TCE Sinais de alerta e conduta

Transcription

1 TCE Sinais de alerta e conduta Luis Fernando Andrade de Carvalho Hospital Infantil João Paulo II Hospital Mater Dei

2 Criança com 3 anos vítima de queda da própria altura, sem perda de consciência, sem vômitos, com cefaléia leve e céfalo-hematoma região frontal esquerda.

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4 Radiat Environ Biophys Mar;54(1):1-12. doi: /s Epub 2015 Jan 8. Risk of cancer incidence before the age of 15 years after exposure to ionising radiation from computed tomography: results from a German cohort study. Krille L 1, Dreger S, Schindel R, Albrecht T, Asmussen M, Barkhausen J, Berthold JD, Chavan A, Claussen C, Forsting M, Gianicolo EA, Jablonka K, Jahnen A, Langer M, Laniado M, Lotz J, Mentzel HJ, Queißer-Wahrendorf A, Rompel O, Schlick I, Schneider K, Schumacher M, Seidenbusch M, Spix C, Spors B, Staatz G, Vogl T, Wagner J, Weisser G, Zeeb H, Blettner M. J Trauma Acute Care Surg Feb;76(2):292-5; discussion doi: /TA Routine repeat brain computed tomography in all children with mild traumatic brain injury may result in unnecessary radiation exposure. Howe J 1, Fitzpatrick CM, Lakam DR, Gleisner A, Vane DW.

5 Ann Emerg Med Aug;64(2):145-52, 152.e1-5. doi: /j.annemergmed Epub 2014 Mar 11. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Easter JS, Bakes K 2, Dhaliwal J 3, Miller M 3, Caruso E 2, Haukoos JS 4 Identificar lesões cerebrais traumáticas clinicamente importantes (morte, neurocirurgia, intubação maior que 24h, internação maior que 2 noites) Experiência do medico e PECARN - 100% sensibilidade e 50% e 62% especificidade CATCH 91% sensibilidade e 44% especificidade CHALICE 84% sensibilidade e 85% especificidade

6 pacientes pediátricos com TCE 100.0% leve. sensitive (95% CI 86.2% 100.0%) estudo foram submetidas for predicting à TC de crânio. Assim, não há DOI: /cmaj Abstract TC em 2043 pacientes (52,8%) 51,9% dos pacientes. Tabela 1 - Tabela 1 - Alto risco Alto risco Background: There is controversy about which children with minor head injury need to undergo computed tomography (CT). We aimed to develop a highly sensitive clinical decision rule for the use of CT in children with minor head injury. Lesões cerebrais em 159 (4,1%) - neurocirurgia em 24 (0,6%) Methods: For this multicentre cohort study, we enrolled consecutive children with blunt head trauma presenting with a score of on the Glasgow Coma Scale and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. For each child, staff in the emergency department completed a standardized assessment form before any CT. The main outcomes were need for neurologic intervention and presence of brain injury as determined by CT. We developed a decision rule by using recursive partitioning to combine variables that were both reliable and strongly associated with the outcome measures and thus to find the best combinations of predictor variables that were highly sensitive for detecting the outcome measures with maximal specificity. Results: Among the 3866 patients enrolled (mean age 9.2 years), 95 (2.5%) had a score of 13 on the Glasgow Coma Medicine (Stiell), University of baseada em sete achados, que são divididos em alto e não ficando claro Pediatrics o motivo. the need for neurologic intervention como saber and se would algumas require crianças deste grupo (Klassen, sem TC McConnell), de baixo risco CMAJ Clinical Research Unit (Correl Principais (Tabela achados 1). that desse 30.2% estudo of patients undergo crânio CT. The apresentavam medium-risk alguma factors pelo para resulted menos a decisão in 98.1% um do uso dos sensitivity fatores assintomática. (95% deci 94.6% 99.4%) prática clínica versity e avaliar of Toronto, o impacto Toronto, O 3 - lesão Necessidade intracraniana de vali Research Institute, Ottawa, Ont Uma Pacientes ferramenta com clínica de TC de crânio em crianças com for TCE the leve prediction foi proposta of brain e injury by CT 2 and - Algumas would crianças requireforam University excluídas of do Western estudo, Ontario, alto risco apresentaram that 52.0% alto of risco patients de undergo intervenção 4 - Uma (Bailey), ferramenta CHU Sainte-Justine, com baseada em sete achados, que são divididos em alto e não CT. ficando claro o motivo. M neurocirúrgica, (Chauvin-Kimoff), McGill Unive baixo risco (Tabela 1). com uma sensibilidade de 100% 3 e- Necessidade com baixa de validar especificidade esta ferramenta levando na CATCH: a clinical Interpretation: decision The rule decision for rule the developed use of in computed this study Medicine (Pusic), Columbia Un especificidade Pacientes de com 70,2%, pelo menos identifies levando um dos children a fatores indicação de prática at two levels de of TC clínica risk. de e avaliar Once the 51,9% o impacto decision das sócio crianças Department econômico. com of Pediatrics TCE leve (Nijs alto risco tomography apresentaram alto in children risco de intervenção with minor head 4 - injury Uma ferramenta com alta Alta.; sensibilidade, the Department masof Pedi crânio em 30,2% dos pacientes. rule has been prospectively validated, it has the 0,5% potential dos pacientes nipeg, Man.; necessitarão and the Departmed neurocirúrgica, com uma sensibilidade de 100% e com baixa especificidade levando à indicação de TC em to standardize and improve the use of CT for children with Halifax, NS. The other members especificidade A presença de 70,2%, levando de pelo a indicação menos de um TC dos de fatores 51,9% das decrianças e com de que TCE leve, apenas a despeito 4 a 7% de apenas apresenta minor head injury. (PERC) Head Injury Study Group alto crânio ou em baixo Martin 30,2% H. dos risco, Osmond pacientes. apresentou MD CM, Terry P. Klassen uma MD, sensibilidade George 0,5% A. Wells dos de PhD, pacientes Rhonda visível. necessitarão Correll RN, de intervenção cirúrgica Anna A presença Jarvis MD, de pelo Gary menos Joubert um MD, dos Benoit fatores Bailey MD, Laurel e que Chauvin-Kimoff apenas 4 a 7% MD apresentarão CM, CMAJ lesão intracraniana DOI: /cma 98,1% e Martin especificidade Pusic MD, Don McConnell de 50,1% MD, Cheri na Nijssen-Jordan identificação MD, Norm de Silver MD, Brett Taylor 5 - Número MD, alto ou baixo risco, apresentou uma sensibilidade de visível. pequeno d Ian G. Stiell MD; for the Pediatric Emergency Research Canada (PERC) Head Injury Study Group pacientes 98,1% e especificidade com lesões de intracranianas 50,1% na identificação detectadas com 5 a- Número 2 anos pequeno (277), de crianças com menores apenas de23 ca Previously published at TC pacientes de crânio. com lesões Isso intracranianas leva à indicação detectadas com TC de a crânio 2 anos (277), em com CMAJ o apenas que MARCH limita 23 casos 9, a 2010 generalização de lesão 182(4) cerebral, e a TC de 3866 crânio. pacientes Isso leva com à indicação ECG 13 de a TC 15 de crânio em o que limita a 2010 generalização Canadian Medical e a confiança Association nos or its resulta- licensors 51,9% dos pacientes. dos. Each year more than children are seen in hospital emergency departments in North America with dos. minor head injury, i.e., history of loss of consciousness, amnesia or disorientation in a patient who is conscious and responsive in the emergency department (Glasgow Coma Scale score ). Although most patients with minor head injury can be discharged after a period of observation, a small proportion experience deterioration of their condition and need to undergo neurosurgical intervention for intracranial hematoma. 2 4 The use of computed tomography (CT) in the emergency department is important in the early diagnosis of these intracranial hematomas. Over the past decade the use of CT for minor head injury has become increasingly common, while its diagnostic yield has remained low. In Canadian pediatric emergency departments the use of CT for minor head injury increased from 15% in 1995 to 53% in ,6 Despite this increase, a small but important number of pediatric intracranial hematomas are missed in Canadian emergency departments at the first visit. 3 Few children with minor head injury have a visible brain injury on CT (4% 7%), Fatores de alto e baixo risco para a presença de lesão intracraniana. - - Escala Histórico de de coma piora da de cefaléia Glasgow < 15 duas horas após o trauma - - Suspeita Irritabilidade de ao fratura exame aberta ou afundamento - Baixo Histórico Risco de piora da cefaléia - - Irritabilidade Qualquer sinal de ao fratura exame da base do crânio Baixo Risco Fatores de alto e baixo risco para a presença de lesão intracraniana. - Escala de coma de Glasgow < 15 duas horas após o trauma - Suspeita de fratura aberta ou afundamento - Hematoma subgaleal volumoso - Mecanismo Scale, de 282 trauma (7.3%) had perigoso a score of (acidente 14, and 3489 automobilístico, (90.2%) had queda and only de 0.5% 1 m have ou an mais intracranial ou 5 degraus, lesion requiring bicicleta urgent sem neurosurgical intervention. 5,7 The increased use of CT adds substan- capacete) a score of 15. CT revealed that 159 (4.1%) had a brain injury, and 24 (0.6%) underwent neurologic intervention. tially to health care costs and exposes a large number of children We derived a decision rule for CT of the head consisting of each year to the potentially harmful effects of ionizing radia- - Qualquer sinal de fratura da base do crânio Rev. Col. Bras. Cir. 2013; 40(6): four high-risk factors (failure to reach score of 15 on the 8,9

