Peds symposium pediatric head trauma 2011 -howard final
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Transcript of Peds symposium pediatric head trauma 2011 -howard final
Management of Pediatric Head Trauma in the Emergency Department: Intracranial and Other Issues
John M. Howard, DOAssistant Director, Emergikids
Alexian Brothers Hospital NetworkApril 16, 2011
Wednesday, April 20, 2011
Disclosure
• I have had no relevant financial relationships with any proprietary entities producing health care goods or services in the past 12 months
Wednesday, April 20, 2011
Objectives
Wednesday, April 20, 2011
Objectives
• Discuss emergency department recognition of intracranial injury via history and physical exam
Wednesday, April 20, 2011
Objectives
• Discuss emergency department recognition of intracranial injury via history and physical exam
• Discuss indications for neuroimaging
Wednesday, April 20, 2011
Objectives
• Discuss emergency department recognition of intracranial injury via history and physical exam
• Discuss indications for neuroimaging
• Review management of head trauma cases in the ED: vital sign stabilization, maintenance of respiratory and circulatory parameters, preparation for neurosurgical intervention
Wednesday, April 20, 2011
WELCOME TO EMERGIKIDS
Wednesday, April 20, 2011
ROOM A
Wednesday, April 20, 2011
ROOM A
CC: UNRESPONSIVE, POOR RESP
Wednesday, April 20, 2011
ROOM A
CC: UNRESPONSIVE, POOR RESP
HPI: 7 MO FELL OFF BED EARLIER IN DAY ~1.5 FT,
Wednesday, April 20, 2011
ROOM A
CC: UNRESPONSIVE, POOR RESP
HPI: 7 MO FELL OFF BED EARLIER IN DAY ~1.5 FT,
“DIDN’T HIT HEAD,” NO LOC, “RECENTLY STARTED CRAWLING”
Wednesday, April 20, 2011
ROOM A
CC: UNRESPONSIVE, POOR RESP
HPI: 7 MO FELL OFF BED EARLIER IN DAY ~1.5 FT,
“DIDN’T HIT HEAD,” NO LOC, “RECENTLY STARTED CRAWLING”
WAS “FINE” EARLIER IN THE DAY...
Wednesday, April 20, 2011
ROOM B
Wednesday, April 20, 2011
ROOM BC/C: MVC
Wednesday, April 20, 2011
ROOM BC/C: MVC
HPI: 3 YR MALE IN CARSEAT WITH SNOWBLOWER IN ADJACENT SEAT
Wednesday, April 20, 2011
ROOM BC/C: MVC
HPI: 3 YR MALE IN CARSEAT WITH SNOWBLOWER IN ADJACENT SEAT
T-BONED BY ONCOMING CAR, LAUNCHING SNOWBLOWER INTO PT
Wednesday, April 20, 2011
ROOM BC/C: MVC
HPI: 3 YR MALE IN CARSEAT WITH SNOWBLOWER IN ADJACENT SEAT
T-BONED BY ONCOMING CAR, LAUNCHING SNOWBLOWER INTO PT
SLEEPY, BUT AROUSES TO VOICE
Wednesday, April 20, 2011
ROOM BC/C: MVC
HPI: 3 YR MALE IN CARSEAT WITH SNOWBLOWER IN ADJACENT SEAT
T-BONED BY ONCOMING CAR, LAUNCHING SNOWBLOWER INTO PT
SLEEPY, BUT AROUSES TO VOICE
EAR LACERATION EXTENDING IN TO EAC, HEMORRHAGIC OTORRHEA
Wednesday, April 20, 2011
ROOM BC/C: MVC
HPI: 3 YR MALE IN CARSEAT WITH SNOWBLOWER IN ADJACENT SEAT
T-BONED BY ONCOMING CAR, LAUNCHING SNOWBLOWER INTO PT
SLEEPY, BUT AROUSES TO VOICE
EAR LACERATION EXTENDING IN TO EAC, HEMORRHAGIC OTORRHEA
Wednesday, April 20, 2011
Introduction
Wednesday, April 20, 2011
Introduction
• What is the leading cause of death in children and adolescents in US?
Wednesday, April 20, 2011
Introduction
• What is the leading cause of death in children and adolescents in US?
• What % of these are due to traumatic brain injuries (TBI)? (40%)
Wednesday, April 20, 2011
Introduction
• What is the leading cause of death in children and adolescents in US?
