Evidence-Based Assessment
And Management Of Pediatric
Mild Traumatic Brain Injury
Abstract
This article will focus on the evaluation and management of pediatric patients in the ED with possible traumatic brain injury. Closed
head injury (CHI) is a common pediatric complaint. The authors
point out the confusion that stems from the perceived definitions of
“concussion” and “mild traumatic brain injury (mTBI)” by families, coaches, and doctors. For purposes of this article they refer to
“mTBI” as the injury pathology and to “concussion” as symptomatology. The authors examine existing literature as well as practice
guidelines to provide the latest in evidence-based treatment for
mTBI.
Case Presentation
It is a busy Saturday afternoon in the ED. You are evaluating a 2-year-old
girl who fell off a swing hitting the back of her head on the dirt approximately 3 feet below. She lost consciousness for 20 seconds, cried, and was
consoled by her parents. She did not vomit, and her parents say that she
seems to be back to her usual self. You approach the tearful toddler who has
a 3 cm occipital cephalohematoma without step-off, laceration, or abrasion. Her vital signs are as follows: heart rate 102 beats per minute, blood
pressure 95/57, respirations 18 with normal pulse oximetry. Her Glasgow
Coma Score (GCS) is 15. She has no neurologic deficits on examination and
AAP Sponsor
Martin I. Herman, MD, FAAP, FACEP
Professor of Pediatrics, Attending
Physician, Emergency Medicine
Department, Sacred Heart
Children’s Hospital, Pensacola, FL
Volume 8, Number 11
Authors
Angela K. Lumba, MD
Pediatric Emergency Medicine, Rady Children’s Hospital,
University of California San Diego, San Diego, CA
David Schnadower MD, MPH
Assistant Professor of Pediatrics, Fellowship Director, Division
of Pediatric Emergency Medicine, Washington University at St.
Louis School of Medicine, St. Louis, MO
Madeline Matar Joseph, MD
Associate Professor of Emergency Medicine and Pediatrics,
Assistant Chair for Pediatrics, Emergency Medicine
Department, Division Chief and Medical Director, Pediatric
Emergency Medicine, University of Florida Health Science
Center, Jacksonville, FL
Peer Reviewers
Tyler Ayalin, MD
Pediatric Emergency Medicine Fellow, Department of
Emergency Medicine, Loma Linda University Medical Center
and Children’s Hospital, Loma Linda, CA
Ghazala Q. Sharieff, MD, FAAP, FACEP, FAAEM
Associate Clinical Professor, Children’s Hospital and Health
Center/University of California, San Diego; Director of Pediatric
Emergency Medicine, California Emergency Physicians, San
Diego, CA
CME Objectives
Upon completion of this article, you should be able to:
1.
Cite the definitions of mTBI and concussion
2.
Identify pediatric patients who are at low risk for
moderate-severe TBI
3.
Identify patients in which CT scanning of the head is
recommended
4.
Recognize the potential complications of mTBI such as
post concussive syndrome and persisting neurologic
deficits as well as second impact syndrome.
Date of original release: November 1, 2011
Date of most recent review: October 10, 2011
Termination date: November 1, 2014
and Dentistry of New Jersey;
Medicine Division, Medical Director Assistant Professor of Emergency
Director, Pediatric Emergency
- Pediatric Emergency Department,
Medicine and Pediatrics, Loma
Medicine, Children’s Medical Center, University of Florida Health Science
Linda Medical Center and
Atlantic Health System; Department
Center Jacksonville, Jacksonville, FL Children’s Hospital, Loma of Emergency Medicine, Morristown Alson S. Inaba, MD, FAAP, Linda, CA
Memorial Hospital, Morristown, NJ
PALS-NF
Brent R. King, MD, FACEP, FAAP,
Ran D. Goldman, MD
Pediatric Emergency Medicine
Associate Professor, Department
Attending Physician, Kapiolani
of Pediatrics, University of Toronto;
Medical Center for Women &
Jeffrey R. Avner, MD, FAAP
Division of Pediatric Emergency
Children; Associate Professor of
Professor of Clinical Pediatrics
Medicine
and
Clinical
Pharmacology
Pediatrics, University of Hawaii
and Chief of Pediatric Emergency
and
Toxicology,
The
Hospital
for
Sick
John A. Burns School of Medicine,
Medicine, Albert Einstein College
Children, Toronto, ON
Honolulu, HI; Pediatric Advanced
of Medicine, Children’s Hospital at
Life Support National Faculty
Montefiore, Bronx, NY
Mark A. Hostetler, MD, MPH Clinical
Representative, American Heart
Professor of Pediatrics and
T. Kent Denmark, MD, FAAP, FACEP
Association, Hawaii and Pacific
Emergency Medicine, University of
Medical Director, Medical Simulation
Island Region
Arizona Children’s Hospital Division
Center; Associate Professor of
of Emergency Medicine, Phoenix, Andy Jagoda, MD, FACEP
Emergency Medicine and Pediatrics,
AZ
Professor and Chair, Department
Loma Linda University Medical
of Emergency Medicine, Mount
Center and Children’s Hospital,
Madeline Matar Joseph, MD, FAAP,
Sinai School of Medicine; Medical
Loma Linda, CA
FACEP Associate Professor of
Emergency Medicine and Pediatrics, Director, Mount Sinai Hospital, New
Michael J. Gerardi, MD, FAAP,
York, NY
Assistant Chair for Pediatrics FACEP
Emergency Medicine Department,
Clinical Assistant Professor of
Chief - Pediatric Emergency
Medicine, University of Medicine
Tommy Y. Kim, MD, FAAP, FACEP
Editorial Board
November 2011
Professor and Head, Department
of Emergency Medicine, University
of Illinois, Chicago, IL
Christopher Strother, MD
Assistant Professor,Director,
Undergraduate and Emergency
Simulation, Mount Sinai School of
Medicine, New York, NY
FAAEM
Professor of Emergency Medicine
and Pediatrics; Chairman,
Adam Vella, MD, FAAP
Department of Emergency Medicine, Assistant Professor of Emergency
The University of Texas Houston
Medicine, Director Of Pediatric
Medical School, Houston, TX
Emergency Medicine, Mount Sinai
Robert Luten, MD
School of Medicine, New York, NY
Professor, Pediatrics and
Michael Witt, MD, MPH, FACEP,
Emergency Medicine, University of
FAAP
Florida, Jacksonville, FL
Medical Director, Pediatric
Ghazala Q. Sharieff, MD, FAAP,
Emergency Medicine, Elliot Hospital
FACEP, FAAEM
Manchester, NH
Associate Clinical Professor, Children’s
Research
Editor
Hospital and Health Center/University
of California, San Diego; Director
Lana Friedman, MD
of Pediatric Emergency Medicine,
Fellow, Pediatric Emergency
California Emergency Physicians, San
Medicine, Mount Sinai School of
Diego, CA
Medicine, New York, NY
Gary R. Strange, MD, MA, FACEP
Accreditation: EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr. Lumba, Dr. Schandower, Dr. Joseph, Dr. Ayalin, Dr.
Sharieff, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.
Commercial Support: This issue of Pediatric Emergency Medicine Practice did not receive any commercial support.
Many clinicians feel uncomfortable with the
diagnosis of mTBI and use the term “concussion”
interchangeably. Although the definitions of these 2
terms do overlap, their connotations have different
meanings to discharged families, sports coaches, and
healthcare providers. A recent study highlighted a
general misinterpretation that an injury described
as a concussion is less severe than one described as
mTBI, which may result in a premature return to
activity in a young athlete.3 In the age of highly competitive youth sports, what discharge recommendations and precautions can we give to families eager
to return to play? Often the ED clinician refers to
medical clearance by follow up with primary medical doctors (PMD), sports physicians, or neurologists
in the concussed athlete. It is unrealistic to assume
that such precautions will be heeded without education of the risks of post-concussive syndrome and
second impact syndrome in the ED. Additionally,
medical follow up after concussion in the pediatric
non-athlete is of equal importance.