7 Lancet 2009; 374: PECARN Published Online September 15, 2009 DOI: /S (09) Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study Nathan Kuppermann, James F Holmes, Peter S Dayan, John D Hoyle, Jr, Shireen M Atabaki, Richard Holubkov, Frances M Nadel, David Monroe, Rachel M Stanley, Dominic A Borgialli, Mohamed K Badawy, Jeff E Schunk, Kimberly S Quayle, Prashant Mahajan, Richard Lichenstein, Kathleen A Lillis, Michael G Tunik, Elizabeth S Jacobs, James M Callahan, Marc H Gorelick, Todd F Glass, Lois K Lee, Michael C Bachman, Arthur Cooper, Elizabeth C Powell, Michael J Gerardi, Kraig A Melville, J Paul Muizelaar, David H Wisner, Sally Jo Zuspan, J Michael Dean, Sandra L Wootton-Gorges, for the Pediatric Emergency Care Applied Research Network (PECARN)* Summary Background CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to Published identify Online children at very low risk of clinically-important traumatic brain injuries (citbi) for whom CT might be unnecessary. September 15, 2009 DOI: /S0140- Methods We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow 6736(09) Coma Scale scores of in 25 North American emergency departments. We derived and validated age-specific prediction rules for citbi (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission See Comment 2 nights). page 1127 See Comment page 1127 Crianças menores 18 anos nas primeiras 24h de trauma *Members listed at end of paper Departments of Emergency Medicine (Prof N Kuppermann MD, than 2 years, and and 6411 aged 2 years and older). We obtained CT scans on (35 3%); citbis occurred Excluídos mecanismos de traumas leves como queda da própria altura sem Prof J F Holmes MD), in 376 (0 9%), and 60 (0 1%) underwent neurosurgery. In the validation population, the prediction rule for children outros sinais younger ou than sintomas 2 years (normal diferentes mental status, no de scalp abrasões haematoma except ou frontal, lacerações. no loss of consciousness or loss of Pediatrics (Prof N Kuppermann), Neurological Surgery (Prof J P Muizelaar MD), Surgery (Prof D H Wisner MD), and Radiology (Prof ECG S L Wootton-Gorges 14 ou MD), 15 - em 25 unidades de urgência americanas University of California, Davis School of Medicine, Davis, CA, USA; Department of Pediatrics, Columbia University College of Regras para predizer TCE clinicamente importante Physicians and Surgeons, New York, NY, USA (P S Dayan MD); Division of Emergency Medicine, Michigan State University TCEci School of (morte, be obviated. neurocirurgia, intubação por mais 24h, internação por mais de 2 Medicine/Helen DeVos noites) Children s Hosp, Grand Rapids, MI, USA (J D Hoyle MD); Departments of Pediatrics and Emergency Medicine, George Washington University School of Medicine, Washington, DC, USA (S M Atabaki MD); Introduction Lancet 2009; 374: *Members listed at end of paper Findings We enrolled and analysed children (derivation and validation populations: 8502 and 2216 younger Departments of Emergency Medicine (Prof N Kuppermann MD, consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally Prof J F Holmes MD), according to the parents) had a negative predictive value for citbi of 1176/1176 (100 0%, 95% CI ) and sensitivity of 25/25 (100%, ). 167 (24 1%) of 694 CT-imaged patients younger than Pediatrics 2 years (Prof were N in Kuppermann), this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, Neurological Surgery no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) (Prof had a J negative P Muizelaar MD), predictive value of 3798/3800 (99 95%, ) and sensitivity of 61/63 (96 8%, ). Surgery 446 (Prof (20 1%) D H Wisner of MD), 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in and Radiology validation populations. (Prof S L Wootton-Gorges MD), Interpretation These validated prediction rules identified children at very low risk of citbis for whom University CT can of routinely California, Davis School of Medicine, Davis, CA, USA; Department of Pediatrics, Funding The Emergency Medical Services for Children Programme of the Maternal and Child Health Columbia Bureau, University and the College of Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services. Physicians and Surgeons, New York, NY, USA need acute intervention, and some are (P false S Dayan positives MD); Division or of a p Nathan Rachel Kathlee Arthur Sandra Summ Backg childr Metho Scale rules Findin than 2 in 376 young consc accord sensit low-ri no vo predic 2223 valida