• What % of these are due to traumatic brain injuries (TBI)? (40%)
• Remember! These are often associated with cervical spine injuries
Wednesday, April 20, 2011
Introduction
Wednesday, April 20, 2011
Introduction
• Goals:
Wednesday, April 20, 2011
Introduction
• Goals:
• Identify and stabilize pts with TBI
Wednesday, April 20, 2011
Introduction
• Goals:
• Identify and stabilize pts with TBI
• Minimize factors that contribute to secondary brain injury
Wednesday, April 20, 2011
Introduction
• Goals:
• Identify and stabilize pts with TBI
• Minimize factors that contribute to secondary brain injury
• Hypoxia
Wednesday, April 20, 2011
Introduction
• Goals:
• Identify and stabilize pts with TBI
• Minimize factors that contribute to secondary brain injury
• Hypoxia
• Hypotension
Wednesday, April 20, 2011
Definitions
• Defined by GCS
Mild (Concussion) 13-15*
Moderate 9-12
Severe <9
Wednesday, April 20, 2011
Definitions
Wednesday, April 20, 2011
Definitions• *Minor head trauma
(GCS 15):
Wednesday, April 20, 2011
Definitions• *Minor head trauma
(GCS 15):
• Chidren < 2 yrs: H+P blunt trauma to scalp/skull/brain and is alert to voice/touch
Wednesday, April 20, 2011
Definitions• *Minor head trauma
(GCS 15):
• Chidren < 2 yrs: H+P blunt trauma to scalp/skull/brain and is alert to voice/touch
• Children >/= 2 yrs: normal MS on initial exam, no focal neuro findings, no exam findings for skull fx
Wednesday, April 20, 2011
Definitions
Wednesday, April 20, 2011
Definitions
• Mild Traumatic Brain Injury (GCS 13-15): brief LOC, disorientation, vomiting
Wednesday, April 20, 2011
Definitions
• Mild Traumatic Brain Injury (GCS 13-15): brief LOC, disorientation, vomiting
• Concussion: Trauma-induced disturbance of neuro fxn and MS, +/- LOC.
Wednesday, April 20, 2011
Definitions
• Mild Traumatic Brain Injury (GCS 13-15): brief LOC, disorientation, vomiting
• Concussion: Trauma-induced disturbance of neuro fxn and MS, +/- LOC.
• Associated sx’s: HA, vomiting, amnesia, AMS
Wednesday, April 20, 2011
Epidemiology
Wednesday, April 20, 2011
Epidemiology
• Children 0-14 years in US, TBI accounts for:
Wednesday, April 20, 2011
Epidemiology
• Children 0-14 years in US, TBI accounts for:
• 475,000 ED visits/yr
Wednesday, April 20, 2011
Epidemiology
• Children 0-14 years in US, TBI accounts for:
• 475,000 ED visits/yr
• 50,000 hospital admissions/yr < 17 yrs(2000)
Wednesday, April 20, 2011
Epidemiology
• Children 0-14 years in US, TBI accounts for:
• 475,000 ED visits/yr
• 50,000 hospital admissions/yr < 17 yrs(2000)
• 29% < 4 yrs old
Wednesday, April 20, 2011
Epidemiology
• Children 0-14 years in US, TBI accounts for:
• 475,000 ED visits/yr
• 50,000 hospital admissions/yr < 17 yrs(2000)
• 29% < 4 yrs old
• 52% 10-17 yrs old
Wednesday, April 20, 2011
Epidemiology
Wednesday, April 20, 2011
Epidemiology • In developed countries: TBI most common
cause of death and disability in childhood
Wednesday, April 20, 2011
Epidemiology • In developed countries: TBI most common
cause of death and disability in childhood
• 3,000 children die each year in US from head injuries
Wednesday, April 20, 2011
Epidemiology • In developed countries: TBI most common
cause of death and disability in childhood
• 3,000 children die each year in US from head injuries
• Overall mortality among children with TBI seen in ED or requiring hospitalization
Wednesday, April 20, 2011
Epidemiology • In developed countries: TBI most common
cause of death and disability in childhood
• 3,000 children die each year in US from head injuries
• Overall mortality among children with TBI seen in ED or requiring hospitalization
• 4.5%
Wednesday, April 20, 2011
Epidemiology • In developed countries: TBI most common
cause of death and disability in childhood
• 3,000 children die each year in US from head injuries
• Overall mortality among children with TBI seen in ED or requiring hospitalization
• 4.5%
• 10.4% adults
Wednesday, April 20, 2011
Epidemiology: Mechanism
• Falls
• MVC
• Pedestrian/bicycle accidents
• Projectiles
• Assaults
• Sports-related
• Inflicted head injuries
• Unknown?
Wednesday, April 20, 2011
Epidemiology
Wednesday, April 20, 2011
Epidemiology
• Highest morbidity/mortality:
Wednesday, April 20, 2011
Epidemiology
• Highest morbidity/mortality:
• < 4 yrs
Wednesday, April 20, 2011
Epidemiology
• Highest morbidity/mortality:
• < 4 yrs
• Low GCS initially
Wednesday, April 20, 2011
Epidemiology
• Highest morbidity/mortality:
• < 4 yrs
• Low GCS initially
• Coagulopathy
Wednesday, April 20, 2011
Epidemiology
• Highest morbidity/mortality:
• < 4 yrs
• Low GCS initially
• Coagulopathy
• Hyperglycemia
Wednesday, April 20, 2011
Epidemiology
• Highest morbidity/mortality:
• < 4 yrs
• Low GCS initially
• Coagulopathy
• Hyperglycemia
• Hypotension
Wednesday, April 20, 2011
Incidence
Wednesday, April 20, 2011
Incidence• True incidence: ...?