This issue of Pediatric Emergency Medicine Practice will discuss the evaluation and management of
pediatric patients with mTBI using the best available
evidence from the literature. In addition to discussing a variety of recent studies, we will also review
management practice guidelines from the American
Academy of Pediatrics, the American College of
Emergency Physicians, and the Children’s Hospital
of Philadelphia. (See Table 1.)
cries inconsolably when you approach her. She does not
appear to have any other injuries.
Upon discussion with her parents, you find that she
has no past medical history, her vaccinations are up to
date, and she is not taking any medication. What are your
next steps in evaluating this patient, and do they include
observation or imaging? What does the “crying” mean?
Does the patient have a headache or is she just terrified
of being in the hospital? Does the time from injury affect your decision to observe her in the ED? In this now
tearful but otherwise well-appearing child, is exposure to
ionizing radiation and potential sedation “worth it”?
Introduction
The rate of pediatric closed head injury (CHI) is approximately 180 per 100,000 in the US. The Centers
for Disease Control (CDC) has called traumatic brain
injury (TBI) a public health problem in children.1
Traumatic brain injury accounts annually for 3000
deaths, 29,000 hospitalizations, and 473,947 emergency department (ED) visits in the US in children
14 years and younger.1 Although TBI is the leading
cause of death in this population, 75% of pediatric
CHIs may be classified as concussions due to mild
traumatic brain injuries (mTBI).2 The diagnosis of
mTBI and management of these patients is often
challenging. The decision to discharge home, to
observe in the ED, or to obtain immediate imaging
in the well-appearing child is multifactorial. Ionizing
radiation and its risk for potential malignancy in
young patients as well as the risks of sedation that
might be needed to obtain imaging are concerns that
ED clinicians consider.
Critical Appraisal Of The Literature
This literature review was launched with Ovid
MEDLINE® and PubMed searches for articles on
mild traumatic brain injury from 1950-2011. Keywords included: mild traumatic brain injury, traumatic
brain injury, concussion, post concussive syndrome,
second impact syndrome, and closed head injury. These
articles were limited to all infants and all children
0 to 18 years old. This search yielded 4392 articles.
Eighty of these articles are included as the basis for
the discussion in this publication with the oldest
published in 1992. They comprise a growing body of
literature of clinical trials, multicenter observational
studies, and meta-analyses that have resulted in
multiple practice guidelines for pediatric mTBI and
concussion. In 2010 the American Academy of Pediatrics published an in-depth report on sports-related
concussion in children.7
Table Of Contents
Abstract........................................................................ 1
Case Presentation.......................................................1
Introduction................................................................2
Critical Appraisal Of The Literature....................... 2
Definition, Epidemiology, Pathophysiology.......... 2
Differential Diagnosis................................................ 4
Prehospital Care......................................................... 4
Emergency Department Evaluation........................ 5
Diagnostic Studies...................................................... 8
Risk Management Pitfalls In The Treatment Of
mTBI....................................................................... 12
Treatment................................................................... 13
Special Circumstances.............................................. 13
Cutting Edge.............................................................13
Disposition................................................................14
Cost-Effective Strategy.............................................14
Summary................................................................... 15
Case Conclusion....................................................... 16
References.................................................................. 16
CME Questions......................................................... 18
Pediatric Emergency Medicine Practice © 2011
Definition, Epidemiology, Pathophysiology
The Mild Traumatic Brain Injury Committee of the
American Congress of Rehabilitation Medicine has
defined mTBI as a “traumatically induced physiological disruption of brain function, as manifested
by a least 1 of the following:
2
www.ebmedicine.net • November 2011
1. Any period of loss of consciousness;
2. Any loss of memory for events immediately
before or after the accident;
3. Any alteration in mental state at the time of the
accident (eg feeling dazed, disoriented or confused); and
4. Focal neurological deficit(s) that may or may not
be transient, but where the severity of the injury
does not exceed the following:
• Post-traumatic amnesia not greater than 24
hours;
• After 30 minutes, an initial GCS of 13 to 15;
and
• Loss of consciousness of approximately 30
minutes or less.”8
American Academy of Neurology Concussion states
that concussion is a “trauma-induced alteration in
mental status that may or may not involve a loss of
consciousness” and is attributable to mild-to-severe
symptoms associated with TBI.9 There is overlap in
these definitions and recent literature uses mTBI and
concussion interchangeably.
Are we contributing to potential under-management by assigning a diagnosis of concussion
due to symptomatology without specific diagnosis of TBI severity? In a recent study, parents who
did not equate mTBI and concussion regarded the
latter as considerably “better” than mTBI.10 In a
prospective cohort of 432 pediatric patients with
TBI, Dematteo found that out of the 32% diagnosed
with concussion, only 37% had a GCS of 13 to 15.3
Pediatric patients with moderate-to-severe TBI are
also diagnosed with concussion. Clinicians caring
for pediatric patients and their families must come
to a consensus on terminology related to pediatric
The Children’s Hospital of Philadelphia Practice Guidelines further define pediatric mTBI in
children with a GCS of 14 to 15 at the initial examination without focal neurologic deficits.7 The
Table 1. Practice Parameters For mTBI
Organization
Topic
Type Of Guideline
Recommendations
American Academy of
Pediatrics4
Sports related concussion in children
Consensus, evidence-based
clinical report
1.
2.
3.
4.
5.
American Academy of
Pediatrics (1999)4
Management of Mild
Closed Head Injury
in Children
Consensus, evidence-based
practice parameter for children 2-20 years of age
1.
2.
3.
4.
American College of
Emergency Physicians5
Neuroimaging and
Decision making in
Adult Mild Traumatic
Brain Injury in the
Acute Setting
Consensus, evidence-based
clinical policy for adults 16
years of age and older
1.
2.
3.
4.
Children’s Hospital of
Philadelphia6
Mild traumatic brain
Injury in Children
Consensus, evidence-based
guideline
1.
2.
3.
4.
5.
Removal from athletic activity after concussion and monitoring
for persisting symptoms
ED referral for symptomatic patients
Neuroimaging if there is a suspicion for intracranial injury ICI
Cognitive and physical rest period after injury
Concussion rehabilitation and graded return to play
Observe minor CHI without LOC or physical findings
Preferential selection of CT scanning in children with minor
CHI and LOC
At least 24 hour duration of observation (not limited to the
hospital) in children with head injury
If there is worsening neurologic condition during observation,
stabilize and obtain immediate CT
CT is indicated in CHI with LOC or post-traumatic amnesia
only if 1 or more other symptoms or signs present
There is no specified role of head MRI over CT
There is no specified role for brain-specific serum biomarkers
in CHI
Patients with isolated mTBI and normal neurologic evaluation,
and with negative CT can be safely discharged
Head CT is recommended for children > 2 years presenting
with abnormal mental status, abnormal neurologic examination, or evidence of skull fracture
CT should be considered if there is a history of LOC, amnesia,
or previous history of TBI, or if the child is < 2 years with intermediate risk factors
Children < 2 years with CHI should be observed at least 4 to 6
hours post injury in the ED
Children with mTBI with normal neurologic examination, without significant extra-cranial injury, and reliable home environment may be discharged home
Anticipatory post-concussion guidelines should be given to
families upon discharge
Abbreviation: ICI, intracranial injury; CHI, closed head injury; LOC, loss of consciousness; CT, computed tomography; MRI, magnetic resonance imaging;
mTBI, mild traumatic brain injury; ED, emergency department.
November 2011 • www.ebmedicine.net
3
Pediatric Emergency Medicine Practice © 2011
CHI. In light of this argument, the remainder of our
discussion will refer to mTBI as the injury pathology
with concussion referring to symptomatology.
Closed head injury resulting in concussion is a
very common pediatric complaint accounting for
half a million ED visits annually.1 Children 0 to 4
years and older adolescents 15 to 19 years are most
likely to sustain a TBI.1 There is a 2:1 male-to-female
preponderance of mTBI across all ages.11 Boys aged
0 to 4 years have the highest rates of TBI-related ED
visits, hospitalizations, and deaths.1
The CDC reports that falls are the leading cause
(50%) of TBI among children aged 0 to 14 years.