8 Lancet 2009; 374: PECARN Published Online September 15, 2009 DOI: /S (09) See Comment page crianças *Members listed at end of paper Departments of Emergency Medicine Tomografia em (35,3%) com lesões traumáticas (5,2%) (Prof N Kuppermann MD, Prof J F Holmes MD), Pediatrics (Prof N Kuppermann), Neurological Surgery TCEci em 376 (0,9%) - neurocirurgia em 60 (0,1%) (Prof J P Muizelaar MD), Surgery (Prof D H Wisner MD), and Radiology (Prof S L Wootton-Gorges MD), Intubações por mais de 24h - 8 pacientes University of California, Davis School of Medicine, Davis, CA, USA; Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY, USA (P S Dayan MD); Division of Emergency Medicine, Michigan State University School of Internações em (9,0%) Nenhum be óbito obviated. Medicine/Helen DeVos Children s Hosp, Grand Rapids, MI, USA (J D Hoyle MD); Departments of Pediatrics and Emergency Medicine, George Washington University School of Medicine, Washington, DC, USA (S M Atabaki MD); Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study Nathan Kuppermann, James F Holmes, Peter S Dayan, John D Hoyle, Jr, Shireen M Atabaki, Richard Holubkov, Frances M Nadel, David Monroe, Rachel M Stanley, Dominic A Borgialli, Mohamed K Badawy, Jeff E Schunk, Kimberly S Quayle, Prashant Mahajan, Richard Lichenstein, Kathleen A Lillis, Michael G Tunik, Elizabeth S Jacobs, James M Callahan, Marc H Gorelick, Todd F Glass, Lois K Lee, Michael C Bachman, Arthur Cooper, Elizabeth C Powell, Michael J Gerardi, Kraig A Melville, J Paul Muizelaar, David H Wisner, Sally Jo Zuspan, J Michael Dean, Sandra L Wootton-Gorges, for the Pediatric Emergency Care Applied Research Network (PECARN)* Summary Background CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to Published identify Online children at very low risk of clinically-important traumatic brain injuries (citbi) for whom CT might be unnecessary. September 15, 2009 DOI: /S0140- Methods We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow 6736(09) Coma Scale scores of in 25 North American emergency departments. We derived and validated age-specific prediction rules for citbi (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission See Comment 2 nights). page 1127 Introduction Lancet 2009; 374: *Members listed at end of paper Findings We enrolled and analysed children (derivation and validation populations: 8502 and 2216 younger than 2 years, and and 6411 aged 2 years and older). We obtained CT scans on (35 3%); citbis occurred Departments of in 376 (0 9%), and 60 (0 1%) underwent neurosurgery. In the validation population, the prediction rule Emergency for children Medicine younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness (Prof N or Kuppermann loss of MD, consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally Prof J F Holmes MD), according to the parents) had a negative predictive value for citbi of 1176/1176 (100 0%, 95% CI ) and sensitivity of 25/25 (100%, ). 167 (24 1%) of 694 CT-imaged patients younger than Pediatrics 2 years (Prof were N in Kuppermann), this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, Neurological Surgery no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) (Prof had a J negative P Muizelaar MD), predictive value of 3798/3800 (99 95%, ) and sensitivity of 61/63 (96 8%, ). Surgery 446 (Prof (20 1%) D H Wisner of MD), 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in and Radiology validation populations. (Prof S L Wootton-Gorges MD), Interpretation These validated prediction rules identified children at very low risk of citbis for whom University CT can of routinely California, Davis School of Medicine, Davis, CA, USA; Department of Pediatrics, Funding The Emergency Medical Services for Children Programme of the Maternal and Child Health Columbia Bureau, University and the College of Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services. Physicians and Surgeons, New York, NY, USA need acute intervention, and some are (P false S Dayan positives MD); Division or of a p Nathan Rachel Kathlee Arthur Sandra Summ Backg childr Metho Scale rules Findin than 2 in 376 young consc accord sensit low-ri no vo predic 2223 valida

