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Minor Head Injury In Children
Larry Kleiner
Medical Director, Dept of Neurosurgery
The Children's Medical Center
Head Trauma
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
• Eye opening: spontaneous 4
to sound 3
to pain 2
none 1
Modification of the GCS
Modification of the GCS
• Verbalization • Appropriate for age 5– fixes and follows – social smile
• cries but consolable 4• persistent irritability 3• restless,lethargy 2• none 1
Modification of the GCS
• Motor Response • Spontaneous 6• localizes to pain
5• withdraws
4• decorticate 3• decerebrate 2• none 1
Modification of GCS
Glasgow-Liege Scale– includes brainstem reflexes– increases prediction of outcome
from 76% to 90% with a .9 confidence level
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
Epidemiology
• 7-8 million “head injuries”/year
• 1.5-2.0 million/year with LOC/amnesia
- 80% considered minor
Epidemiology
• 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
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
Compared to severe head injuries: generally younger
• higher frequency of students
• percentage of males is less
• alcohol less frequently involved
Demographics
Demographics
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
Demographics
• Children aren’t little adults
• Infants aren’t little children
Physiology Unique to Children
Skull
• relation to spine
• deformability
• thickness
• open sutures
• open fontanel
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
Physiology Unique to Children
Brain
• Increased water content
• autoregulatory mechanisms
• pressure/volume compliance shifted left
• contracoup
• post traumatic unconsciousness
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
Treatment
Efficacy of head trauma sheets
• 66% referred to the document
• 84% found it answered all questions
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%
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
Sequellae
• 10-15% have surgical lesions
• EDH, SDH, ICH, Depressed skull Fx
• <1% demonstrate talk and die phenomena
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
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
Primary Head Injuries
Skull fractures of concern:
• open,depressed
• crosses suture lines
• crosses known vascular channels– arterial– dural sinuses
• enters into sinuses
• basilar
• Metabolic
hypoxia/hypercarbia
hypo/hypernatremia
hyperglycemia• hormonal dysregulation• dysautonomia• nutritional
Classification of Head Injury
Secondary • swelling• hemorrhage• edema• vasospasm• seizures• hypotension• ischemia
CT Scans of Intracranial HemorrhageCT Scans of Intracranial Hemorrhage
Mechanism of Injury
Translational• linear• focal
Acceleration-deceleration
• rotational • concussive-shearing
forces
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
TriageApproach/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
Triage
History• mechanism of injury (should “fit” what you see)
• neurologic- recent, remote; baseline, SZ, HI
• general-medical, drugs
• psychological/educational
Triage
Physical Exam
• CGLCS
• pupils
• respiratory pattern
• sensory modalities
SEARCH FOR FOCALITY!
• reflexes – DTR– cutaneous
• mental status
Signs of Rostro-caudal deterioration
• decreased LOC • headache • vomiting
• visual changes • pupilary change
• Cushing Triad
• loss of function– motor/sensory
• respiratory pattern
change
Triage
As A Rule
Any pupillary inequality> 1 mm in a head injured child must be attributed to an intracranial injury until proven otherwise
Pathophysiology
Monroe-Kellie doctrine
• three compartments
blood
brain
CSF
• change in one requires reciprocal change in the others
Clinical Findings in 4500 pediatric head injuries
• Initial LOC %
normal 56.0
confused 30.2
major impairment 13.8
• Vomiting 30.3• Skull Fx 26.6
linear 72.8
depressed 27.2
compound 19.7
• Seizures 7.4
• paralysis 3.8
• pupil abn 3.6
• retinal hem 2.6
• subdural hem 5.2
• epidural hem 0.9
• major sequellae 5.9
• mortality 5.4
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
Clinical profile
Presence of Mass lesionsGlasgow Coma Scale 15: 7.1 %
Glasgow Coma Scale 14: 9.7 %
Glasgow Coma Scale 13: 13.6 %
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%
Identifying Risk Facteurs
• GCGS and the patient’s MENTAL STATUS were the best predicteurs of potential deterioration or the presence of a mass lesion
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
Etiologies of delayed detoriation
• Mass lesions: EDH/SDH/ICH
• electrolyte imbalance
• cerebral edema
• seizures
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.
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
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
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
Is it a crap shoot?
KNOWLEDGEIS
POWER