Collisions with moving or stationary objects (including motor vehicle collisions) are the second leading cause of TBI in children (25%).1 Nonaccidental
trauma is responsible for 2.9% of reported TBIs and
is an important differential diagnosis in all children
with head injury, especially in those 2 years and
younger.
Thirty million American children participate in
athletic programs each year, and sports-related TBI
occurs frequently.12 Each year, EDs in the US treat an
estimated 135,000 sports- and recreation-related TBIs
among children ages 5 to 18.13
In 1999, Powell et al evaluated data from the
National Athletic Trainer Association (NATA) injury
surveillance program of high school sports and
identified 1217 mild traumatic brain injuries out
of over 23,000 reported sports injuries and further
quantified them. Out of the 10 popular high school
sports evaluated, football accounted for two-thirds
of reported mTBI followed by 10% attributable to
wrestling.14 (See Table 2.)
It has been shown that under-reporting of youth
concussions in organized play occurs often and
epidemiologic data of such injuries is difficult to
accurately describe.15 The NATA injury surveillance
program describes a reportable mTBI as an injury
identified by a certified athletic trainer requiring the
cessation of a player’s participation for evaluation
and observation before returning to play.14 However,
in competitive youth sports, coaches and players
may be hesitant to report injuries for fear of absence
from play. In a case series of 592 children by Browne
et al, severe concussive head injuries are 6 times
more likely to have resulted from organized sports
than simple play.16 Additionally, the incidence of serious head injury is higher in young athletes than in
adults.17 High school athletes sustaining concussion
as compared to college athletes had longer memory
dysfunction and scored lower on neuropsychological evaluations.18 Second impact syndrome is a serious concern in this active population. The neurobiochemical mechanisms of mTBI
manifestations are related to biochemical derangements marked by reactive oxygen species (ROS)
mediated damage, energy metabolism depression,
Pediatric Emergency Medicine Practice © 2011
and alteration of gene expression potentially leading to a variation of N-Acetyl aspartate (NAA)
concentration.19 N-Acetyl aspartate is found in high
concentrations in the brain, is visible by proton magnetic resonance (MR) spectroscopy, and is decreased
in situations of TBI. Studies evaluating the usage of
proton MR spectroscopy to mark concussion resolution are underway. Persisting learning impairments
following mTBI are attributed to enhancements of
gamma-amnobutyric acid (GABA)-mediated inhibition that suppresses a type of synaptic plasticity.20
Animal models have been employed to gather such
data to relate to pediatric mTBI.
Differential Diagnosis
The differential diagnosis of mTBI is clinically
focused on more ominous sequelae of CHI such as
moderate or severe TBI. Since mTBI often presents
with symptoms of concussion such as loss of consciousness (LOC), amnesia, confusion, headache,
nausea, and vomiting, these symptoms should be
evaluated for other potential etiologies. See Table 3
for differential diagnoses for mTBI and strategies
to rule these out.
Prehospital Care
The prehospital care of pediatric CHI does not
necessarily start with emergency medical services
(EMS). Many school nurses, gym teachers, and
athletic trainers are educated to identify concussive
symptoms. A position statement by NATA recommended that institutions that sponsor athletic activities establish emergency response plans including
written emergency plans and the education/training
of school personnel that coordinate care with local
EMS.21 The American Academy of Pediatrics (AAP)
Committee on School Health guidelines state a need
for school leaders to establish emergency response
plans as well as maintain school personnel including
Table 2. Incidence Of Reported mTBI In High
School Sports14
4
Sport
% Total Reported mTBIs
Football
63.4%
Wrestling
10.5%
Girls’ soccer
6.2%
Boys’ soccer
5.7%
Girls’ basketball
5.2%
Boys’ basketball
4.2%
Softball
2.1%
Baseball
1.2%
Field Hockey
1.1%
Volleyball
0.5%
www.ebmedicine.net • November 2011
Emergency Department Evaluation
nurses and athletic trainers educated in emergency
response training and emergency care.22,23
Prehospital care is focused on stabilization and
identification of potentially serious injury. Pediatric
patients who have sustained an mTBI are generally
awake and maintaining their airway upon EMS arrival. Standard initial assessment of airway, breathing, circulation, and disability (ABCD) should be
evaluated for regardless of seemingly well appearance.
Children with CHI and symptoms of concussion
are at risk of having life-threatening injuries such
as intracranial hemorrhage (ICH), cervical spine
fractures, or facial fractures contributing to airway
obstruction. The appropriate evaluation with immobilization during transport is necessary if cervical spine or other relevant injuries are suspected.
This may be more challenging in younger patients
as demonstrated in a study by Collopy evaluating
EMS interventions in children with head, neck, and
face injuries. The authors found that C-collar placement was less commonly implemented for children
younger than 5.24 The National Emergency Medical
Services Education Standards provides paramedics
with guidelines and protocols including the evaluation of pediatric CHI and related considerations.25
History
Kelly et al described 3 issues to be addressed in the
management of the concussed patient, (1) the appropriate management of the injured athlete at the
time of injury to identify potential neurosurgical
emergencies (epidural, subdural, and intracerebral
hemorrhages); (2) the prevention of catastrophic
outcome related to acute brain swelling; and (3)
the avoidance of cumulative brain injury related to
repeated concussions.26 In evaluating a patient with
concussive symptoms, a clinician will address and
exclude these issues in order to diagnose mTBI.
The ED evaluation of the pediatric patient with
CHI and suspected mTBI relies on historical description as well as physical findings to lend to our
clinical assessment. Much of our evidence based
data comes from studies by the Pediatric Emergency
Care Applied Research Network (PECARN) as well
as a large meta-analysis by Dunning in 2004 describing the findings of 16 papers to assess factors in the
presentation of ICH in children with CHI.27 Dunning
went on to publish the children’s head injury algorithm for the prediction of important clinical events
(CHALICE).28 This study examined 14 clinical variables, which are listed in Table 4. Importantly, the
CHALICE study did not exclude patients with moderate or severe head injury and hence the algorithm
is most valuable for its negative predictive value.
In another notable study, the Canadian CATCH
derived decision rules evaluate the use of head CT
in minor CHI though has yet to be validated.29
PECARN derived and validated clinical prediction rules for children at very low risk of clinically
important TBI defined as “death from TBI, neurosurgery, intubation for more than 24 hours due
to TBI, or hospital admission of 2 nights or more
associated with TBI on CT.”30 The study evaluated
over 40,000 children presenting to the ED within 24
hours of CHI and with a GCS of 14 to 15. It assessed
the following potential predictors: severity of injury
mechanism, history of LOC, duration of LOC, headache, severity of headache, vomiting and number
of times, acting abnormally according to parent,
altered mental status, signs of basilar skull fracture,
palpable skull fracture, and scalp hematoma and its
location. Ultimately the 6 predictors that were validated in the pediatric population less than 2 years of
age included: altered mental status, scalp hematoma,
LOC, severe mechanism of injury, palpable skull
fracture, and acting normally per parents. If none
of these predictors were present, the patient had a
0.02% or less risk of clinically important TBI with
100% specificity and sensitivity. In children 2 years
of age and older, the validated predictors for clinically important TBI included: altered mental status,
LOC, history of vomiting, severe mechanism of in-
Table 3. The Emergency Physician’s
Differential Of mTBI
Differentials of mTBI
Strategies to Rule them Out
Intracranial hemorrhage
Head CT
Cerebral edema
Brain MRI, head CT
Skull fracture
Head CT, skull x-rays
Non-accidental trauma
Head CT, skeletal survey, Child Protective Services investigation, social work
evaluation
Stroke
Physical examination, head CT, carotid
angiography
Cephalohematoma
Physical examination
Drug ingestion
Urine drug screen, serum drug screen,
history
Seizure
History, electrolytes, EEG, brain MRI
Meningitis/encephalitis
History and physical examination, lumbar
puncture and CSF evaluation
DKA
History and physical examination, basic
metabolic panel, venous blood gas
Heat Illness
History, basic metabolic panel, response
to fluid resuscitation
Migraine headache
History and physical examination,
response to supportive care
Abbreviations: CT, computed tomography; MRI, magnetic resonance
imaging; EEG, electroencephalogram
November 2011 • www.ebmedicine.net
5
Pediatric Emergency Medicine Practice © 2011
jury, signs of basilar skull fracture, and severe headache. With a negative predictive value of 99.95% and
sensitivity of 96.8%, if none of these predictors were
present, the patient had a 0.05% or less risk of clinically important TBI.