9 Crianças menores 2 anos Lancet 2009; 374: Published Online September 15, 2009 Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study Nathan Kuppermann, James F Holmes, Peter S Dayan, John D Hoyle, Jr, Shireen M Atabaki, Richard Holubkov, Frances M Nadel, David Monroe, Rachel M Stanley, Dominic A Borgialli, Mohamed K Badawy, Jeff E Schunk, Kimberly S Quayle, Prashant Mahajan, Richard Lichenstein, Kathleen A Lillis, Michael G Tunik, Elizabeth S Jacobs, James M Callahan, Marc H Gorelick, Todd F Glass, Lois K Lee, Michael C Bachman, Arthur Cooper, Elizabeth C Powell, Michael J Gerardi, Kraig A Melville, J Paul Muizelaar, David H Wisner, Sally Jo Zuspan, J Michael Dean, Sandra L Wootton-Gorges, for the Pediatric Emergency Care Applied Research Network (PECARN)* Summary DOI: /S0140- Nível consciência normal Background CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to Published identify Online children at very low risk of clinically-important traumatic brain injuries (citbi) for whom CT might be unnecessary. September 15, 2009 DOI: /S0140- Methods We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow 6736(09) Coma Scale scores of in 25 North American emergency departments. We derived and validated age-specific prediction rules for citbi (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission See Comment 2 nights). page (09) See Comment page 1127 Sem céfalo-hematoma (exceto frontal) *Members listed at end of paper Departments of Emergency Medicine (Prof N Kuppermann MD, Prof J F Holmes MD), Sem perda de consciência ou perda menor que 5 segundos Pediatrics (Prof N Kuppermann), Neurological Surgery (Prof J P Muizelaar MD), Surgery (Prof D H Wisner MD), Mecanismo de trauma não grave and Radiology (Prof S L Wootton-Gorges MD), University of California, Davis School of Medicine, Davis, CA, Sem fratura de crânio palpável USA; Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY, USA Comportamento normal segundo os pais (P S Dayan MD); Division of Emergency Medicine, Michigan State University School of Medicine/Helen DeVos Children s VPN Hosp, 100% Grand Rapids, (1.176/1.176) e sensibilidade 100% (25/25) para TCEci MI, USA (J D Hoyle MD); Departments of Pediatrics and Emergency Medicine, George Washington 167 University (24,1%) School das 694 TCs em menores de 2 anos eram desse grupo of Medicine, Washington, DC, USA (S M Atabaki MD); Introduction Lancet 2009; 374: *Members listed at end of paper Findings We enrolled and analysed children (derivation and validation populations: 8502 and 2216 younger than 2 years, and and 6411 aged 2 years and older). We obtained CT scans on (35 3%); citbis occurred Departments of in 376 (0 9%), and 60 (0 1%) underwent neurosurgery. In the validation population, the prediction rule Emergency for children Medicine younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness (Prof N or Kuppermann loss of MD, consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally Prof J F Holmes MD), according to the parents) had a negative predictive value for citbi of 1176/1176 (100 0%, 95% CI ) and sensitivity of 25/25 (100%, ). 167 (24 1%) of 694 CT-imaged patients younger than Pediatrics 2 years (Prof were N in Kuppermann), this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, Neurological Surgery no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) (Prof had a J negative P Muizelaar MD), predictive value of 3798/3800 (99 95%, ) and sensitivity of 61/63 (96 8%, ). Surgery 446 (Prof (20 1%) D H Wisner of MD), 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in and Radiology validation populations. (Prof S L Wootton-Gorges MD), Interpretation These validated prediction rules identified children at very low risk of citbis for whom University CT can of routinely California, Davis be obviated. School of Medicine, Davis, CA, USA; Department of Pediatrics, Funding The Emergency Medical Services for Children Programme of the Maternal and Child Health Columbia Bureau, University and the College of Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Physicians and Surgeons, Department of Health and Human Services. New York, NY, USA need acute intervention, and some are (P false S Dayan positives MD); Division or of a p Nathan Rachel Kathlee Arthur Sandra Summ Backg childr Metho Scale rules Findin than 2 in 376 young consc accord sensit low-ri no vo predic 2223 valida

