Evidence-Based Management of Pediatric Head Trauma. Mariann Nocera, MD Siraj Amanullah, MD, MPH November 13, 2014

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1 Evidence-Based Management of Pediatric Head Trauma Mariann Nocera, MD Siraj Amanullah, MD, MPH November 13, 2014

2 Objectives Discuss the types and mechanisms of blunt head trauma in children Discuss the management of blunt head trauma in children Evaluate the evidence behind the management of pediatric blunt head trauma

3 Pediatric Head Trauma Trauma is the leading cause of death in children >1 year TBI is the leading cause of trauma-related death >600,000 ED visits annually 60,000 hospitalizations 6,000 deaths

4 Assessing and managing a patient with head trauma

5 Glasgow Coma Scale Standard GCS Pediatric GCS Eye Opening 4 Spontaneous 3 To verbal stimuli 2 To pain 1 None Eye Opening 4 Spontaneous 3 To speech 2 To pain 1 None J Trauma Acute Care Surg.

6 Glasgow Coma Scale Standard GCS Pediatric GCS Best Verbal Response 5 Oriented 4 Confused 3 Inappropriate words 2 Incomprehensible sounds 1 None Best Verbal Response 5 Coos, babbles 4 Irritable, cries 3 Cries to pain 2 Moans to pain 1 None J Trauma Acute Care Surg.

7 Glasgow Coma Scale Standard GCS Best Motor Response 6 Follows commands 5 Localizes pain 4 Withdraws to pain 3 Flexion to pain 2 Extension to pain 1 None Pediatric GCS Best Motor Response 6 Normal spontaneous moves 5 Withdraws to touch 4 Withdraws to pain 3 Abnormal flexion 2 Abnormal extension 1 None J Trauma Acute Care Surg.

8 Severe / Moderate Head Injury Severe Moderate Minor GCS Management: Airway Intracranial pressure Normal hemodynamic status Seizure prophylaxis Appropriate radiological investigations Hospitalization

9 Classifications of Head Injuries Severe Moderate Minor GCS ??? 97 % of patients seen in ED with blunt head trauma Risk of TBI 0-7 % if GCS is 15 <1 % require surgery J Trauma Acute Care Surg.

10 Risk of TBI GCS Risk of TBI 15 ~2-3% 14 ~7-8% 13 ~25%

11 Indications of Head Imaging - Hasbro Blunt Head Injury GCS 14 or AMS, palpable skull fracture, focal neurologic findings No History of LOC History of vomiting Significant headache Concerning mechanism Behavioral changes (esp <2 years) Scalp hematoma (<2 years) No CT not recommended Yes Yes Observation CT Recommended Consider CT based on: - Worsening signs or symptoms - Clinical judgment

12 Clinically-important traumatic brain injury

13 PECARN Clinically-important TBI Goal: Identify low-risk patients with GCS 15 who do not need to have head CT, not to identify patients for whom CT scans should be obtained.

14 Definition of clinically important TBI Death from TBI Neurosurgical intervention Intubation 24 hours for TBI Hospital admission 2 nights for TBI in association with TBI on CT citbi: 0.9 %

15 Prediction Rule <2 years Altered mental status Scalp hematoma Loss of consciousness Mechanism of injury Skull fracture Acting normally per parent 2 years Altered mental status Loss of consciousness Vomiting Basilar skull fracture Mechanism of injury Severe headache

16 Severe mechanism of injury MVC with patient ejection, death of another passenger, rollover Pedestrian or bicyclist without helmet struck by a motorized vehicle Falls more than 3 feet < 2 years or more than 5 feet 2 years Head struck by a high-impact object

17 < 2 years of age

18 2 years of age

19 Online Tool

20 Prediction Rule < 2 years Altered mental status Scalp hematoma Loss of consciousness Mechanism of injury Skull fracture Acting normally per parent 2 years Altered mental status Loss of consciousness Vomiting Basilar skull fracture Mechanism of injury Severe headache

