Closed Head Injury. Dan Schumacher, MD, MEd

Transcription

1 Closed Head Injury Dan Schumacher, MD, MEd

2 The Plan Mild to Moderate TBI (will not cover severe TBI as not as relevant for you to know) C-spine considerations Concussion

3 The Problem

4 Defining the Problem Head injury is most frequent diagnosis in injured children About 5 million head injuries in kids each year About 1 in 20 need admission Almost half of winter sport injuries are head injuries Clinically important traumatic brain injury is uncommon...but can be catastrophic if missed

5 Cases and Discussion

6 Case 1 18 month old boy who was running to mom when he fell and struck the front of his head 3 hours ago at 10AM Cried immediately, not sleepy since, drank some juice, no vomiting Mom says acting like himself Exam shows 6cm x 5cm frontal hematoma without underlying bony injury palpable Assessment? Plan?

7 Lancet, 2009

8 Risk of CT Head Exact risk not really known Lethal malignancy risk extrapolated from WWII atomic explosions 1/1250 if under 1 year of age 1/5000 for 10 year-olds Bottom line: Likely not insignificant!

9 Under 2 Years Old

10 Case 2 2 month old girl who was laying in bed with mom breast feeding when mom changed position, lost control of baby, and she fell onto hardwood floor 1.5 hours ago Cried immediately, no LOC, one normal breast feed attempt since injury, not fussy or unusually sleepy Exam shows 3cm x 3cm parietal hematoma without underlying bony injury palpable, AFOSF, awake, alert, MAEE, good tone, good suck Assessment? Plan?

11 Under 2 Years Old

12 Under 2 Years Old

13 Case 3 13 year-old boy who was biking without a helmet when he took a corner, fell, and struck the side of his head about 1 hour ago Friend with him says he had about 30 second LOC Patient c/o mild headache, mild nausea but has had no vomiting Exam shows alert, oriented, interactive, appropriate, GCS 15 with superficial abrasions to left side of face and scalp and without other traumatic injury noted Assessment? Plan?

14 Over 2 Years Old

15 Case 4 4 year-old girl who was climbing on jungle gym when she fell approximately 4-5 feet and struck her head 1.5 hours ago Was not witnessed but thought to possibly have up to 30 seconds of LOC before mom got to her Awake and appropriate since but has vomited once Exam shows well-appearing child who is alert, interactive, GCS 15 and without any evidence of trauma Assessment? Plan?

16 Over 2 Years Old

17 Case 5 8 year-old girl who was riding bike without helmet when she crashed her bike and hit head and left arm 2 hours ago now No LOC, cried a lot right after injury, vomited once in the first 5 minutes after injury, no vomiting since Exam shows abrasions over left side of face, no hematoma, ecchymosis under left eye, GCS 15, alert, oriented, abrasions to left arm without bony TTP, otherwise unremarkable Assessment? Plan?

18 Over 2 Years Old

19 Case 5 continued 8 year-old girl who was riding bike without helmet when she crashed her bike and hit head and left arm 2 hours ago now No LOC, cried a lot right after injury, vomited once in the first 5 minutes after injury, no vomiting since Exam shows abrasions over left side of face, no hematoma, ecchymosis under left eye, GCS 15, alert, oriented, abrasions to left arm without bony TTP, otherwise unremarkable She vomits again about 30 min into ED observation (now about 3 hours out from injury) Now what?

20 Case 6 10 year-old boy is riding his bike, no helmet, falls and sustains a handlebar to the abdomen injury Arrives via EMS in a c-collar Does not believe he hit his head, no HEENT trauma, no chest trauma, some abdominal pain that is mild only over the area of the injury, no extremity trauma, normal VS No midline c-spine tenderness Keep collar on? Take it off? Anything else you want to know?

21 3065/34,069 patients were kids No patients under 2 years Only 27% of the kids under 8 years

22 *16 years and older

23 Case 7 16 year-old boy is restrained front seat passenger in high speed MVC (60mph on highway) Arrives via EMS with collar in place Does not believe he hit his head, no LOC, small lacs on face from shattered glass, skin exam notable for what is seen in photo, minimal chest pain and abdominal pain over seatbelt marks, extremity pain over areas of abrasions and ecchymosis only Leave collar on? Take it off?

24 *16 years and older

25 Case 8 4 month old, fell from bed Ecchymosis as shown in photo, no LOC, happened 2 hours ago, no vomiting, normal feed once since injury, not sleepy, no other abnormalities on exam The RN wants to know if you want a collar placed on child. What are you going to tell her/him?

26

27 Case 9 12 year old girl presenting with headache worsened by playing on computer and slow thinking one day after being kicked in the head while playing soccer Parents coming because they are afraid she could have a concussion and want to be sure she can play in her soccer game in 2 days Exam is completely unremarkable What are you going to tell the family?

28 Pediatrics, 2010

29 Definition Direct blow to head, face, or neck or elsewhere on body with force transmitted to head Rapid onset of short-lived neuro impairment that resolves on own +/- LOC No abnormality on imaging (not that we should get it!)

30 Patient Assessment

31 Management Goal: Safe, efficient return to play (these things compete!) Medications No evidence they help beyond anecdotal Cognitive Rest No school, shortened school days, less workload at/from school, more time for tests, no leisure reading, limit screen time and loud music Teacher education: Look great but cognitively impaired Physical Rest

32 Return to Play Bottom Lines: 5 days minimum Never the same day

33 Take Home Points Few children with closed head injury require CT scans, but some need to be observed Concussion is annoying: minimum 5 days out, lots of cognitive and physical rest that challenges our young, active patients