10 Crianças menores 2 anos Lancet 2009; 374: Published Online September 15, 2009 Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study Nathan Kuppermann, James F Holmes, Peter S Dayan, John D Hoyle, Jr, Shireen M Atabaki, Richard Holubkov, Frances M Nadel, David Monroe, Rachel M Stanley, Dominic A Borgialli, Mohamed K Badawy, Jeff E Schunk, Kimberly S Quayle, Prashant Mahajan, Richard Lichenstein, Kathleen A Lillis, Michael G Tunik, Elizabeth S Jacobs, James M Callahan, Marc H Gorelick, Todd F Glass, Lois K Lee, Michael C Bachman, Arthur Cooper, Elizabeth C Powell, Michael J Gerardi, Kraig A Melville, J Paul Muizelaar, David H Wisner, Sally Jo Zuspan, J Michael Dean, Sandra L Wootton-Gorges, for the Pediatric Emergency Care Applied Research Network (PECARN)* Summary DOI: /S0140- Nível consciência normal Background CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to Published identify Online children at very low risk of clinically-important traumatic brain injuries (citbi) for whom CT might be unnecessary. September 15, 2009 DOI: /S0140- Methods We enrolled patients younger (risco than TCEci 18 years presenting 4,4%) within 24 h of head trauma with Glasgow 6736(09) Coma Scale scores of in 25 North American emergency departments. We derived and validated age-specific prediction rules for citbi (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission See Comment 2 nights). page (09) See Comment page 1127 Sem céfalo-hematoma (exceto frontal) *Members listed at end of paper Departments of Emergency Medicine (Prof N Kuppermann MD, *Members listed at end of paper Findings We enrolled and analysed children (derivation and validation populations: 8502 and 2216 younger than 2 years, and and 6411 aged 2 years and older). We obtained CT scans on (35 3%); citbis occurred Departments of in 376 (0 9%), and 60 (0 1%) underwent neurosurgery. In the validation population, the prediction rule Emergency for children Medicine younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness (Prof N or Kuppermann loss of MD, consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally Prof J F Holmes MD), according to the parents) had a negative predictive value for citbi of 1176/1176 (100 0%, 95% CI ) and sensitivity of 25/25 (100%, ). 167 (24 1%) (risco of 694 TCEci CT-imaged 0,9%) patients younger than Pediatrics 2 years (Prof were N in Kuppermann), this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, Neurological Surgery no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) (Prof had a J negative P Muizelaar MD), predictive value of 3798/3800 (99 95%, ) (risco and sensitivity TCEci of 4,4%) 61/63 (96 8%, ). Surgery 446 (Prof (20 1%) D H Wisner of MD), 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in and Radiology validation populations. (Prof S L Wootton-Gorges MD), (risco TCEci 0,9%) Interpretation These validated prediction rules identified children at very low risk of citbis for whom University CT can of routinely California, Davis be obviated. School of Medicine, Davis, CA, USA; Department of Pediatrics, Funding The Emergency Medical Services for Children Programme of the Maternal and Child Health Columbia Bureau, University and the College of Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Physicians and Surgeons, Department of Health and Human Services. New York, NY, USA need acute intervention, and some are (P false S Dayan positives MD); Division or of Prof J F Holmes MD), Sem perda de consciência ou perda menor que 5 segundos Pediatrics (Prof N Kuppermann), Neurological Surgery (Prof J P Muizelaar MD), Surgery (Prof D H Wisner MD), Mecanismo de trauma não grave and Radiology (Prof S L Wootton-Gorges MD), University of California, Davis School of Medicine, Davis, CA, Sem fratura de crânio palpável USA; Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY, USA Comportamento normal segundo os pais (P S Dayan MD); Division of Emergency Medicine, Michigan State University School of Medicine/Helen DeVos Children s VPN Hosp, 100% Grand Rapids, (1.176/1.176) e sensibilidade 100% (25/25) para TCEci MI, USA (J D Hoyle MD); Departments of Pediatrics and Emergency Medicine, George Washington 167 University (24,1%) School das 694 TCs em menores de 2 anos eram desse grupo of Medicine, Washington, DC, USA (S M Atabaki MD); Introduction (risco TCEci 0,9%) Lancet 2009; 374: (risco TCEci 0,9%) a p Nathan Rachel Kathlee Arthur Sandra Summ Backg childr Metho Scale rules Findin than 2 in 376 young consc accord sensit low-ri no vo predic 2223 valida

11 Crianças maiores Summary2 anos Lancet 2009; 374: Published Online 6736(09) See Comment page 1127 Sem perda de consciência *Members listed at end of paper Departments of Emergency Medicine (Prof N Kuppermann MD, Sem Prof J F Holmes vômitos MD), Pediatrics (Prof N Kuppermann), Neurological Surgery (Prof J P Muizelaar MD), Surgery (Prof D H Wisner MD), Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study Nathan Kuppermann, James F Holmes, Peter S Dayan, John D Hoyle, Jr, Shireen M Atabaki, Richard Holubkov, Frances M Nadel, David Monroe, Rachel M Stanley, Dominic A Borgialli, Mohamed K Badawy, Jeff E Schunk, Kimberly S Quayle, Prashant Mahajan, Richard Lichenstein, Kathleen A Lillis, Michael G Tunik, Elizabeth S Jacobs, James M Callahan, Marc H Gorelick, Todd F Glass, Lois K Lee, Michael C Bachman, Arthur Cooper, Elizabeth C Powell, Michael J Gerardi, Kraig A Melville, J Paul Muizelaar, David H Wisner, Sally Jo Zuspan, J Michael Dean, Sandra L Wootton-Gorges, for the Pediatric Emergency Care Applied Research Network (PECARN)* September 15, 2009 DOI: /S0140- Nivel consciencia normal Background CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to Published identify Online children at very low risk of clinically-important traumatic brain injuries (citbi) for whom CT might be unnecessary. September 15, 2009 DOI: /S0140- Methods We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow 6736(09) Coma Scale scores of in 25 North American emergency departments. We derived and validated age-specific prediction rules for citbi (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission See Comment 2 nights). page 1127 Mecanismo de trauma não grave and Radiology (Prof S L Wootton-Gorges MD), University of California, Davis School of Medicine, Davis, CA, Sem sinais de fratura de base de crânio USA; Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY, USA Sem cefaléia grave (P S Dayan MD); Division of Emergency Medicine, Michigan State University School of Medicine/Helen DeVos VPN 99.95% (3.798/3.800) e sensibilidade 96,8% (61/63) para TCEci Children s Hosp, Grand Rapids, MI, USA (J D Hoyle MD); Departments of Pediatrics and Emergency Medicine, George Department of Health and Human Services. Washington 446 University (20,1%) School das TCs em maiores de 2 anos eram desse grupo of Medicine, Washington, DC, USA (S M Atabaki MD); Introduction Lancet 2009; 374: *Members listed at end of paper Findings We enrolled and analysed children (derivation and validation populations: 8502 and 2216 younger than 2 years, and and 6411 aged 2 years and older). We obtained CT scans on (35 3%); citbis occurred Departments of in 376 (0 9%), and 60 (0 1%) underwent neurosurgery. In the validation population, the prediction rule Emergency for children Medicine younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness (Prof N or Kuppermann loss of MD, consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally Prof J F Holmes MD), according to the parents) had a negative predictive value for citbi of 1176/1176 (100 0%, 95% CI ) and sensitivity of 25/25 (100%, ). 167 (24 1%) of 694 CT-imaged patients younger than Pediatrics 2 years (Prof were N in Kuppermann), this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, Neurological Surgery no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) (Prof had a J negative P Muizelaar MD), predictive value of 3798/3800 (99 95%, ) and sensitivity of 61/63 (96 8%, ). Surgery 446 (Prof (20 1%) D H Wisner of MD), 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in and Radiology validation populations. (Prof S L Wootton-Gorges MD), Interpretation These validated prediction rules identified children at very low risk of citbis for whom University CT can of routinely California, Davis be obviated. School of Medicine, Davis, CA, USA; Department of Pediatrics, Funding The Emergency Medical Services for Children Programme of the Maternal and Child Health Columbia Bureau, University and the College of Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Physicians and Surgeons, New York, NY, USA need acute intervention, and some are (P false S Dayan positives MD); Division or of a p Nathan Rachel Kathlee Arthur Sandra Summ Backg childr Metho Scale rules Findin than 2 in 376 young consc accord sensit low-ri no vo predic 2223 valida