The Lancet published the PECARN Suggested
CT Algorithm for children younger than 2 years and
for those aged 2 years and older with a GCS of 14 to
15 after head trauma.30 See Figure 1, a reproduction
of Kupperman’s algorithm. Computed tomography
is recommendedor children less than 2 years of age
with a GCS of 14 or other signs of altered mental
status or palpable skull fracture. These children with
occipital, parietal, or temporal scalp hematomas; a
history of LOC 5 seconds or longer; a severe mechanism of injury; or not acting normally per parents
should be observed with the decision to obtain CT
being multifactorial. For example, clinician experience, multiple symptoms, worsening ED course,
very young infants, and parental preference are all
aspects of management that must be considered in
the decision for imaging. The algorithm for children
2 years and older is similar in that children with a
GCS of 14 or other signs of altered mental status or
signs of basilar skull fracture are recommended to
have CT imaging. If these findings are absent but
the child has a history of LOC, history of vomiting,
severe injury mechanism, or severe headache then
the decision to observe versus obtain CT imaging
becomes multifactorial and dependent on clinician
experience, worsening or multiple symptoms, and
parental preference. Finally, CT is generally not
recommended if the child (of any age) does not have
any of the above findings.30
Important historical questions that we will
further individually discuss include the timing of injury, precise mechanism of injury, occurrence of LOC
or post-traumatic seizure, occurrence of vomiting,
significant past medical history, and medications.
Timing Of Injury
Timing of CHI is important to ascertain. A delay in
seeking medical care for a head injury in a pediatric
patient should alert the clinician to the possibility of
non-accidental trauma (NAT) or medical neglect.31
Neurologic deterioration after minor head injury is
very rare. A retrospective cohort of almost 18,000
children presenting with minor head injury to the
ED showed that only 2 of these patients had delayed
deterioration after 6 hours.32 The1999 AAP’s practice
parameters for mTBI recommended 24 hours of observation in hospital, ED, doctor’s office, responsible
home environment, or any combination of the above
for patients with suspected mTBI.2 ED clinicians’
threshold for observation times post head injury
vary from practice to practice with some departments having observation units for monitoring after
closed head injury.33 A recent study by Nigrovic et al
reported that clinical observation in the ED was associated with reduced head CT use in children with
minor head injury though exact observation times
were not quantified.34
Mechanism Of Injury
Mild traumatic brain injuries can occur from simple
bumps to the head to major motor vehicle collisions.
Most institutions have trauma criteria depending on
the severity of the mechanism of injury that would
direct an unrestrained rollover passenger to the
trauma bay. However, mechanism of injury alone
does not absolutely necessitate head CT.
In the PECARN study, the definition of severe
CHI mechanisms are the following: motor vehicle
crash with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without
helmet struck by a motorized vehicle; falls of more
than 3 feet in children less than 2 years old or more
than 5 feet in children 2 years and older, or head
struck by a high-impact object.30 The CHALICE
rules recommend imaging in children with severe
injury mechanism such as high speed accidents or
projectiles and falls >3 meters.28 The clinician will
ultimately determine if the mechanism described is
severe or not. Gruskin evaluated children younger
than 2 years of age with found that increasing height
of fall had a higher incidence of ICH or skull fracture
but also noted that 7% of the children who fell less
than 3 feet also had these injuries.35 Severe mechanism of injury places the child at higher risk for all
types of TBI. Similarly, mild mechanism of injury
does not rule out the possibility of ICH.
Table 4. CHALICE Clinical Variables28
LOC > 5 minutes
Amnesia > 5 minutes
Drowsiness
Vomiting > 2 times
Suspicion of NAT
Seizure
GCS < 14, or < 15 if under 1 year old
Suspicion of penetrating or depressed skull injury or tense fontanelle
Signs of basilar skull fracture
Neurologic deficit
Cephalohematoma or laceration > 5 cm in children < 1 year old
High speed accident
Fall > 3 meters
High speed injury from projectile
Loss Of Consciousness
Most clinicians are concerned by a history of LOC
and its duration. It has been reported that traumatic
brain injury occurs more commonly in children with
a history of LOC than those without.25,36 The CHALICE rules recommend CT imaging in children with
Abbreviations: LOC, loss of consciousness; NAT, non-accidental
trauma; GCS, Glasgow Coma Score.
Pediatric Emergency Medicine Practice © 2011
6
www.ebmedicine.net • November 2011
LOC greater than 5 minutes.28
Often, a history of LOC post head injury occurs
in isolation of other signs and symptoms. In the
single center study by Palchak, 142 children presented with isolated LOC or amnesia, and none of them
had clinically important TBI. Of note, 9.4% of those
with LOC or amnesia in addition to other symptoms
(ie, not isolated LOC or amnesia) after CHI did have
findings on CT.37 In PECARN’s abstract of secondary analysis of isolated LOC following blunt head
injury, it was reported that the risk of TBI is very
small; 4 of 790 children with isolated LOC had positive CT findings with only 1 requiring intervention.)
The authors concluded that LOC should not drive
the decision to obtain imaging when it occurs in
isolation.36
Past Medical History
It is important to elicit a thorough past medical history in patients presenting to the ED with a history
of minor head trauma. Seizure disorders, history of
syncope, or stroke could be the underlying cause of
trauma due to fall. A history of previous head injury
or symptoms of concussion should heighten the ED
clinician’s concern for TBI sequelae such as second
impact syndrome.
Patients with congenital or acquired bleeding
disorders are at increased risk of ICH after minor
head injuries. However it is important to note that
most of these patients will be symptomatic if ICH
is present.41 A secondary analysis of the PECARN
study by Lee compared head CT results after CHI
in 230 children with bleeding disorders and almost
15,000 children without. They found that head CTs
were obtained in this population twice as often
though there was not a higher incidence of positive
findings. This study confirms that children with
bleeding disorders sustaining head injury with ICH
are generally symptomatic.42
Vomiting
The large meta-analysis by Dunning found that
vomiting was not a predictor of ICH.27 In fact, this
analysis showed that even repeated vomiting over a
limited period of time may not be more significant
than a single emesis. The limitations of this analysis included the lack of documentation of duration
for observation of vomiting. Dunning et al later
published the prospective CHALICE rules that
recommend CT in children with CHI and history of
vomiting 3 or more times.28 In an abstract presented
by PECARN, preliminary data suggested that 1.7%
of children with isolated vomiting had TBI on CT,
while 0.2% required intervention.38 In this study, the
risk of TBI did not seem to increase with increased
number of vomiting episodes. In a large study of
adults and children by Nee et al in 1999 there was
an increased relative risk of skull fracture in patients with head injury and vomiting.39 However
this study also demonstrated that a single episode
of vomiting was as significant as multiple episodes.
These studies challenge our concern for the number
of episodes of emesis.
Medications
A history of medication use and abuse contributes
to potential secondary causes for head injury and
symptoms of concussion such as with fall after acute
alcohol intoxication. Additionally, anticoagulant use
(warfarin for example) furthers the likelihood of
ICH in mTBI.43 A very recent study from the Journal
of Trauma highlights a relationship between high
INR and likelihood of ICH with a suggested cutoff
value of 2.43, holding a negative predictive value of
97%.44
Physical Examination
Important physical findings in the patient with suspected mTBI include: vital signs assessment, pediatric GCS and neurologic examination, presence of
cephalohematoma or skull abnormality, and evaluation of other injuries that may prove to be distractors
from TBI or may suggest NAT.