Wednesday, April 20, 2011
Incidence• True incidence: ...?
• > 2 yrs w/ minor head trauma + normal neuro exam
Wednesday, April 20, 2011
Incidence• True incidence: ...?
• > 2 yrs w/ minor head trauma + normal neuro exam
• 3-7% with intracranial injury (ICI)
Wednesday, April 20, 2011
Incidence• True incidence: ...?
• > 2 yrs w/ minor head trauma + normal neuro exam
• 3-7% with intracranial injury (ICI)
• < 2 yrs w/ minor head trauma + normal neuro exam
Wednesday, April 20, 2011
Incidence• True incidence: ...?
• > 2 yrs w/ minor head trauma + normal neuro exam
• 3-7% with intracranial injury (ICI)
• < 2 yrs w/ minor head trauma + normal neuro exam
• 3-10% with ICI
Wednesday, April 20, 2011
Incidence• True incidence: ...?
• > 2 yrs w/ minor head trauma + normal neuro exam
• 3-7% with intracranial injury (ICI)
• < 2 yrs w/ minor head trauma + normal neuro exam
• 3-10% with ICI
• Many of these pts have no clinical symptoms
Wednesday, April 20, 2011
Incidence• True incidence: ...?
• > 2 yrs w/ minor head trauma + normal neuro exam
• 3-7% with intracranial injury (ICI)
• < 2 yrs w/ minor head trauma + normal neuro exam
• 3-10% with ICI
• Many of these pts have no clinical symptoms
• Most have scalp hematomas
Wednesday, April 20, 2011
Clinical Features
Symptom Percentage Comment
LOC 5% (< 2), 13% (>2)Longer duration of
LOC assoc with CITBI*
HA 45% Preverbal children = irritable
Vomiting 14% Assoc w/ slight risk of TBI
Sz 0.6% Smaller studies report larger %
Skull Fx 15-30% Mostly linear when assoc w/ ICI
*Clinically Important TBI
Wednesday, April 20, 2011
Clinical Features
Wednesday, April 20, 2011
Clinical Features
• Scalp hematomas:
Wednesday, April 20, 2011
Clinical Features
• Scalp hematomas:
• When < 1 yr, large size or location (parietal or temporal) may be assoc w/ fx
Wednesday, April 20, 2011
Clinical Features
• Scalp hematomas:
• When < 1 yr, large size or location (parietal or temporal) may be assoc w/ fx
• Others:
Wednesday, April 20, 2011
Clinical Features
• Scalp hematomas:
• When < 1 yr, large size or location (parietal or temporal) may be assoc w/ fx
• Others:
• Transient cortical blindness or confusional states
Wednesday, April 20, 2011
Types of Brain Injury
Wednesday, April 20, 2011
Types of Brain Injury
• Diffuse brain injury (DBI): most common type of severe TBI
Wednesday, April 20, 2011
Types of Brain Injury
• Diffuse brain injury (DBI): most common type of severe TBI
• acceleration or deceleration
Wednesday, April 20, 2011
Types of Brain Injury
• Diffuse brain injury (DBI): most common type of severe TBI
• acceleration or deceleration
• mildest form = Concussion
Wednesday, April 20, 2011
Types of Brain Injury
Wednesday, April 20, 2011
Types of Brain Injury
• Diffuse axonal injury (DAI): more severe form
Wednesday, April 20, 2011
Types of Brain Injury
• Diffuse axonal injury (DAI): more severe form
• Tissue shearing at interface of grey-white matter
Wednesday, April 20, 2011
Types of Brain Injury
• Diffuse axonal injury (DAI): more severe form
• Tissue shearing at interface of grey-white matter
• Associated with focal injuries:
Wednesday, April 20, 2011
Types of Brain Injury
• Diffuse axonal injury (DAI): more severe form
• Tissue shearing at interface of grey-white matter
• Associated with focal injuries:
• Cerebral Contusions
Wednesday, April 20, 2011
Types of Brain Injury
• Diffuse axonal injury (DAI): more severe form
• Tissue shearing at interface of grey-white matter
• Associated with focal injuries:
• Cerebral Contusions
• Intracranial Hemorrhage
Wednesday, April 20, 2011
Types of Brain Injury
http://www.braininjury.com/children.html
Wednesday, April 20, 2011
Types of Brain Injury
• Focal injuries: Cerebral contusion:
http://www.braininjury.com/children.html
Wednesday, April 20, 2011
Types of Brain Injury
• Focal injuries: Cerebral contusion:
• Usually due to acceleration/deceleration injury
http://www.braininjury.com/children.html
Wednesday, April 20, 2011
Types of Brain Injury
• Focal injuries: Cerebral contusion:
• Usually due to acceleration/deceleration injury
• Coup, contracoup, or both
http://www.braininjury.com/children.html
Wednesday, April 20, 2011
Types of Brain Injury
Wednesday, April 20, 2011
Types of Brain Injury
• Focal injuries: Intracranial hemorrhage
Wednesday, April 20, 2011
Types of Brain Injury
• Focal injuries: Intracranial hemorrhage
• Epidermal hematoma: arise from middle meningeal artery or others
Wednesday, April 20, 2011
Types of Brain Injury
• Focal injuries: Intracranial hemorrhage
• Epidermal hematoma: arise from middle meningeal artery or others
• Subdural hematoma: rupture of bridging veins
Wednesday, April 20, 2011
Types of Brain Injury
• Focal injuries: Intracranial hemorrhage
• Epidermal hematoma: arise from middle meningeal artery or others
• Subdural hematoma: rupture of bridging veins
• Subarachnoid hematoma: tearing of small vessels in pia mater
Wednesday, April 20, 2011
Associated Injuries
• Multiple trauma
• Cervical spine injury
Wednesday, April 20, 2011
Pathophysiology
Wednesday, April 20, 2011
Pathophysiology
• Two insult model:
Wednesday, April 20, 2011
Pathophysiology
• Two insult model:
• Primary event--direct injury to brain parenchyma
Wednesday, April 20, 2011
Pathophysiology
• Two insult model:
• Primary event--direct injury to brain parenchyma
• Impaired Autoregulation -->
Wednesday, April 20, 2011
Pathophysiology
• Two insult model:
• Primary event--direct injury to brain parenchyma
• Impaired Autoregulation -->
• Cerebral hypoperfusion -->
Wednesday, April 20, 2011
Pathophysiology
• Two insult model:
• Primary event--direct injury to brain parenchyma
• Impaired Autoregulation -->
• Cerebral hypoperfusion -->
• increased metabolic demand...
Wednesday, April 20, 2011
Pathophysiology
• Two insult model:
• Primary event--direct injury to brain parenchyma
• Impaired Autoregulation -->
• Cerebral hypoperfusion -->
• increased metabolic demand...
• Secondary event--result of exogenous insults: hypoxia and hypotension
Wednesday, April 20, 2011
Evaluation
Wednesday, April 20, 2011
Evaluation
• Prompt recognition: Interventions, Follow up, Neuroimaging
Wednesday, April 20, 2011
Evaluation
• Prompt recognition: Interventions, Follow up, Neuroimaging
• Emergent stabilization
Wednesday, April 20, 2011
Evaluation
• Prompt recognition: Interventions, Follow up, Neuroimaging
• Emergent stabilization
• Primary survey: A, B, C’s, and identification of life-threatening conditions
Wednesday, April 20, 2011
Evaluation
• Prompt recognition: Interventions, Follow up, Neuroimaging
• Emergent stabilization
• Primary survey: A, B, C’s, and identification of life-threatening conditions
• Secondary survey: Head-to-toe exam with thorough neurological evaluation
Wednesday, April 20, 2011
Evaluation: History
Wednesday, April 20, 2011
Evaluation: History
• Obvious vs. Subtle:
Wednesday, April 20, 2011
Evaluation: History
• Obvious vs. Subtle:
• Prolonged LOC or AMS
Wednesday, April 20, 2011
Evaluation: History
• Obvious vs. Subtle:
• Prolonged LOC or AMS
• Persistent vomiting
Wednesday, April 20, 2011
Evaluation: History
• Obvious vs. Subtle:
• Prolonged LOC or AMS
• Persistent vomiting
• Severe HA
Wednesday, April 20, 2011
Evaluation: History
• Obvious vs. Subtle:
• Prolonged LOC or AMS
• Persistent vomiting
• Severe HA
• Progression of symptoms
Wednesday, April 20, 2011
Evaluation: History
• Obvious vs. Subtle:
• Prolonged LOC or AMS
• Persistent vomiting
• Severe HA
• Progression of symptoms
• Occult: Inflicted head injury
Wednesday, April 20, 2011
Wednesday, April 20, 2011
Evaluation: Physical Exam
Wednesday, April 20, 2011
Evaluation: Physical Exam
• General assessment
Wednesday, April 20, 2011
Evaluation: Physical Exam
• General assessment
• Vitals + Pulseox:
Wednesday, April 20, 2011
Evaluation: Physical Exam
• General assessment
• Vitals + Pulseox:
• Hypoxia, hypotension
Wednesday, April 20, 2011
Evaluation: Physical Exam
• General assessment
• Vitals + Pulseox:
• Hypoxia, hypotension
• Irregular respirations, bradycardia, hypertension...