12 Crianças maiores Summary2 anos Lancet 2009; 374: Published Online 6736(09) See Comment page 1127 Sem perda de consciência *Members listed at end of paper Departments of Emergency Medicine (Prof N Kuppermann MD, Sem Prof J F Holmes vômitos MD), Pediatrics (Prof N Kuppermann), Neurological Surgery (Prof J P Muizelaar MD), Surgery (Prof D H Wisner MD), Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study Nathan Kuppermann, James F Holmes, Peter S Dayan, John D Hoyle, Jr, Shireen M Atabaki, Richard Holubkov, Frances M Nadel, David Monroe, Rachel M Stanley, Dominic A Borgialli, Mohamed K Badawy, Jeff E Schunk, Kimberly S Quayle, Prashant Mahajan, Richard Lichenstein, Kathleen A Lillis, Michael G Tunik, Elizabeth S Jacobs, James M Callahan, Marc H Gorelick, Todd F Glass, Lois K Lee, Michael C Bachman, Arthur Cooper, Elizabeth C Powell, Michael J Gerardi, Kraig A Melville, J Paul Muizelaar, David H Wisner, Sally Jo Zuspan, J Michael Dean, Sandra L Wootton-Gorges, for the Pediatric Emergency Care Applied Research Network (PECARN)* September 15, 2009 DOI: /S0140- Nivel consciencia normal Background CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to Published identify Online children at very low risk of clinically-important traumatic brain injuries (citbi) for whom CT might be unnecessary. September 15, 2009 DOI: /S0140- Methods We enrolled patients younger (risco than 18 years TCEci presenting 4,3%) within 24 h of head trauma with Glasgow 6736(09) Coma Scale scores of in 25 North American emergency departments. We derived and validated age-specific prediction rules for citbi (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission See Comment 2 nights). page 1127 Mecanismo de trauma não grave and Radiology (Prof S L Wootton-Gorges MD), University of California, Davis School of Medicine, Davis, CA, Sem sinais de fratura de base de crânio USA; Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY, USA Sem cefaléia grave (P S Dayan MD); Division of Emergency Medicine, Michigan State University School of Medicine/Helen DeVos VPN 99.95% (3.798/3.800) e sensibilidade 96,8% (61/63) para TCEci Children s Hosp, Grand Rapids, MI, USA (J D Hoyle MD); Departments of Pediatrics and Emergency Medicine, George Department of Health and Human Services. Washington 446 University (20,1%) School das TCs em maiores de 2 anos eram desse grupo of Medicine, Washington, DC, USA (S M Atabaki MD); Introduction (risco TCEci 0,9%) Lancet 2009; 374: *Members listed at end of paper Findings We enrolled and analysed children (derivation and validation populations: 8502 and 2216 younger than 2 years, and and 6411 aged 2 years and older). We obtained CT scans on (35 3%); citbis occurred Departments of in 376 (0 9%), and (risco 60 (0 1%) TCEci underwent 0,9%) neurosurgery. In the validation population, the prediction rule Emergency for children Medicine younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness (Prof N or Kuppermann loss of MD, consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally Prof J F Holmes MD), according to the parents) had a negative predictive value for citbi of 1176/1176 (100 0%, 95% CI ) and sensitivity of 25/25 (100%, ). 167 (24 1%)(risco of 694 CT-imaged TCEci patients 0,9%) younger than Pediatrics 2 years (Prof were N in Kuppermann), this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, Neurological Surgery no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) (Prof had a J negative P Muizelaar MD), predictive value of 3798/3800 (99 95%, ) and sensitivity (risco of 61/63 TCEci (96 8%, 4,3%) ). Surgery 446 (Prof (20 1%) D H Wisner of MD), 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in and Radiology validation populations. (risco TCEci 0,9%) (Prof S L Wootton-Gorges MD), Interpretation These validated prediction rules identified children at very low risk of citbis for whom University CT can of routinely California, Davis be obviated. School of Medicine, Davis, CA, USA; Department of Pediatrics, Funding The Emergency Medical Services for Children Programme of the Maternal and Child Health Columbia Bureau, University and the College of Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Physicians and Surgeons, New York, NY, USA need acute intervention, and some are (P false S Dayan positives MD); Division or of a p Nathan Rachel Kathlee Arthur Sandra Summ Backg childr Metho Scale rules Findin than 2 in 376 young consc accord sensit low-ri no vo predic 2223 valida