History Of Seizure
Post-traumatic seizures occur in less than 10% of
pediatric head injuries, most commonly with severe
TBI but can occur after minor CHI.11,40 In a study by
Holmes et al, 52 children who sustained blunt head
trauma and post-traumatic seizure with a negative
head CT in the ED were evaluated for neurologic
sequelae and none had neurologic deterioration
or required neurosurgical intervention. Of note, 7
children of the 20 who were hospitalized received
phenytoin and it is unclear if this had an effect. The
authors support that such a population may be
safely considered for discharge from the ED though
the study was limited by its small sample size. The
CHALICE rules recommend CT imaging in children
without history of epilepsy who sustain a seizure
after CHI.28
November 2011 • www.ebmedicine.net
Cephalohematoma
An abstract of a secondary analysis by PECARN
concluded that there is a low risk (0.5%) of clinically
important TBI in children less than 2 years of age
with isolated scalp hematomas. However, it was
noted that the likelihood of TBI on CT was higher
in those children less than 3 months (20% with 1.9%
requiring intervention) and those with large temporal-parietal cephalohematomas.45 The CHALICE
rules recommend CT in patients less than 1 year of
age with the presence of a bruise, swelling or laceration >5 cm after CHI.28 The CATCH rules attribute a
“medium risk” of TBI on CT (though not as likely to
necessitate neurologic intervention) in children with
large, boggy cephalohematomas after CHI.29 Simon
7
Pediatric Emergency Medicine Practice © 2011
et al refers to frontal cephalohematomas as potentially obscuring palpable skull fractures.46
biomarkers being studied include: S100B, D-dimer,
myelin basic protein, and neuronal specific enolase.
These biomarkers will be discussed in the “Cutting
Edge” section of this review.
Specific evaluation with routine laboratory tests
such as CBC or electrolytes is not useful in mTBI
but rather more useful in evaluating for differential
diagnosis such as bleeding disorders or seizure or
the presence of other traumatic injuries.
Suggestion Of Skull Fracture
Skull fracture is often difficult to assess for on clinical examination. Large cephalohematomas can easily
obscure any step off that would suggest cranial abnormality as in displaced skull fracture. Meanwhile,
linear non-displaced fractures would be difficult to
ascertain upon palpation. The Chalice rules defined
signs of basilar skull fracture to include blood or
cerebrospinal fluid (CSF) from ear or nose, periorbital ecchymosis, Battles sign, hemotympanum,
facial crepitus, or serious facial injury.28 A cerebrospinal fluid leak as a manifestation of rhinorrhea
or otorrhea suggests basilar skull fracture and can
be confirmed with a beta-2-transferrin assay when
there is clinical suspicion. In a large meta-analysis,
it was reported that the presences of skull fracture
increases the risk of intracranial injury by 4 times.25
PECARN’s 2009 Lancet study as well as the CHALICE rules found that children with signs of skull
fracture have a higher risk of clinically important
TBI and should be imaged.28,30 The CATCH rules report a high risk for the need for neurologic intervention in children with suspected open or displaced
skull fracture and therefore require CT imagaing.29
Those with signs of basilar skull fracture are attributed a medium risk.
Imaging
Head Computed Tomography
Currently as many as 50% of children assessed for
head trauma in North American EDs undergo head
CT scanning.50 It remains the best test to evaluate for
traumatic intracranial pathology in the acute setting
as it is obtained in minutes, rarely requires sedation,
and is accurate for ICH and skull fracture. Notably,
with strict adherence to the derived CHALICE rules,
the recommended head CT rate is increased. In the
implementation study of the CHALICE head CT
rule, application of the guideline resulted in an extra
21 (4.6%) scans as compared to pre-existing guidelines.51 Similarly, an Australian study implementing
the CHALICE rules found that its application doubled the proportion of scans.52 Several large studies
have sought to create guidelines in the decision to
obtain a pediatric head CT after CHI and these are
summarized in Table 5.
It is important to consider that children are 10
times more radiosensitive than adults and that CT
imaging carries a risk of subsequent malignancy extrapolated as 1 fatal cancer per 1000 to 5000 pediatric
head CT examinations.53,54 This malignancy risk is
extrapolated from data on Japan’s atomic bomb survivors and for this reason, is not universally accepted by radiologists. Regardless, emergency medicine
clinicians in non-children’s hospitals must consider
that the principles of employing radiation amounts
“as low as reasonably achievable” (ALARA) for
imaging may yet to be initiated and that an adultprotocolled head CT scan delivers twice the amount
of radiation as a similar pediatric-protocolled scan.55
The National Cancer Institute reports a single unadjusted head CT (200mAs) produces 1.8 to 3.8 mSv
of radiation while a pediatric adjusted head CT (100
mAs) produces 0.9 to 1.9 mSv.56
The decision to obtain a head CT need not be
immediate if indications are unclear. Nigrovic et al
studied approximately 40,000 children with minor
blunt head trauma comparing a subset of 5433 who
were observed. It was found that rate of head CT in
those observed was 31.1% as compared to 35% in
those not observed supporting clinical monitoring as
a factor in the decision to obtain head CT.34
Glasgow Coma Score
Recent literature indicates that children with CHI
and a GCS < 14 have a risk of more than 20% of TBI
on head CT justifying the risk of radiation associated
with obtaining a head CT scan.28,47 Initially, the American Congress of Rehabilitation Medicine’s definition
of mTBI included a GCS of 13 and above, supported
by adult studies. However the 2003 CHOP pediatric
mTBI practice guidelines rejected incorporating a
GCS of 13 or lower into the mTBI algorithm as a large
review had shown that 33.8% of patients with a GCS
of 13 had an intracranial lesion and 10.8% required
emergency surgery.48 Dietrich et al reminds us that a
normal GCS is not a reliable indicator of the absence
of TBI.49 Notably, the CATCH rules recommended CT
scanning in any child with a GCS < 15 2 hours after
the injury and the CHALICE rules recommend imaging in children less than 1 year with a GCS < 15 or 1
year and older with a GCS <14.28,29
Diagnostic Studies
Laboratory Testing
There is little support for laboratory testing in identifying mTBI. However, studies investigating biochemical “brain biomarkers” are underway. An ideal
brain biomarker would be measurable in the serum
after TBI and correlate with brain injury. Current
Pediatric Emergency Medicine Practice © 2011
Magnetic Resonance Imaging Brain
Sigmund et al published a prospective cohort of 40
8
www.ebmedicine.net • November 2011
Figure 3: Suggested CT Algorithm For Children Younger Than 2 years (A) And For Those Aged 2
Years And Older (B) With GCS Of 14–15 After Head Trauma*
A
GCS=14 or other signs of altered mental
status† or palpable skull fracture
NO
Occipital or parietal or temporal scalp haematoma, or history of LOC ≥ 5 seconds, or
severe mechanism of injury‡, or not acting
normally per parent
NO
YES
CT recommended
13.9% of population
4.4% risk of ciTBI
YES
32.6% of population
0.9% risk of ciTBI
53.5% of population
< 0.02% risk of ciTBI
Observation versus CT on the basis
of other clinical factors including:
• Physician experience
• Multiple versus isolated§ findings
• Worsening symptoms or signs after emergency department observation
• Age < 3 months
• Parental preference
CT not recommended¶
B
GCS=14 or other signs of altered mental
status† or signs of basilar skull fracture
NO
History of LOC, history of vomiting, severe
mechanism of injury,‡ or severe headache
NO
YES
CT recommended
14.0% of population
4.3% risk of ciTBI
YES
27.7% of population
0.9% risk of ciTBI
58.3% of population
< 0.05% risk of ciTBI
Observation versus CT on the basis
of other clinical factors including:
• Physician experience
• Multiple versus isolated§ findings
• Worsening symptoms or signs after emergency department observation
• Parental preference
CT not recommended¶
GCS=Glasgow Coma Score. ciTBI=clinically-important traumatic brain injury. LOC=loss of consciousness. *Data are from the combined derivation and
validation populations. †Other signs of altered mental status: agitation, somnolence, repetitive questioning, or slow response to verbal communication.