Wednesday, April 20, 2011
Evaluation: Physical Exam
• General assessment
• Vitals + Pulseox:
• Hypoxia, hypotension
• Irregular respirations, bradycardia, hypertension...
• Cervical spine immobilization!
Wednesday, April 20, 2011
Evaluation: Physical Exam
• General assessment
• Vitals + Pulseox:
• Hypoxia, hypotension
• Irregular respirations, bradycardia, hypertension...
• Cervical spine immobilization!
Wednesday, April 20, 2011
Evaluation: Physical Exam
• Calculation of GCS!
• Scalp abnormalities: AF, hematoma, depression?
• Basilar skull fx? periorbital ecchymosis, Battle’s sign, hemotympanum, CSF otorrhea/rhinorrhea
Wednesday, April 20, 2011
Evaluation: Physical
Wednesday, April 20, 2011
Evaluation: Physical
• Focused neuro exam: LOC, pupils, EOM, fundoscopic eval, brainstem reflexes (gag, cornea), DTR’s, response to pain?
Wednesday, April 20, 2011
Evaluation: Physical
• Focused neuro exam: LOC, pupils, EOM, fundoscopic eval, brainstem reflexes (gag, cornea), DTR’s, response to pain?
• Any Abnormalities noted may signal in increase in ICP or possible herniation...!
Wednesday, April 20, 2011
Herniation
Wednesday, April 20, 2011
Evaluation: Physical Exam
Wednesday, April 20, 2011
Evaluation: Physical Exam
• Signs of herniation:
• Uncal herniation --> CN III palsy --> hemiplegia
• Changes in respiratory patterns, pupil size, vestibuloocular reflexes, posture
• Cushing’s triad
Wednesday, April 20, 2011
Evaluation: Laboratory Studies
• Trauma labs: Hct, Type + Screen, UA
• Blood glucose*, serum electrolytes, osmolarity
• Coagulation studies*
• * = abnormality associated with poor outcome in TBI
Wednesday, April 20, 2011
Evaluation: Imaging
• Mild TBI: Skull radiographs for:
• Unclear hx,
• R/O FB,
• Screen for fx in asymptomatic pts 3-24 mos with scalp hematomas
Wednesday, April 20, 2011
Medline ® Abstract for Reference 39of 'Minor head trauma in infants and children'
39
TISkull radiograph interpretation of children younger than two years: how good are pediatric emergency physicians?AUChung S, Schamban N, Wypij D, Cleveland R, Schutzman SASOAnn Emerg Med. 2004;43(6):718. STUDY OBJECTIVE: We determine pediatric emergency physicians' accuracy in interpreting skull radiographs of children younger than 2 years and determine the characteristics of misidentified skull radiographs.METHODS: A set of 31 skull radiographs (16 with fractures, 15 normal) was compiled from children younger than 2 years who were evaluated for head trauma in a pediatric emergency department from March 3, 1997, to March 3, 1998. A pediatric radiologist reinterpreted the films and agreed with all of the original readings in the final set. Participants (attending level physicians) were asked to identify the presence, location, and pattern of any fracture. Skull radiograph interpretation was considered radiographically correct if the presence, location, and pattern of fracture were correctly identified and was considered diagnostically correct if the presence of a fracture was recognized.RESULTS: Twenty-five of 26 eligible pediatric emergency physicians completed the study. The mean of each participant's radiographically correct interpretation was 65%+/-10% (mean+/-SD), and diagnostically correct interpretation was 80%+/-9%. The group's mean sensitivity for diagnostically correct interpretation was 76%+/-15%, and specificity was 84%+/-14%. Shorter fractures were identified correctly less often (63%<or =5 cm versus 93%>5 cm; mean difference 30%; 95% confidence interval 21% to 39%). Diagnostically correct rates did not differ according to age of patient, physician practice location, years in practice, or practice in ordering skull radiographs.CONCLUSION: Pediatric emergency physicians have limited accuracy in interpreting skull radiographs of children younger than 2 years. Shorter fractures are more commonly misinterpreted.ADDivision of Emergency Medicine, Children's Hospital, Harvard Medical School, Boston, MA 02115, USA. [email protected]
Wednesday, April 20, 2011
Evaluation: Imaging
Wednesday, April 20, 2011
Evaluation: Imaging
• Head CT preferred initial modality for children with severe TBI
Wednesday, April 20, 2011
Evaluation: Imaging
• Head CT preferred initial modality for children with severe TBI
• By definition, all children with moderate to severe TBI have an abnormal neuro evaluation and should have head CT
Wednesday, April 20, 2011
Evaluation: Imaging
• Head CT preferred initial modality for children with severe TBI
• By definition, all children with moderate to severe TBI have an abnormal neuro evaluation and should have head CT
• Imaging for mild TBI is more complex...