13

14 Lancet 2009; 374: Pontos fortes Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study Nathan Kuppermann, James F Holmes, Peter S Dayan, John D Hoyle, Jr, Shireen M Atabaki, Richard Holubkov, Frances M Nadel, David Monroe, Rachel M Stanley, Dominic A Borgialli, Mohamed K Badawy, Jeff E Schunk, Kimberly S Quayle, Prashant Mahajan, Richard Lichenstein, Kathleen A Lillis, Michael G Tunik, Elizabeth S Jacobs, James M Callahan, Marc H Gorelick, Todd F Glass, Lois K Lee, Michael C Bachman, Arthur Cooper, Elizabeth C Powell, Michael J Gerardi, Kraig A Melville, J Paul Muizelaar, David H Wisner, Sally Jo Zuspan, J Michael Dean, Sandra L Wootton-Gorges, for the Pediatric Emergency Care Applied Research Network (PECARN)* Summary Published Online September 15, 2009 DOI: /S0140- Background CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to Published identify Online children at very low risk of clinically-important traumatic brain injuries (citbi) for whom CT might be unnecessary. September 15, 2009 DOI: /S0140- Methods We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow 6736(09) Coma Scale scores of in 25 North American emergency departments. We derived and validated age-specific prediction rules for citbi (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission See Comment 2 nights). page Foram 6736(09) excluídos os pacientes com ECG < 14 (TC alterada em 20% dos pacientes), See Comment page 1127 assintomáticos *Members listed at end of paper e com mecanismo de lesão de muito baixo risco. Departments of Emergency Medicine 2 - Estudo (Prof N Kuppermann multicêntrico, MD, com grande número de pacientes e prospectivo. Prof J F Holmes MD), Pediatrics (Prof N Kuppermann), Neurological Surgery Permitindo análise de uma população de crianças com idade inferior a 2 anos (Prof J P Muizelaar MD), Surgery (Prof D H Wisner MD), and Radiology 3 -(Prof O S L Wootton-Gorges estudo MD), estabelece um algoritmo eficaz e de fácil aplicabilidade na prática clínica. University of California, Davis School of Medicine, Davis, CA, 4 USA; - O Department desfecho of Pediatrics, final predictive é o value TCEci, of 3798/3800 o que (99 95%, impede ) a perda and de sensitivity pacientes of 61/63 em (96 8%, que ). TC de 446 crânio (20 1%) não of Columbia University College of Physicians and Surgeons, foi sensível para validation o diagnóstico populations. mas clinicamente o TCE trouxe repercussões (concussões). New York, NY, USA (P S Dayan MD); Division of Emergency Medicine, Michigan State University School of Medicine/Helen DeVos Children s Hosp, Grand Rapids, MI, USA (J D Hoyle MD); Departments of Pediatrics and Emergency Medicine, George Washington University School of Medicine, Washington, DC, USA (S M Atabaki MD); Introduction Lancet 2009; 374: *Members listed at end of paper Findings We enrolled and analysed children (derivation and validation populations: 8502 and 2216 younger than 2 years, and and 6411 aged 2 years and older). We obtained CT scans on (35 3%); citbis occurred Departments of in 376 (0 9%), and 60 (0 1%) underwent neurosurgery. In the validation population, the prediction rule Emergency for children Medicine younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness (Prof N or Kuppermann loss of MD, consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally Prof J F Holmes MD), according to the parents) had a negative predictive value for citbi of 1176/1176 (100 0%, 95% CI ) and sensitivity of 25/25 (100%, ). 167 (24 1%) of 694 CT-imaged patients younger than Pediatrics 2 years (Prof were N in Kuppermann), this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, Neurological Surgery no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) (Prof had a J negative P Muizelaar MD), Surgery (Prof D H Wisner MD), 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in and Radiology (Prof S L Wootton-Gorges MD), Interpretation These validated prediction rules identified children at very low risk of citbis for whom University CT can of routinely California, Davis be obviated. School of Medicine, Davis, CA, USA; Department of Pediatrics, Funding The Emergency Medical Services for Children Programme of the Maternal and Child Health Columbia Bureau, University and the College of Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Physicians and Surgeons, Department of Health and Human Services. New York, NY, USA need acute intervention, and some are (P false S Dayan positives MD); Division or of a p Nathan Rachel Kathlee Arthur Sandra Summ Backg childr Metho Scale rules Findin than 2 in 376 young consc accord sensit low-ri no vo predic 2223 valida

15 risco adequada, trazendo assim benefícios aos pacientes (menor incidência de radiação ionizante) e ao sistema de saúde (economia de recursos). Crianças menores 2 anos 13 9% da população 4 4% risco TCEci 32 6% da população 0 9% risco de TCEci 53 5% da população <0 02% risco de TCEci Tabela 4 - Crianças com idade inferior a 2 anos. Tabela

16 lico leve Crianças maiores 2 anos 519 ão de ientes ma de 14% da população 4 3% risco TCEci 27 7% da população 0 9% risco de TCEci 58 3% da população <0 05% risco de TCEci

17 Pediatric Emergency Care Applied Research Network (PECARN) guidelines have a near 100 per cent negative predictive value for clinically important traumatic brain (citbi) in children with mild head injury (Glasgow Coma Score [GCS] 14 or 15). Our goal was to retrospectively apply their criteria to our database to determine the po impact on the rates of unnecessary head computed tomography (CT) and citbi detection. The records of pediatric patients with GCS 14 to 15 that had a head CT for Computed Tomography of the Head in Children with Mild Home (/;jsessionid=limiassso6sg.alice) / The American Surgeon (/content/sesc/tas;jsessionid=limiassso6sg.alice), Volume 80, Number 9 Traumatic Brain Injury Computed Tomography of the Head in Children with Mild Traumatic Brain Injury The American Surgeon, Volume 80, Number 9, September 2014, pp (3) Authors: Mihindu, Esther; Bhullar, Indermeet; Tepas, Joseph; Kerwin, Andrew plus tax Entre 2008 e crianças com TCE e ECG 14 ou 15 (Refund com PolicyTC Source: The American Surgeon (/content/sesc/tas;jsessionid=limiassso6sg.alice), Volume 80, Number 9, September 2014, pp (3) 91% das TCs normais (447) Publisher: Southeastern Surgical Congress (/content/sesc;jsessionid=limiassso6sg.alice) $70.00 plus tax BUY NOW Usando PECARN (36%) não fariam TC, todas normais 315 fariam TC com 46 alteradas (15%) e 2 necessitando neurocirurgia (0,6%) < previous article (/content/sesc/tas/2014/ / /art00011;jsessionid=limiassso6sg.alice) view table of contents (/content/sesc/tas/2014/ / ;jsessionid=limiassso6sg.alice) next article > (/content/sesc/tas/2014/ / /art00013;jsessionid=limiassso6sg.alice) Buy Article: ( ADD TO CART ADD T Abstract:

18 Arch Dis Child May;99(5): doi: /archdischild Epub 2014 Jan 15. Pediatric Emergency Care Applied Research Network head injury clinical prediction rules are reliable in practice. Schonfeld D 1, Bressan S, Da Dalt L, Henien MN, Winnett JA, Nigrovic LE. EUA e Itália crianças com TCE e ECG 14 ou crianças menores 2 anos (39%) 373 fizeram TC (15%) 69 com lesão intracraniana (3%) 19 pacientes com TCEci (0,8%) PECARN - nenhuma criança com TCEci foi classificada como baixo risco