‡Severe mechanism of injury: motor vehicle crash with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet
struck by a motorised vehicle; falls of more than 0.9 m (3 feet) (or more than 1.5 m [5 feet] for panel B); or head struck by a high-impact object. §Patients with certain isolated fi ndings (ie, with no other fi ndings suggestive of traumatic brain injury), such as isolated LOC, isolated headache,isolated
vomiting, and certain types of isolated scalp haematomas in infants older than 3 months, have a risk of ciTBI substantially lower than 1%. ¶Risk of
ciTBI exceedingly low, generally lower than risk of CT-induced malignancies. Therefore,CT scans are not indicated for most patients in this group.
Reprinted with permission from: Kupperman N, Holmes J, Dayan P, et al. Identification of chilren at very low risk of clinically-important brain injuries after
head trauma: a prospective cohort study. Lancet 2009: (374)9696:1160-1170.
November 2011 • www.ebmedicine.net
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Pediatric Emergency Medicine Practice © 2011
Table 5. CT Imaging For Pediatric CHI Guideline Study Summaries57
Study
Criteria
Variables/Predictors of Decision Rule
Study
Design
# of Patients
Results
Osmond M H. CATCH: a clinical decision rule for the use
of computed tomography
in children with minor head
injury. Canadian Med Assoc
Jrnl. 2010;182(4):341-348.29
• < 16 years old
• Acute minor
head injury
• GCS 13-15
• 10 pediatric hospitals in Canada
• GCS < 15 within 2 hours
• Suspicion of open skull
fracture
• Worsening headache
• Worsening irritability
Prospective
cohort
3866
Prediction of the need for neurologic intervention and requiring
CT imaging:
Sensitivity: 97.9%
Specificity: 70.2%
Kupperman N, et al. Identification of children at very low
risk of clinically-important
brain injuries after head
trauma: a prospective cohort
study. The Lancet. 2009;
9696(374):1160-117030
• < 18 years old
• CHI within the
last 24 hours
• GCS 14-15
• 25 PECARN EDs
• Severe injury mechanism
• History of LOC, or LOC > 5
seconds
• Severe headache
• History of vomiting
• Acting abnormally per
parents
• GCS 14-15
• Altered mental status
• Signs of basilar skull fracture
or palpable skull fracture
• Non-frontal scalp hematoma
Prospective
cohort, derived and
validated
42,412
Validation
Children < 2 years old (normal
mental status, no scalp hematoma except frontal, no LOC or
LOC < 5 seconds, non-severe
injury mechanism, no palpable
skull fracture, and acting normally according to the parents)
NPV 100%
Sensitivity 100%
Children ≥ 2 years (normal mental status, no LOC, no vomiting,
non-severe injury mechanism,
no signs of basilar skull fracture, and no severe headache)
NPV 99.9%
Sensitivity 96.8%
Atabaki SM, Stiell IG, Bazarian JJ, et al. A clinical
decision rule for cranial
computed tomography in
minor pediatric head trauma.
Arch Pediatr Adolesc Med.
2008;162(5):439–445.
• < 21 yrs old
• Minor head
trauma
• 4 US pediatric
EDs
•
•
•
•
•
•
•
•
Dizziness
Skull defect
Sensory deficit
Mental status change
Bicycle-related injury
< 2 years old,
GCS < 15
Evidence of a basilar skull
fracture
Prospective
Observational
Study
1000
Sensitivity 95.4%
Specificity 48.9%
NPV 99.3%
for detection of intracranial injury
Sun BC, Hoffman JR, Mower
WR. Evaluation of a modified
prediction instrument to
identify significant pediatric
intracranial injury after blunt
head trauma. Ann Emerg
Med. 2007;49(3):325–332,
332e1.58
• < 18 yrs old
• NEXUS II pediatric cohort
• Acute blunt head
trauma
• 21 US EDs
• Abnormal mental status
• Signs of skull fracture
• Scalp hematoma in children
≤ 2 years old
• High risk vomiting
• Severe headache
Retrospective cohort
1666
Sensitivity 90.4%
Specificity 42.7%
To detect significant intracranial
injury
Dunning J, Daly JP, Lomas
JP, et al. Derivation of
the children’s head injury
algorithm for the prediction
of important clinical events
decision rule for head injury
in children. Arch Dis Child.
2006;91(11):885– 891.28
• < 16 years old
• Any severity CHI
• 10 EDs in England
•
•
•
•
•
•
•
Prospective
cohort
22,772
Sensitivity 98%
Specificity 87%
NPV 99.9%
•
•
•
•
•
•
Pediatric Emergency Medicine Practice © 2011
LOC > 5 minutes
Amnesia > 5 minutes
Drowsiness
Vomiting ≥ 3 times
Suspicion of NAT
Seizure after injury
GCS < 14 or GCS >15 if <
1 year
Penetrating or depressed
skull injury
Suspected or tense fontanel
Signs of basal skull fracture
Positive focal neurology;
Bruise, swelling or laceration
> 5 cm if < 1 year
Road traffic crash at > 40
miles per hour
Fall from > 3 m ---Highspeed injury from a projectile
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Table 5. CT Imaging For Pediatric CHI Guideline Study Summaries57
Study
Criteria
Variables/Predictors of Decision Rule
Study
Design
# of Patients
Results
Oman JA, Cooper RJ, Holmes
JF, et al; NEXUS II Investigators. Performance of a
decision rule to predict need
for computed tomography
among children with blunt
head trauma. Pediatrics.
2006;117(2).59
• < 18 years old
• Closed head
trauma
• 21 NEXUS II
centers
• Evidence of significant skull
fracture
• Altered level of alertness
• Neurologic deficit
• Persistent vomiting
• Scalp hematoma
• Abnormal behavior
• Coagulopathy
Retrospective cohort
analysis
1666
Identification of clinically important intracranial injury children
< 3 years old:
Sensitivity 100%
- Low risk classification
NPV 100%
specificity 5.3%
All children
Sensitivity 98.6%
- Low risk classification NPV
99.1%
Specificity 15.1%
Da Dalt L, Marchi AG, Laudizi
L, et al. Predictors of intracranial injuries in children
after blunt head
trauma. Eur J Pediatr.
2006;165(3):142–148.60
• < 16 years old
• Acute closed
head trauma
• 5 Italian pediatric
EDs
•
•
•
•
•
•
LOC > 20 seconds
Persistent drowsiness
Amnesia
GCS < 15
Prolonged headache
Clinical evidence of basal or
non-frontal skull fracture
Prospective
cohort
3806
Sensitivity 100%
Specificity 73%
NPV 100%
Haydel MJ, Shembekar AD.
Prediction of intracranial
injury in children aged 5
years and older with loss of
consciousness after minor
head injury due to nontrivial
mechanisms. Ann Emerg
Med. 2003;42(4):507–514.61
• 5 to 17 yrs old
• Major mechanism of injury
• GCS 15
• Normal neuro
examination
• + LOC
• CT head imaging
•
•
•
•
•
•
Headache
Emesis
Intoxication
Seizure
Memory deficit
Trauma above clavicles
Prospective
questionnaire
175
The presence of any of the 6
criteria was associated with an
abnormal CT result
Palchak MJ, Holmes JF,
Vance CW, et al. A decision
rule for identifying children at low risk for brain
injuries after blunt head
trauma. Ann Emerg Med.