Wednesday, April 20, 2011
THE CT DEBATE...Wednesday, April 20, 2011
THE CT DEBATE...Wednesday, April 20, 2011
THE CT DEBATE...Wednesday, April 20, 2011
THE CT DEBATE...Wednesday, April 20, 2011
Evaluation: Imaging
Wednesday, April 20, 2011
Evaluation: Imaging
• Increased use of CT in US
Wednesday, April 20, 2011
Evaluation: Imaging
• Increased use of CT in US
• 13% to 22% b/t 1995 and 2003
Wednesday, April 20, 2011
Evaluation: Imaging
• Increased use of CT in US
• 13% to 22% b/t 1995 and 2003
• Goal: eliminate pediatric pts receiving head CT in minor head trauma
Wednesday, April 20, 2011
Evaluation: Imaging
• Increased use of CT in US
• 13% to 22% b/t 1995 and 2003
• Goal: eliminate pediatric pts receiving head CT in minor head trauma
• More likely to occur in community hospitals
Wednesday, April 20, 2011
Evaluation: Imaging
• Increased use of CT in US
• 13% to 22% b/t 1995 and 2003
• Goal: eliminate pediatric pts receiving head CT in minor head trauma
• More likely to occur in community hospitals
• Rare, significant injuries vs risks of CT
Wednesday, April 20, 2011
Evaluation: Imaging
Wednesday, April 20, 2011
Evaluation: Imaging
• Lifetime risk for cancer in pediatric pts with head CT? (1:1500 HEAD CT)
Wednesday, April 20, 2011
Evaluation: Imaging
• Lifetime risk for cancer in pediatric pts with head CT? (1:1500 HEAD CT)
• Worse for children vs. adults
Wednesday, April 20, 2011
Evaluation: Imaging
• Lifetime risk for cancer in pediatric pts with head CT? (1:1500 HEAD CT)
• Worse for children vs. adults
• Longer subsequent lifetime
Wednesday, April 20, 2011
Evaluation: Imaging
• Lifetime risk for cancer in pediatric pts with head CT? (1:1500 HEAD CT)
• Worse for children vs. adults
• Longer subsequent lifetime
• Greater sensitivity to radiation in some developing organs
Wednesday, April 20, 2011
Evaluation: Imaging
• Lifetime risk for cancer in pediatric pts with head CT? (1:1500 HEAD CT)
• Worse for children vs. adults
• Longer subsequent lifetime
• Greater sensitivity to radiation in some developing organs
• Sedation issues
Wednesday, April 20, 2011
Evaluation: Imaging
• Goal: identify pts with clinically important TBI:
• neurosurgery,
• ET intubation > 24 hrs,
• hospitalized > 2 days
Wednesday, April 20, 2011
Evaluation: Imaging
Wednesday, April 20, 2011
Evaluation: Imaging
• Predictors of Intracranial Injury (ICI)
Wednesday, April 20, 2011
Evaluation: Imaging
• Predictors of Intracranial Injury (ICI)
• Consistent: skull fx, focal neuro deficit, depressed MS
Wednesday, April 20, 2011
Evaluation: Imaging
• Predictors of Intracranial Injury (ICI)
• Consistent: skull fx, focal neuro deficit, depressed MS
• Variable: sz, LOC, amnesia, vomiting, < 2 yrs, trauma mechanism, scalp swelling (pt < 1yr), HA
Wednesday, April 20, 2011
FOCUS! 2 MOST IMPORTANT
SLIDES AHEAD!
Wednesday, April 20, 2011
FOCUS! 2 MOST IMPORTANT
SLIDES AHEAD!