19 FOCUS ON TRAUMATIC BRAIN INJURY NATURE REVIEWS NEUROLOGY VOLUME 9 APRIL VOLUME 9 APRIL 2013 lishers Limited. All rights reserved 2013 Macmillan Publishers Limited. All rights reserved n these indivis well as TAR ion, have been pproximately contact sports tic Aβ plaques een found in single episode P-43 deposisting that this guish patients m those with contact with its composioccur in this be considered Biomarkers of mild traumatic brain injury in cerebrospinal fluid and blood FOCUS ON TRAUMATIC BRAIN INJURY Biomarkers of mild traumatic brain injury in cerebrospinal fluid and blood Henrik Zetterberg, Douglas H. Smith and Kaj Blennow Abstract Mild traumatic brain injury (TBI), which is defined as a head trauma resulting in a brief loss of consciousness and/or alteration of mental state, is usually benign, but occasionally causes persistent and sometimes Henrik progressive Zetterberg, symptoms. Douglas Whether H. Smith a and threshold Kaj Blennow for the amount of brain injury and/or individual vulnerability might contribute to the development of these long-term consequences is unknown. Furthermore, Abstract Mild traumatic brain injury (TBI), which is defined as a head trauma resulting in a brief loss of reliable diagnostic consciousness methods and/or that alteration can establish of mental whether state, is a blow usually to benign, the head but has occasionally affected causes the brain persistent (and in and what way) sometimes are lacking. progressive In this Review, symptoms. we discuss Whether potential a threshold biomarkers for the amount of injury of brain to different injury and/or structures individual and cell types vulnerability in the CNS might that can contribute be detected to the development in body fluids. of We these present long-term arguments consequences in support is unknown. of the Axon need Furthermore, for further development reliable diagnostic and validation methods that of such can biomarkers, establish whether and for a blow their to use the head in assessing has affected patients the terminals brain with (and head in trauma in what whom way) the are brain lacking. might In have this NSE, Review, been SBPs affected. we discuss Specifically, potential biomarkers we focus of on Tau injury the need to different for such structures biomarkers and in the management cell types in of the sports-related CNS that and can be concussion, UCH-L1 detected in the body most fluids. common NFL We present cause protein arguments of mild TBI in support in young of individuals, the need for to prevent long-term further development neurological and sequelae validation due of such to concussive biomarkers, or and subconcussive for their use in blows assessing to the patients head. with head Dendrites trauma in whom the brain might have been affected. AxonSpecifically, we focus on the need for such biomarkers Zetterberg, H. et al. Nat. Rev. Neurol. 9, (2013); published online 12 February 2013; doi: /nrneurol in the management of sports-related concussion, the most common cause of mild TBI in young individuals, to prevent long-term neurological sequelae due to concussive or subconcussive blows to the head. Introduction A blow to Zetterberg, the head H. can et al. result Nat. Rev. in Neurol. anything 9, from (2013); a superficial skin laceration published online The 12 detection February 2013; of brain doi: /nrneurol injury in individuals who have Soma Myelin sheath MBP to severe brain injury. The extremes experienced a concussive or subconcussive blow to the of this range Introduction are easy to recognize by clinical examination and neuroimaging, but whether the brain has been S100-B hockey, rugby and American football. Head injuries are head is of particular relevance in sports such as boxing, A blow to the head can result in anything from a superficial skin laceration to severe brain injury. The extremes experienced a concussive or subconcussive blow to the The detection of brain injury in individuals who have injured by a blow to the head (in the presence of non-gfapcommospecific symptoms such as dizziness, nausea or headache) Interleukins careers have ended because of chronic neurological in players of these sports, and several athletes of this range are easy to recognize by clinical examination and neuroimaging, but whether the brain has been hockey, rugby and American football. Head plaques injuries are head is of particular relevance in sports Amyloid such as boxing, is more difficult to assess. The definition of mild traumatic and or cytokines injured by a blow to psychiatric symptoms. 6 An objective test to determine whether an athlete can safely return to their sport brain injury (TBI) has changed Astroglial the head (in the presence of nonspecific symptoms such over the past 60 years, 1 common in players of these sports, and several athletes cell as dizziness, nausea or headache) careers have ended APP because and amyloid-β of chronic neurological but the American is more difficult Congress to assess. of Rehabilitation The definition of Medicine mild traumatic would, or therefore, psychiatric be symptoms. highly desirable, 6 An objective and would test to reduce determine whether over-reliance athlete on can CT safely scans return (and to the their associ- sport currently brain defines injury mild (TBI) has head changed trauma over resulting the past 60 in years, the 1 current one of the but following: Capillary the American loss of Congress consciousness of Rehabilitation for less than Medicine ated would, exposure therefore, to ionizing be highly radiation) desirable, for and this would purpose reduce 30 min, alteration currently of defines mental mild state TBI for as head up to trauma 24 Cerebrospinal h (being resulting Another fluid:serum current group albumin of over-reliance individuals ratio on at CT risk scans of brain (and the injury associated personnel, exposure to who ionizing might radiation) be exposed for this to several purpose is dazed, confused one of the or disorientated), following: loss of or consciousness loss of memory for for less than military events immediately 30 min, alteration before or of after mental the state trauma. for up 2 to 24 h (being types Another of brain group trauma of individuals the battlefield. risk 7 of In brain addition injury to is The terms dazed, mild confused TBI and or concussion disorientated), have or loss historically of memory for bio markers military for personnel, use in the who acute might and be subacute exposed phases to several of Figure been used 1 events interchangeably Possible immediately biomarkers to before suggest or after an the of inconsequen- trauma. traumatic 2 brain mild types injury. TBI, of develop brain These trauma ment molecules of in biomarkers the battlefield. include that 7 In will addition enable to Clinical Neurochemistry Laboratory, Institute of Neuroscience and Clinical Neurochemistry Physiology, Department