2003;42(4):492–506.47
• < 18 yrs old
• Blunt head
trauma
• 1 US pediatric
ED
•
•
•
•
P < 0.05
Identification of patients with ICI
Sensitivity 100%
Abnormal mental status
Signs of skull fracture
Scalp hematoma if ≤ 2 years
History of vomiting
Prospective
observational
cohort
2043
The presence of any of the 4
predictors for TBI on CT:
Sensitivity 94.9%
Specificity 49.5%
Absence of all 4 predictors: NPV
99.6%
Abbreviations: GCS, Glasgow Coma Score; CHI, closed head injury; ED, emergency department; LOC, loss of consciousness; CT, computed tomography; NPV, negative predictive value; NAT, non-accidental trauma.
November 2011 • www.ebmedicine.net
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Pediatric Emergency Medicine Practice © 2011
Risk Management Pitfalls To Avoid In The Treatment Of mTBI
1. “I am concerned about child abuse, but this
patient does not have current signs of mTBI.”
If there is any suspicion of NAT, the pediatric
patient warrants a head CT for evaluation
of acute as well as old intracranial injury. A
“physician is required to report a suspicion of
child abuse, not to prove the etiology.”82
identification of palpable skull fracture regardless of their location.
7. “The 7-year-old boy who hit his head while
skateboarding appears well. We can send him
home with an antiemetic and pain medication.” Take caution in discharging an older
child with an antiemetic after CHI that has not
been evaluated with head CT, since vomiting
may be an indicator of intracranial process.
2. “Though the patient appears well and there
wasn’t suspicious history of severe injury, I am
not comfortable with discharge unless I obtain
a head CT to rule out injury.” Ordering imaging studies without true indications to “completely rule out” a diagnosis is a practice of “defensive
medicine” that is not in the patient’s best interest
nor is it cost efficient. 83
8. “A 5-year-old boy who came to the ED after
falling off his tricycle was diagnosed with an
upper respiratory infection. He appeared well
without cephalohematoma or vomiting and
was sent home. But he returned the next day
with vomiting and was found to have a basilar
skull fracture.” Cerebrospinal fluid rhinorrhea
or otorrhea is a sign of basilar skull fracture.
Children who have these signs should have the
fluid tested for the presence of CSF.
3. “It’s the PMD’s job to discuss concussion management.” The ED clinician is responsible for
providing discharge instructions and return to
activities information as well as recommended
appropriate follow up.
9. “A 5-month-old baby rolled off the bed and is
now lethargic and with a large parietal cephalohematoma and has been intubated. We do
not have neurosurgery or PICU in our community hospital. I will obtain a head CT to confirm ICH prior to transfer.”
If there is a suspicion for medical condition that
is not best managed in your institution, transfer
to the appropriate facility should be discussed as
soon as possible and should not be delayed for
imaging.
4. “I will order the head CT because I don’t want
to miss something and be sued.” Doctors with
a higher fear of malpractice order more head
CTs in pediatric patients with minor head injury.84 Such practices have been termed “defensive
medicine” and are not in the patient’s best interest. Radiation exposure carries a risk of future
malignancy which may be legally implicating in
a patient who develops such a malignancy with
identification of excessive scanning in the past.
5. “The patient has a mild head injury and seems
well.Although there was a similar injury last
week, this patient likely does not have TBI.”
Second impact syndrome is an important concern for the re-injured concussive patient. The
threshold to obtain imagining in a symptomatic
patient with repeat injury should be lower.
10. “This family appears reliable to monitor the
patient with a closed head injury and concussive symptoms at home.” It is the ED clinician’s
responsibility to ensure (1)that the patient has a
primary medical provider to follow up with, (2)
to discuss a course of action with the patient’s
family in the event of return to the ED, (3) to
ensure that the family has a way to get to the
hospital, and (4) to discuss returning to the nearest facility in case of an emergency.
6. “There’s a large cephalohematoma, but it’s
frontal, so I am less concerned for skull fracture.” Large cephalohematomas may hinder
Pediatric Emergency Medicine Practice © 2011
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www.ebmedicine.net • November 2011
Special Circumstances
pediatric patients with TBI examining the value of 4
different imaging modalities: CT, T2-weighted MRI,
fluid-attenuated inversion recovery (FLAIR) MRI,
and susceptibility-weighted imaging (SWI) MRI.62
The study showed that T2, FLAIR, and SWI MRI
sequences were more accurate in assessing injury severity and detection of outcome-influencing lesions
than CT. Computed tomography was inconsistent
at lesion detection and outcome prediction classified by the Pediatric Cerebral Performance Category
Scale. However, CT remains the gold standard for
ED evaluation of intracranial pathology after CHI
as it is quickly obtained and accurate in diagnosing
clinically important TBI.
Another small study of 20 adult patients evaluated whether there was any detectable abnormalities
in patients with head injury and concussion with
maximum LOC of 5 minutes.63 Magnetic resonance
imaging was obtained first at 24 hours, then at 3
months, and then compared to a matched group
of 20 orthopedic patients without any findings of
diffuse axonal injury or other abnormality in the
concussion group.
Post-Concussive Syndrome And Second
Impact Syndrome
Post concussive syndrome is a potential sequelae of
TBI in which the symptoms of concussion persist
longer than 7 to 10 days. Somatic, cognitive, and affective symptoms may be present such as headache,
sleep disturbance, dizziness, nausea, fatigue, attention
problems, irritability, anxiety, depression, and emotional lability.66 A recent study assessed for post-concussive symptoms in children with mTBI compared
to children with uncomplicated orthopedic injuries.67
They found that LOC, acute CT scan abnormality,
parenchymal lesion on MRI, hospitalization, and
injuries to body regions other than the head predicted
higher levels of post concussive symptoms.
Molecular researchers have suggested that
mTBI can potentiate complex biochemical derangements in the brain at the time of injury and through
recovery. This period of recovery marks a “situation of metabolic vulnerability, to the point that if
another, equally ‘mild’ injury were to occur, the 2
mTBIs would show the biochemical equivalence of a
[severe] TBI,” which may be part of the pathophysiology of the second impact syndrome.8
Second impact syndrome is a catastrophic brain
injury occurring after an initial TBI, generally before
the symptoms of concussion have resolved. The
hypothesized pathology involves cerebral vascular congestion with progression to diffuse cerebral
swelling and death.68 All reported cases have been
in patients under 20 years old.69,70 It is important to
elicit any history of recent head trauma (eg athletics,
motor vehicle accidents, or simple play) in the patient presenting with CHI to evaluate for the potential for second impact syndrome.9
Treatment
Symptom control is the main objective in mTBI
when the concern for ICH or skull fracture has been
effectively ruled out via imaging or clinical examination and observation. Nausea and vomiting are
symptoms of concussion that may be ameliorated by
anti-emetics such as ondansetron. However, there is
valid concern in administering ondansetron in pediatric patients who do not receive head CTs to rule
out ICH as protracted vomiting in this population
would likely warrant imaging.
Pain control of headache associated with direct
blow, cephalohematoma, and concussion should be
achieved and initiated in the ED. Acetaminophen,
unlike ibuprophen, does not have an effect on platelet count or function or the potential for sedation
as with narcotics. Acetaminophen is a prudent first
line medication in the patient who has not had ICH
effectively ruled out by imaging. There is no evidence that acetaminophen or non-steroidal anti-inflammatory agents (NSAIDs) alleviate or shorten the
duration of concussive symptoms.64 A single animal
study showed that chronic ibuprofen use post-TBI
worsens cognitive outcome.65
If the patient persists with symptoms of severe
concussion despite pain control and anti-emetics,
admission to an inpatient ward or observational
unit is warranted for further therapy. However, it is
important to consider cost issues related to inpatient
admission for mTBI and explore alternative approaches such as observation units. November 2011 • www.ebmedicine.net
Non-Accidental Trauma
Children less than 2 years of age are a special group
of patients in which CHI is more concerning and a
threshold to evaluate with imaging is lower despite
higher risks of radiation. Inherently, these young
patients lack verbal skills to relate historical aspects
of the injury or symptoms, making communication
and evaluation by the clinician more complex. The
PECARN study successfully evaluated more than
10,000 children less than 2 years of age to derive
and validate prediction rules in children at very low
risk of clinically important TBI after head trauma.16
However, this study does not allude to incidences
in which mTBI may have been sustained by NAT.
