Transcript (Canadian Assessment of Tomography for Childhood Head Injury

Mild Head Injury in
Children and
Adolescents
Dr. Juan Antonio Garcia-R
Dr. Roger Thomas
MD, MSc, CCFP (SEM), FCFP, Dip Sports Med.
MD, Ph.D, CCFP, MRCGP
Professor of Family Medicine
Assistant Professor Dept. Family Medicine
Outline
1. Definitions
2. Diagnosis: SCAT3 and SCAT3-child
Imaging
3.
Treatment
Interchangeable terms:
*Concussion
*Mild traumatic brain injury
*Mild head injury (MHI)
*Minor head injury
*Minor closed head injury
* What symptoms would you enquire about with a person with a
concussion?
*
Definition:
* A form of head injury characterized by any alteration in
cerebral function and caused by a direct or indirect
(rotation) force transmitted to the head.
Acute signs or symptoms:
* Brief loss of consciousness
* Light-headedness,
* Vertigo, tinnitus, blurred vision, photophobia
* Cognitive and memory dysfunction, difficulty
concentrating, amnesia
* Headache, nausea, vomiting
* Balance disturbance.
Delaney J, Frankovich R. Discussion Paper. Head Injuries and Concussions in soccer.
Canadian Academy of Sport and Exercise Medicine. 2010.
Delayed signs and symptoms:
* Sleep irregularities
* Fatigue
* Personality changes
* Inability to perform usual daily activities
* Depression or lethargy.”
*
Definition:
* Disturbance in brain function caused by a direct or
indirect force to the head. It results in a variety of
non-specific signs and/or symptoms and most often
does not involve loss of consciousness.
* Suspected if any one or more of:
- Symptoms (e.g., headache), or
- Physical signs (e.g., unsteadiness), or
- Impaired brain function (e.g. confusion) or
- Abnormal behaviour (e.g., change in personality)”
Guskiewicz KM. Register-Mihalik J. McCrory P. McCrea M. Johnston K. Makdissi M. Dvorak J. Davis G. Meeuwisse W.
Evidence-based approach to revising the SCAT2: introducing the SACT3. British Journal of Sports Medicine
2013;47(5):289-93
* 1/3 of all mild head injuries in US occur in 5-19 year olds
* For children > 1 year trauma is main cause of death, and head
trauma is leading cause of disability and death
* In high schoolers 9% of athletic injuries involve mild head
injury
*
*80% to 90% of MHI cases resolve within 7 to 10 days
*24.5% of 13 to 21 year olds still having disabling symptoms
one month after head trauma (up to 3 months)
*5.9% remain symptomatic after six months
*Symptoms of concussion can persist up to one year
*
The reaction to head trauma in the
pediatric and adult population
differs from the adult population.
*Pathophysiologic changes after MHI are more pronounced
in immature brains
*Mechanism of injury:
Direct trauma to the face, head or
neck or transmitted force from trauma to other parts of
the body.
*
*History of prior MHI
*Younger age (children and adolescents)
*Mechanism and force of the injury
*The sport that is practiced and the position
played on the field
*Female gender
*
* Symptoms
* Details of the mechanism of injury
* The time line of symptoms
* Aggravating factors
Child abuse should be ruled out.
*
* What signs would you look for in a person with a concussion?
*
Full Physical exam, focused on
*Head
- Signs of trauma
- Lacerations and abrasions
- Skull irregularities - fractures (e.g. depression,
determination of skull discontinuity through lacerations).
- Signs of basilar skull fracture (Hemotympanum, drainage
of fluid or blood from the nose or ears, Battle’s sign, or
the “raccoon eyes” sign)
*
*Complete neurological exam
(focal neurological signs are frequently not found)
* A balance test
*Mental status: Start with Glasgow Coma Scale
*
Instructions for the Balance Error Exam (also printed at end
of the SCAT3)
3 stance tests timed over 20 seconds:
* all without shoes, socks and trousers rolled above ankle so
you can observe balance
* all hands on hips, eyes closed
1. Double leg stance. Feet together.
2. Single leg stance. Stand on non-dominant foot, with
dominant leg 30 degrees hip flexion, 45 degrees knee
flexion
3. Tandem stance: heel-to-toe, non-dominant foot behind
*
Take off one point for each error during each 20 second test
(max errors = 10 for each test)
1.