21 Isolated vomiting citbi with non-isolated vomiting: 2.5 % citbi with isolated vomiting : 0.2 %

22 Isolated loss of consciousness citbi with no LOC: 0.5 % citbi with any LOC: 2.5 % citbi with isolated LOC: 0.5 %

23 Isolated severe injury mechanism citbi with isolated severe mechanism, <2 years: 0.3 % citbi with isolated severe mechanism, 2 years: 0.5 %

24 Isolated scalp hematoma (<2 years) citbi with isolated scalp hematoma: 0.4 % <6 months more at risk < 3 months with any scalp hematomas Older infants with larger temporal or parietal scalp hematomas

25 Isolated headache citbi with isolated headache: very low

26 Isolated basilar skull fracture Intracranial pathology in patients with basilar skull fracture: 21 %

27 Summary TBI is the most common cause of death and disability among pediatric trauma patients Most children do not have a clinicallyimportant traumatic brain injury Low-risk criteria have been validated to help manage patients and identify those who DO NOT need head CT

28 References Advanced Trauma Life Support, 9 th edition. J Trauma Acute Care Surg May;74(5): Brenner DJ. Estimating cancer risks from pediatric CT: going from the qualitative to the quantitative. Pediatric radiology 2002;32: Dayan PS, Holmes JF, Atabaki S, et al. Association of Traumatic Brain Injuries With Vomiting in Children With Blunt Head Trauma. Annals of emergency medicine 2014;63: Dayan PS, Holmes JF, Schutzman S, et al. Risk of traumatic brain injuries in children younger than 24 months with isolated scalp hematomas. Annals of emergency medicine Hamilton M, Mrazik M, Johnson DW. Incidence of delayed intracranial hemorrhage in children after uncomplicated minor head injuries. Pediatrics 2010;126:e33-e9. Injury Prevention & Control: Traumatic Brain Injury. Centers for Disease Control and Prevention. Accessed Kadish HA, Schunk JE. Pediatric basilar skull fracture: do children with normal neurologic findings and no intracranial injury require hospitalization? Annals of emergency medicine 1995;26: 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. The Lancet 2009;374: Lee LK, Monroe D, Bachman MC, et al. Isolated loss of consciousness in children with minor blunt head trauma. JAMA pediatrics 2014;168: MDCalc: PECARN Pediatric Head Injury / Trauma Algorithm. Accessed Nigrovic LE, et al. Prevalence of clinically important traumatic brain injuries in children with minor blunt head trauma and isolated severe injury mechanisms. Arch of ped & adol med 2012;166: Nigrovic LE, Schonfeld D, Dayan PS, Fitz BM, Mitchell SR, Kuppermann N. Nurse and physician agreement in the assessment of minor blunt head trauma. Pediatrics 2013;132:e689-e94. Pearce MS, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. The Lancet 2012; 380: Rabiner JE, Friedman LM, Khine H, Avner JR, Tsung JW. Accuracy of point-of-care ultrasound for diagnosis of skull fractures in children. Pediatrics 2013;131:e1757-e64. Rogers AJ, et al. Incidental findings in children with blunt head trauma evaluated with cranial CT scans. Pediatrics 2013;132:e356-e63 Schonfeld D, et al. Effect of the duration of emergency department observation on computed tomography use in children with minor blunt head trauma. Annals of emergency medicine 2013;62: Smits M, Dippel DW, de Haan GG, et al. External validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head injury. Jama 2005;294: Stanley RM, Hoyle JD, Dayan PS, et al. Emergency Department Practice Variation in Computed Tomography Use for Children with Minor Blunt Head Trauma. The Journal of pediatrics Trauma Handbook. Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Department of Surgery, Division of Trauma and Surgical Critical Care Trenchs V, Curcoy AI, Castillo M, et al. Minor head trauma and linear skull fracture in infants: cranial ultrasound or computed tomography? European Journal of Emergency Medicine 2009;16:150-2.

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