Transcript Intracranial Bleed 11/18/11 Morning Report

PEDIATRIC HEAD INJURY
Myra Lalas Pitt
PEDIATRIC HEAD INJURY
More than 1.5 million head injuries occur in the US
annually
 2M: 1F
 Motor vehicle collisions- most common cause of
pediatric head injury, followed by falls
 Football is the most common of sports-related injury.

ANY HEAD TRAUMA CAN TRANSFER ENERGY
FROM THE SKIN, THROUGH THE SKULL AND
MENINGES, TO THE BRAIN.
SUBDURAL HEMATOMA

Subdural Hematoma classic presentation is
an acute and
persistent LOC
associated with the
initial injury.
EPIDURAL HEMATOMA

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Epidural Hematoma brief period of
unconsciousness,
followed by a lucid
period, and then a
subsequent
deterioration over 15-30
minutes.
Usual cause is tearing of
the middle meningeal
artery secondary to an
associated temporal
skull fracture.
SUBARACHNOID HEMORRHAGE

Subarachnoid
Hemorrhage Worsening headache
and other signs of
increasing
intracranial pressure
will gradually grow
after the initial event.
SUBARACHNOID HEMORRHAGE

Trauma to the blood
vessels in the pia
mater or in the brain
can lead to leakage of
blood in the
subarachnoid space.
INTRACEREBRAL HEMORRHAGE

Parenchymal damage
occurs as the result of
contact forces, inertial
forces, and global
hypoxia/ischemia.
ASSESSMENT
Stabilize ABC’s.
 Prevention of hypoxia, ischemia, and increased
intracranial pressure is essential.
 Intubate any child with a GCS of 8 or less.
 Prompt neurosurgical intervention is necessary
in the majority of seriously head-injured or
multisystem-injured children.
 Physical exam for associated injuries and
neurologic examination followed by
neuroimaging.

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CT Scan

Indications: focal neurologic examination findings, signs or
symptoms of increased intracranial pressure, GCS
score less than 15, and seizures related to trauma, LOC

Imaging study of choice in evaluating an acute head injury.
1. Better imaging of an acute hemorrhage
2. Speed of the study
3. Improved ability to monitor the patient.

MRI
Imaging study of choice for patients who have prolonged
symptoms (> 7 d) or for a late change in an individual's
neurologic signs or symptoms.
Offers a more detailed examination and possibly detects more
subtle findings.
Delayed or slowly developing bleeds may be easier to detect
on MRI.
FOR SUSPECTED CHILD ABUSE
Associated injuries include skull, metaphyseal,
and rib fractures; retinal hemorrhages; and
intracranial bleeding, especially subdural
hematomas.
 Do Ophtho Exam.
 Bone Scan

TREATMENT
ABC’s
 In the ER, mild hyperventilation and correlation
with end-tidal CO2 may be used in unconscious
patients, prior to insertion of an ICP monitor.
 Hypotension should be treated with isotonic fluid
boluses and inotropic medications prn to
maintain an adequate MAP and cerebral
perfusion pressure.
 Mannitol is often used to maintain optimal
intracranial pressure by reducing intravascular
volume.



SIADH or DI may occur in children with serious
head injury- monitor fluid & electrolyte balance.
Seizures: Those with serious injuries are treated
with fosphenytoin either to treat active seizures
or for prophylaxis.
QUESTION

You are evaluating an 18-month-old girl for
vomiting. She has a history of febrile seizures
and recurrent ear infections. She is receiving no
medications. Over the past several weeks, her
parents have noticed that she has been
"increasingly clumsy." She has vomited each of
the last three mornings but has had no diarrhea
or fever. Physical examination findings are
normal except for an ataxic gait and
hyperreflexia.

Of the following, the MOST appropriate next step
is
A. administration of an antiemetic
B. computed tomography scan of the head
C. electroencephalography
D. lumbar puncture
E. reassurance and re-evaluation in 3 to 5 days
B
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Initial symptoms of increased intracranial pressure often
consist of headaches and confusion that may be accompanied
by lethargy.
The child described in the vignette exhibits signs of a
progressive increase in pressure, such as vomiting (especially
in the morning) and changes in motor tone.
CT or MRI of the head is the first priority in evaluating
suspected increased intracranial pressure.
Meningitis is unlikely in this patient due to the chronicity of
symptoms and absence of fever. Accordingly, lumbar puncture
is not indicated at this time.
Electroencephalography might be indicated if atypical
migraines or seizures were suspected, but the initial priority is
to evaluate the patient for potential life-threatening disease
processes.
The child has no evidence of viral infection, and reassurance
or administration of antiemetics is not appropriate.
REFERENCES
Atabaki, S. Pediatric Head Injury. Pediatr.
Rev. 2007;28;215-224
Baker Robert J, "Chapter 34. Acute Head and Neck
Trauma" (Chapter). Dilip R. Patel, Donald E.
Greydanus, Robert J. Baker: Pediatric Practice:
Sports Medicine:
http://www.accesspediatrics.com/content/6981964
Quayle Kimberly S, "Chapter 29. Head Trauma"
(Chapter). Gary R. Strange, William R. Ahrens,
Robert W. Schafermeyer, Robert A. Wiebe: Pediatric
Emergency Medicine, 3e:
http://www.accesspediatrics.com/content/5330570.
www.emedicine.com
www.uptodate.com