2.
3.
4.
5.
6.
Lifted hands off iliac crest
Opened eyes
Step, stumble or fall
Moved hip into > 30 degrees abduction
Lifted forefoot or heel
Remained out of test position > 5 seconds
*
*
Tandem gait
* Walk heel-toe along 38 mm wide tape for 3 meters then
return
* 4 trials and choose best time (should complete in 14 seconds)
* Fail test if step off the line, or separate heel and toe, or grab
an object for support
Finger-Nose
* Starting position: sit on chair, shoulder flexed to 90 degrees,
elbow and fingers extended
* Now touch nose and return to starting position 5 x
* Score 1 point for 5 correct repetitions in < 4 seconds
* Perform a SCAT3 pre sports-season exam on your colleague
* If your colleague did not score 100 figure out why
(explanations later)
*
*
* 1134 high school athletes, Arizona, preseason
(262 female, 872 male)
* Average SCAT2 score 88.3 (range 58-100)
* 12th graders = 89, 9th graders = 86.9 (p<.001)
* No concussion history = 88.7, concussion history = 87 (p
<.001)
*
* Average score = 89
* Average balance score 26 (max 30), all completed double leg
stance
* Only 67% could recite months of year backwards (55%
footballers)
* Only 41% could correctly sequence 5 digits backwards (32%
footballers)
*
*
Average
Max possible
Symptom score 19.75
22
Physical signs
score
Glasgow Coma
Scale
Balance score
2
2
15
15
25.82
30
Coordination
0.90
1.00
Subtotal
63.46
70.00
*
Average
Max possible
Orientation
4.79
5.00
Immediate
memory score
Concentration
score
Delayed recall
13.82
15
2.96
5.00
3.96
5.00
SAC subtotal
25.52
30.00
SCAT2 total
100
100
* Radiographs have low predictive value in patients with no loss
of consciousness and no clinical signs of skull fracture.
* CT if a major concern exists about intracranial lesion
(Controversial)
* No consensus exists about the use of neuropsychological
testing.
Possible indications: Persistent symptoms
preventing return to academic or sport activities or
determination of resolution of the concussion.
*
*It is done according to the status and progress of the
individual patient rather than on grading as it was
suggested in the past
*Severe injury or complications have been ruled out
*The main strategy of the management of MHI is rest and
prudent observation for 24 to 48 hrs.
*
*Any deterioration in clinical status during at any
should prompt further evaluation
*Tests providing standardized symptom scores are
helpful to assess the patient’s progress
*
* The child should be allowed to sleep but checked periodically for
clinical deterioration
* During the initial hours medications should be avoided that could affect
evaluation of cognition (e.g. meclizine, benzodiazepines), mask
symptoms (e.g. anti-emetics) or facilitate bleeding (e.g. ASA, NSAIDs).
* Avoid participation in sports/physical activities and this decision should
made clear to parents, coaches, trainers and teachers
* Gradual return: Mental and Physical activities
* F MD Roll:
Acute phase, after the acute phase or as part of postconcussion syndrome
*
Abstain from intense mental activities:
*Reading
*Use of computers
*Videogames
*Solving puzzles or Sudokus
*Texting
*Watching TV
*Schoolwork
*
 Regular assessment (clinic or at home)
 Educate how to identify improvement, chronicity or
worsening of the condition (Symptoms, time lines, course,
how to cope with symptoms, access to medical services)
 Are adequate resources available for that purpose?
*
* Geographical accessibility
* Adequate transport
* Assess for reliable caregivers or parents
Impediments for parental participation:
* Incompetence
* Previous neglect of children
* Intoxication
* Unavailability
* Language barrier.
If conditions are not adequate observation to be done in a health care
facility.
