modalities

74. Radiological Rapid MRI Low dosing CT scan

75. Biomarkers for Head Injury Neuron-specific endolase Glial fibrillary acidic protein D-dimerS100B Myelin-basic protein Cleaved tau

76. In Summary Minor Head Injury is extremely common ICI on CT is seen about 5% of time Clinically important ICI <1% Requiring NS approx. 0.1% CT use has skyrocketed Medical radiation exposure not benign Clinical Prediction Rule Exists More things to come…

77. Thank you…Any Questions? Thank you!

78. References Berger RP. The use of serum biomarkers to predict outcome after traumatic brain injury in adults and children. J Head Trauma Rehabil 2006;21:315-333. Brenner, Elliston C, Hall E and Berdon W. Estimated Risk of radiation-induced fatal cancer from pediatric CT. Am J Roentgenol 2001; 176:286-296. CDC, MMWR, Nonfatal Traumatic Brain Injuries from Sports and Recreation Activities --- United States, 2001—2005. July 27, 2007:56 (29); 733-737. Dietrich AM, Bowman MJ, Ginn-Pease ME, Kosnick E, King DR. Pediatric head injuries: can clinical factors reliably predict an abnormality on computer tomography? Ann Emerg Med 1993;22:1535-1540. Minimizing Radiation Dose for Pediatric Body Applications of Single-Detector Helical CT: Strategies at a Large Children's Hospital. AM J Roengtenol 2001; 176:303-306. Donnelly LF, Emery KH, Brody AS, Laor T, et al. Minimizing Radiation Dose for Pediatric Body Applications of Single-Detector Helical CT: Strategies at a Large Children's Hospital. AM J Roengtenol 2001; 176:303-306. Frush DP, Donnelly LF, Rosen NS. Computer Tomography and Radiation Risks: What the Pediatric Health Care Providers Should Now. Pediatrics 2003; 112:951-957. Greenes DS, Schutzman SA. Clinical Indicators of Intracranial Injury in Head-Injured Infants. Pediatrics 1999;104:861-867. Halstead ME, Walter KD and the Council on Sports Medicine and Fitness. Clinical Report- Sports Related Concussion in Children and Adolescents. Pediatrics 2010; 126:597-615. Homer CJ and Kleinman L. Technical Report: Minor Head Injury in Children. Pediatrics 1999;104:e78

79. References Kupperman N, Holmes JF, Dayan PS, et al; for the Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009; 374: 1160-1170. Llyod DA, Carty H, Patterson, M, Butcher CK, Roe D. Predictive value of skull radiography for intracranial injury in children with blunt head injury. Lancet 1997;349:821-824. Maguire JL, Boutis K, Uleryk EM, Laupacis A and Parkin PC. Should a head-injured child receive a head CT scan? A systematic review of clinical prediction rules. Pediatrics 2009;124:e145-154, Osmond MH, Klassen TP, Wells GA, et al; for the Pediatric Emergency Research Canada (PERC) Head Injury Study Group. CATCH: a clinical decision rule for the use of computer tomography in children with minor head injury. CMAJ 2010; 184: 341- 348. Palchak MJ, Holmes JF, Vance, CW, et al. Does an isolated history of loss of consciousness or amnesia predict brain injuries in children after blunt head trauma? Pedaitrics 2004; 113,e507-513. Paterson A, Frush DP and Donnelly LF. Helical CT of the body: are settings adjusted for the pediatric patient. Am J Roentgenol 2001;176: 297-301.

80. References Schutzman SA, Barnes P, Dujaime, AC, et al. Evaluation and management of children younger than two years old with apparently minor head injury: Proposed guidelines. Pediatrics 2001;107:983-993. Teasdale GM, Murray G, Anderson E, et al. Risks of acute traumatic intracranial hematomas in children and adults:implications for head injuries. BR Med J 1990;300:363-367. Williams WH, Potter S and Ryland H. Mild traumatic brain injury and postconcussion syndrome: a neuropsychological perspective. J Neurol Neurosurg Psychiatry 2010;81:1116-1122.