Wednesday, April 20, 2011
Wednesday, April 20, 2011
Wednesday, April 20, 2011
Management: TBI
Wednesday, April 20, 2011
Management: Airway and Breathing
Wednesday, April 20, 2011
Management: Airway and Breathing
• Maintaining an oral airway, supplemental O2
Wednesday, April 20, 2011
Management: Airway and Breathing
• Maintaining an oral airway, supplemental O2
• Bag-valve-mask ventilations
Wednesday, April 20, 2011
Management: Airway and Breathing
• Maintaining an oral airway, supplemental O2
• Bag-valve-mask ventilations
• Endotracheal intubation via Rapid sequence intubation (RSI) if:
Wednesday, April 20, 2011
Management: Airway and Breathing
• Maintaining an oral airway, supplemental O2
• Bag-valve-mask ventilations
• Endotracheal intubation via Rapid sequence intubation (RSI) if:
• Decreasing LOC (GCS < 9)
Wednesday, April 20, 2011
Management: Airway and Breathing
• Maintaining an oral airway, supplemental O2
• Bag-valve-mask ventilations
• Endotracheal intubation via Rapid sequence intubation (RSI) if:
• Decreasing LOC (GCS < 9)
• Marked respiratory distress
Wednesday, April 20, 2011
Management: Airway and Breathing
• Maintaining an oral airway, supplemental O2
• Bag-valve-mask ventilations
• Endotracheal intubation via Rapid sequence intubation (RSI) if:
• Decreasing LOC (GCS < 9)
• Marked respiratory distress
• Hemodynamic instability
Wednesday, April 20, 2011
Management: Airway and Breathing
• Maintaining an oral airway, supplemental O2
• Bag-valve-mask ventilations
• Endotracheal intubation via Rapid sequence intubation (RSI) if:
• Decreasing LOC (GCS < 9)
• Marked respiratory distress
• Hemodynamic instability
• Use cuffed tracheal tubes to protect airway from aspiration
Wednesday, April 20, 2011
Management: Airway and Breathing
Wednesday, April 20, 2011
Management: Airway and Breathing
• RSI considerations:
Wednesday, April 20, 2011
Management: Airway and Breathing
• RSI considerations:
• Pretreat with Lidocaine --> minimizes increase in ICP that can be associated with airway manipulation
Wednesday, April 20, 2011
Management: Airway and Breathing
• RSI considerations:
• Pretreat with Lidocaine --> minimizes increase in ICP that can be associated with airway manipulation
• Sedation --> Etomidate and thiopental* = neuroprotective
Wednesday, April 20, 2011
Management: Airway and Breathing
• RSI considerations:
• Pretreat with Lidocaine --> minimizes increase in ICP that can be associated with airway manipulation
• Sedation --> Etomidate and thiopental* = neuroprotective
• Paralysis --> Succinylcholine (+/-) vs. Rocuronium
Wednesday, April 20, 2011
Management: Airway and Breathing
• Role of Hyperventilation
HYPERVENTILATION
DECREASE PCO2
CEREBRAL VASOCONSTRICTION
DECREASED CEREBRAL PERFUSION
REDUCTION OF INTRACRANIAL
PRESSURE
Wednesday, April 20, 2011
Management: Airway and Breathing
• Role of Hyperventilation
HYPERVENTILATION
DECREASE PCO2
CEREBRAL VASOCONSTRICTION
DECREASED CEREBRAL PERFUSION
REDUCTION OF INTRACRANIAL
PRESSURE
HYPOPERFUSION = HYPOXIA?
Wednesday, April 20, 2011
Management: Airway and Breathing
• Role of Hyperventilation
HYPERVENTILATION
DECREASE PCO2
CEREBRAL VASOCONSTRICTION
DECREASED CEREBRAL PERFUSION
REDUCTION OF INTRACRANIAL
PRESSURE
HYPOPERFUSION = HYPOXIA?
IDEAL PACO2 35-38...*
Wednesday, April 20, 2011
Management: Fluid Managment
Wednesday, April 20, 2011
Management: Fluid Managment
• Outcome is poor for pts with severe TBI and initial hypotension
Wednesday, April 20, 2011
Management: Fluid Managment
• Outcome is poor for pts with severe TBI and initial hypotension
• Target blood pressure to maintain cerebral perfusion pressure is not clearly defined, but may be age-dependent.
Wednesday, April 20, 2011
Management: Fluid Managment
• Outcome is poor for pts with severe TBI and initial hypotension
• Target blood pressure to maintain cerebral perfusion pressure is not clearly defined, but may be age-dependent.
• Maintain SBP > 5th percentile, as a minimum
Wednesday, April 20, 2011
Management: Fluid Managment
• Outcome is poor for pts with severe TBI and initial hypotension
• Target blood pressure to maintain cerebral perfusion pressure is not clearly defined, but may be age-dependent.
• Maintain SBP > 5th percentile, as a minimum
• Isotonic fluids preferred (vs. hypertonic)
Wednesday, April 20, 2011
Management: Other
Head positioning Hyperventilation
Sedation/paralysis AVOID HYPERGLYCEMIA
Antiseizure Corticosteroids (?)