*
Headache
Acetaminophen
>6 weeks: Multidisciplinary mng
Sleep disturbance
Sleep hygiene, observation
If persistent:
Meds and cognitive therapy
Daytime somnolence
No meds in acute phase
Mood disorders management
No meds
If >6-12 weeks
Meds and counseling
Vertigo
Vestibular therapy
Attention Deficits
No meds
Decrease academic demands
Management
After acute phase/PCS
*
* Key problems are attention, executive function,
memory and social interaction
* Cognitive training to improve attention performing
everyday and work activities, including pacing,
training on single tasks then combining them
* Cognitive training in planning, problem solving,
reasoning skills
* Social communication with communication partners
and in group formats
* Improving memory skills and integrating them with
external memory aids (e.g. cell phones)
*
1.
A thorough history and physical are required to describe
the trauma, symptoms and pre-trauma baseline status
2.
The SCAT3 and SCAT3-child are evidence-based assessment
tools
3.
The CATCH and PECARN studies provide detailed guidance
in ordering imaging and predicting outcomes
4.
Pre-trauma baselines are variable and should be measured
before the sports season
5.
6.
Studies of follow-up of concussion have marked attrition
There are many guidelines but minimal evidence how to
accomplish full rehabilitation
Thank you for listening
!
* 3866 children, median age 9 years (range 1-16)
* Mechanism: 45% falls, 23% sports, 12% hit by object, 9 %
bicycle, 4 % struck as pedestrian, 3% MVA
Symptoms and signs:
* 59% Amnesia
* 54% Witnessed disorientation or confusion
* 41% Vomited ≥ 2
* 33% Witnessed loss of consciousness
* Glasgow Coma Scale score: 15 in 90%, 14 in 7%, 13 in 2.5%
*
Definition of minor head injury:
* within past 24 hours
* Glasgow Coma Scale 13-15
* witnessed loss of consciousness, amnesia
* witnessed disorientation
* 1 episode vomiting
* persistent irritability (in child < 2 years)
Rule: CT of head required for children with any one high or
medium risk finding
*
High risk signs:
1. GCS < 15, two hours after injury
2. Suspected skull fracture
3. Worsening headache
4. Irritability
* Your colleague’s 5 year old was hit hard at sports and has 2
high risk signs. Your colleague does not want to image but
explain your decision.
*
≥ 1 high risk
factor
No high risk
factors
Needed
neurologic
intervention
Did not need
neurologic
intervention
24
1144
0
2698
95%CI
Sensitivity
100%
86% to 100%
Specificity
70%
69% to 72%)
*
Medium risk signs:
5. Any sign of basal skull fracture
6. Large boggy hematoma of scalp
7. Dangerous mechanism of injury (MVA, Fall ≥ 3
feet or 5 stairs, fall from bike no helmet
*
Needed
neurologic
intervention
Did not need
neurologic
intervention
≥ 1 risk factor
156
1851
No risk factors
3
1856
95%CI
Sensitivity
98%
95% to 99%
Specificity
50%
49% to 52%)
*
Results:
* 5% (192) skull fractures
* 4% (159) acute brain lesion
* 1.4% (55) epidural hematoma
* 1 % cerebral contusion
* 1% pneumocephalus
* 0.8% subdural hematoma
0.6% neurological intervention
(20 craniotomy, 6 intubation)
*
* 42,412 children 25 US emergency departments
* 35% (14,969) received CT
Rule for children < 2 years:
* normal mental status
* no scalp hematoma (except frontal)
* no loss of consciousness (or < 5 seconds)
* non-severe injury mechanism
* no palpable skull fracture
* acting normally according to parents
*
*
95%CI
Negative
predictive
value
Sensitivity
100%
99.7 to 100%
100%
86.3 to 100%
Rule for children ≥ 2 years:
* normal mental status
* no loss of consciousness (or < 5 seconds)
* no vomiting
* non-severe injury mechanism
* no signs of basilar skull fracture
* No severe headache
*
*
95%CI
Negative
predictive
value
Sensitivity
99.95%
99.81 to 100%
96.8%
89.0 to 99.6%
* Discuss with a colleague the sensitivity and specificity of
imaging and the likely outcome for the child based on these
studies
*