Transcript Minor Head Trauma - Lenox Hill Hospital

Minor Head Trauma:
What a headache!
Joshua Rocker, MD
Director of Education, PEM Dept
Cohen Children’s Medical Center/LIJ
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.
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.
Not this…
But this…
And don’t
forget this…
Objectives
What are the stats?
Review the literature.
– Where we have been and where we are now
Other concerns
Why do we care?
Just look at the
numbers!!
Why do we care?
Traumatic Brain Injury (TBI)
– leading cause of pediatric death/disability
– > 7000 deaths
– > 60k hospitalizations
– > 600,000 ED visits
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
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?
Why not?
Its simple, just CT everyone!!!
Why not?
Its simple, just CT everyone!!! NIKHIL????
How did this happen?
What motivated this drastic increase?
Yes, CT technology improved
– Faster
– More detailed
– More accessible
BUT….
Let’s look at the literature?
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 AMS80 fold increase risk of intracranial hematoma
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%
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!
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
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!!!
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)
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
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%
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”
4 month old presents after
falling off the couch, from dad’s
sleeping arms, onto a hard
wood floor…
Patient at high risk for ICI,
right? Looks well… but may
be asymptomatic!
Play it safe!!!!
This is also why CT rates
skyrocketed?
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 SingleDetector Helical CT: Strategies at a Large
Children's Hospital. Donnelly, et al.
People recognized the risk
and things are out of control
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
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.”
Schutzman, 2001:
Management Strategy
Stratify patients into 4 groups
– High risk
– Some risk because of concerning symptoms
– Some risk without symptoms
– Low risk
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)
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
Schutzman
Low Risk
– Observation/ Discharge
Minimal mechanism and clinically well
More studies trying to figure this
issue out – the search for the
low risk patients
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
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
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!!!!!
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
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
Palchak, 2003
Decision tree
for predicting
TBI with acute
intervention
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
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 _____?
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 ZERO (0
164).
of
Palchak, 2004
Conclusion:
– Recommendation to eliminate isolated LOC
and/or amnesia as indications for CT in
pediatric trauma patients
Maguire, et al, 2009
Should a Head-Injured Child Receive a
Head CT Scan? A Systematic Review of
Clinical Prediction Rules
Pediatrics, July 2009
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.”
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.
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
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
AND THEN…
…there is the BIG momma
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 Network25 PEDs
– 42,412 children enrolled
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%
>2 yrs
Potential 86% reduction in CT
<2 yrs
Potential 86.1% reduction in CT
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.
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?
Not so simple
Pros
Cons
– Parental concerns
– Medical Legal
Almost the end…
How to dispo the CT- kids?
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.
Concussion
Return to play
recommendations
AAP Policy: Clinical Report—SportRelated Concussion in Children and
Adolescents
2010
Concussions
Constellation of symptoms
– Physical
Fatigue, HA
– Cognitive
Memory and concentration dysfunction
– Emotional
Irritability, anxiety
– Sleep disturbance
Typically resolved in 7-10 days
Management
Assessment with PE and Neuropsych
testing
Cognitive and Physical Rest
Progressive Exercise Program
– No immediate return
– A gradual and graded return
Rest-> light aerobic activity-> sport-specific
exercise-> full contact practice-> return to play
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
Postconcussion Syndrome
WHO- no clear definition
DSMIV- >3mo, >3 symptoms
Down the pipeline
Other Diagnostic Modalities
Radiological
Rapid MRI
Low dosing CT scan
Biomarkers for Head Injury
Neuron-specific endolase
Glial fibrillary acidic protein
D-dimer
S100B
Myelin-basic protein
Cleaved tau
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…
Thank you…Any Questions?
Thank you!
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.
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
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: 341348.
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.
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.