Hyper-/Hypothermia Emergent surgery
Hyperosmolar Tx
Wednesday, April 20, 2011
Management: Monitoring
• HR, BP, Pulse oximetry
• Capnography: end-tidal CO2
• ICP monitoring if abn head CT or GCS 3-8
Wednesday, April 20, 2011
ED Management Decisions
Wednesday, April 20, 2011
ED Management Decisions
• Immediate neurosurgical evaluation required for:
Wednesday, April 20, 2011
ED Management Decisions
• Immediate neurosurgical evaluation required for:
• Focal injuries identified on CT
Wednesday, April 20, 2011
ED Management Decisions
• Immediate neurosurgical evaluation required for:
• Focal injuries identified on CT
• Depressed, basilar, widely diastatic skull fx
Wednesday, April 20, 2011
ED Management Decisions
• Immediate neurosurgical evaluation required for:
• Focal injuries identified on CT
• Depressed, basilar, widely diastatic skull fx
• Increased ICP
Wednesday, April 20, 2011
ED Management Decisions
• Immediate neurosurgical evaluation required for:
• Focal injuries identified on CT
• Depressed, basilar, widely diastatic skull fx
• Increased ICP
• Deteriorating clinical condition
Wednesday, April 20, 2011
ED Management Decisions
Wednesday, April 20, 2011
ED Management Decisions
• Children with signs of herniation:
Wednesday, April 20, 2011
ED Management Decisions
• Children with signs of herniation:
• O2, breathing, BP
Wednesday, April 20, 2011
ED Management Decisions
• Children with signs of herniation:
• O2, breathing, BP
• Hyperosmolar Tx (Mannitol)
Wednesday, April 20, 2011
ED Management Decisions
• Children with signs of herniation:
• O2, breathing, BP
• Hyperosmolar Tx (Mannitol)
• Mild hyperventilation (PaCO2 30-35)
Wednesday, April 20, 2011
ED Management Decisions
• Children with signs of herniation:
• O2, breathing, BP
• Hyperosmolar Tx (Mannitol)
• Mild hyperventilation (PaCO2 30-35)
• Immediate neurosurgical evaluation
Wednesday, April 20, 2011
Disposition: Minor Head Trauma
Wednesday, April 20, 2011
Disposition: Minor Head Trauma
• May go home after observation period without deterioration and/or negative head CT --> F/U PCP IN 24 HRS
Wednesday, April 20, 2011
Disposition: Minor Head Trauma
• May go home after observation period without deterioration and/or negative head CT --> F/U PCP IN 24 HRS
• If home, f/u if worsening HA, persistent vomiting, AMS, gait/coordination issues, sz
Wednesday, April 20, 2011
Disposition: Minor Head Trauma
• May go home after observation period without deterioration and/or negative head CT --> F/U PCP IN 24 HRS
• If home, f/u if worsening HA, persistent vomiting, AMS, gait/coordination issues, sz
• Admit: brain injury, depressed/basilar skull fracture (with Neurosurg), AMS, persistent vomiting, suspected abuse, unreliable caretakers
Wednesday, April 20, 2011
Disposition: TBI
Wednesday, April 20, 2011
Disposition: TBI
• Children in field with GCS < or = 12 should go directly to pediatric trauma center.
• Once stabilized, pts should be transferred from community hospital to peds trauma center if:
• GCS < or = 8
• GCS < or = 12 with associated major injuries
• Deterioration in clinical condition / GCS drop
Wednesday, April 20, 2011
Return to Play Guidelines
Wednesday, April 20, 2011
Return to Play Guidelines
• Children/adolescents at increased risk for Second Impact Syndrome
• Diffuse cerebral swelling after 2nd concussion -- rare, often FATAL.
• Any LOC or symptoms of concussion > 15 minutes -- no sports until asymptomatic x 7 days
Wednesday, April 20, 2011
NFL Players Association
What is the cumulative effect of recurrent mild
TBI?
Wednesday, April 20, 2011
Some final words...
http://www.cdc.gov/traumaticbraininjury/prevention.html
Wednesday, April 20, 2011
ROOM A: 7 MO MALE
Wednesday, April 20, 2011
ROOM A: 7 MO MALE
ACTIVE SZ
INTUBATED, ANTICONVULSANTS
URGENT NEUROSURG CONSULT
MANNITOL
Wednesday, April 20, 2011
ROOM A: 7 MO MALE
ACTIVE SZ
INTUBATED, ANTICONVULSANTS
URGENT NEUROSURG CONSULT
MANNITOL
Wednesday, April 20, 2011
ROOM B: 3 YR MALE
Wednesday, April 20, 2011
ROOM B: 3 YR MALE
Wednesday, April 20, 2011
ROOM B: 3 YR MALE
Wednesday, April 20, 2011
bibliographyLanglois, JA, Rutland-Brown, W, Thomas, KE. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta 2006.
Schneier AJ, Shields BJ, Hostetler SG, et al. Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States. Pediatrics 2006; 118:483.
White JR, Farukhi Z, Bull C, et al. Predictors of outcome in severely head-injured children. Crit Care Med 2001; 29:534.
Luerssen TG, Klauber MR, Marshall LF. Outcome from head injury related to patient's age. A longitudinal prospective study of adult and pediatric head injury. J Neurosurg 1988; 68:409.
Vavilala MS, Muangman S, Tontisirin N, et al. Impaired cerebral autoregulation and 6-month outcome in children with severe traumatic brain injury: preliminary findings. Dev Neurosci 2006; 28:348.
Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009; 374:1160.
McCrory P. Does second impact syndrome exist? Clin J Sport Med 2001; 11:144.
Kirkwood MW, Yeates KO, Wilson PE. Pediatric sport-related concussion: a review of the clinical management of an oft-neglected population. Pediatrics 2006; 117:1359.
Wednesday, April 20, 2011
QUESTIONS?Questions?
Wednesday, April 20, 2011
ROOM C
Wednesday, April 20, 2011