Importantly, children under 2 are at higher risk for
NAT. In such circumstances in which NAT is suspected due to delay in seeking care, or the injury
does not match the stated mechanism of injury or
the child’s developmental stage, a head CT and skeletal survey are warranted.
13
Pediatric Emergency Medicine Practice © 2011
the potential to correlate with moderate-severe TBI;
however, its value lies in younger children and may
require several samples to identify a correlation to
outcome making this a less than ideal marker in the
ED.
S100B is a calcium binding protein found in the
astroglial cells of the central nervous system (CNS),
though it is not exclusive to the CNS. A limited
study of 152 children suggested that S100B was
elevated in children with ICH, those with long bone
fractures, and children of certain races.73 With a
short half-life, in the event of multiple injuries, and
in the non-white patient, S100B definitely has limits
in the acute ED setting. Another study by Castellani
showed that normal S-100B levels ruled out ICH
in mTBI pediatric patients with a strong sensitivity
(sensitivity of 1.00, specificity of 0.42.)74 However,
the large number of false positive patients in the
study limits it use as an ideal confirmatory tool.
An interesting study by Geyer sought to evaluate a
difference in NSE and S100B levels in children with
mTBI presenting with concussion and those with
CHI without concussive symptoms. They demonstrated no difference in either NSE or S100B levels
in these populations, which is supportive of these
biomarkers having more diagnostic potential in ruling out moderate-severe pediatric TBI especially in
the symptomatic patient.24
Glial Fibrillary Acidic Protein (GFAP) is found in
the cytoskeleton of astrocytes exclusive to the CNS.
Studies reflect elevated levels of GFAP in serum and
cerebrospinal fluid after severe TBI in children, but
there is nothing to date quantifying it in pediatric
mTBI.75
Myelin basic protein (MBP) is found in CNS
white matter. Berger et al evaluated levels of MBP
in children with TBI, along with NSE and S100B
by.24 It was noted that initial levels of MBP were
not correlated with outcome in older children, and
similar to NSE, levels correlated in children 4 years
and younger. This study alludes to the value of
MBP in NAT. Myelin basic protein was comparably
elevated initially in those children 4 and younger
whose injury was the result of NAT rather than
those with non-inflicted trauma. The article suggests that a delay in initial presentation in cases of
NAT may influence this finding. Berger et al went
on to look at trajectory analysis of MBP and similar
biomarkers in 2010 and reports a half-life of approximately 24 hours for MBP.76 The study went on
to intuitively confirm that elevations in MBP were
present in hypoxic ischemic encephalopathy as well
as TBI further limiting its use as a specific marker
for acute pediatric TBI.
In a recent small retrospective study of 57
children, a D-dimer level < 500 pg/ul had a 94%
negative predictive value for TBI on head CT.77
This test has the potential to be used in the current
Cognitively Impaired
There is paucity of literature and recommendations
regarding the management of moderate-severely
cognitively impaired children who sustain CHI. It is
our recommendation that not only are these patient
similar to the pediatric population less than 2 years
of age in that they have poor verbal skills and are at
higher risk for NAT, these patients may have abnormal baseline neurologic examinations that make
clinical evaluation of mTBI very difficult. In a situation where there is any suspicion of ICH or skull
fracture, head CT should be obtained.
Cutting Edge
A hot topic in TBI diagnosis over the last 10 years
has been the identification of brain biomarkers that
could reflect injury. Biochemical serum markers
measured after TBI may be used in identification of
the injury, determining the injury extent, and potentially predicting outcome. This field of research is
relatively new to pediatrics but of special interest in
supporting the ever present pediatric question of “to
CT or not to CT.”
Neuron specific enolase (NSE) is a glycolytic
enzyme found mainly in the cytoplasm of neurons
and released into the serum after traumatic damage.
A large pediatric study from Children’s Hospital of
Pittsburgh showed that the number of hours that
NSE was abnormally elevated in serum correlated to
short-term outcomes.71 They also noted that initial
and peak levels only were correlated to outcome in
children 4 years and under. A study by Geyer et al
in 2009 looked at S100B and NSE specifically in the
pediatric population with mTBI.72 The study was
unable to show a significant difference of levels in
patients with symptomatic mTBI and in those without symptomatic injury. Neuron specific enolase has
Cost-Effective Strategy
Order a head CT for patients only when there
is clinical suspicion of intracranial injury or
skull fracture. Resist practicing “defensive
medicine” or obtaining imaging in a child to
“rule out” an intracranial injury as radiation
carries risks for potential malignancy.
Risk Management Caveat: ED observation in the
patient with closed head injury is warranted in
the patient in which the imminent need for head
CT may be unclear. In well-appearing children
without symptoms, be sure that the families will
receive follow up care with their pediatrician,
understand return precautions, and are in
proximity to a hospital.
Pediatric Emergency Medicine Practice © 2011
14
www.ebmedicine.net • November 2011
ED settings and laboratories but more research is
needed.
Identifying a brain biomarker that reliably suggests clinically important pediatric TBI would be the
answer to concerns for unnecessary CT scans and
would change pediatric CHI protocols. A challenge
will be to identify a laboratory that will isolate this
biomarker in a timely fashion.
While 4% of these patients required further inpatient
management for basilar skull fracture, head laceration, and the need for ED intravenous fluids, most
of these patients with mild CHI do not need further
intervention. This raises the question of whether an
observation unit is even necessary in a reliable home
environment.
This being said, pediatric patients who sustained
mTBI must pass discharge criteria prior to leaving
the ED.
Criteria for discharge include
1. Hemodynamic stability with clinician expectation of persisting stability
2. No alteration in mental status
3. Resolved or tolerably mild headache
4. Tolerating oral fluids
5. Reliability of follow up with primary care
physician, neurologist, neurosurgeon, or
sports medicine physician to re-evaluate
symptoms of mTBI
6. Family communication and understanding
of discharge instructions including reasons
to return to the ED
Disposition
The pediatric patient with mTBI may be observed in
the ED or observation unit, admitted for inpatient
hospitalization, or may be discharged home.
A study by Hamilton et al in 2010 examined the
incidence of delayed ICH in children after uncomplicated minor CHI.32 This 8-year retrospective
cohort study evaluated 17,962 children less than 14
years of age presenting to an ED with minor CHI.
It was found that 2 of these patients had delayed
symptomatic presentation of ICH at 8 and 38 hours.
This data was extrapolated to summarize that the
incidence of delayed deterioration following minor
head injuries was 0.57 cases per 100,000 children per
year. Nigrovic’s study reported a lower rate of head
CT in pediatric patients with CHI who were observed in the ED versus those who were not initially
observed.34 This again supports the fact that patients
with mTBI rarely exhibit neurologic deterioration
however ED observation may be justified in those
patients with concern for intermediate risk for clinically important TBI.
The PECARN group evaluated over 13,000
children with a GCS of 14 or 15 and normal ED
head CT scan. The study stated that this population
is at very low risk for traumatic findings on neuroimaging and extremely low risk of needing neurosurgical intervention.78 The authors concluded that
hospitalization of this population for neurologic
observation is generally unnecessary. However
neurologic observation is not the only reason why
such patients would be admitted to the hospital
– protracted vomiting, severe pain, and inability
to tolerate fluids orally would be reasons to admit
children with a GCS of 14 to 15 and normal head
CT. The article did mention that 18% of the admissions documented vomiting.
A retrospective study of 1033 children without
neurologic deficit and a GCS of 15 admitted to the
hospital for observation found that all were discharged alive within 3 days irrespective of the fact
that a comparable cohort had skull fracture or “intracerebral diagnosis.”79 A study by Holsti et al evaluated blunt head injuries treated in an observation
unit and found that 96% of these observed pediatric
patients with small intracranial hematomas, skull
fractures, and concussions were discharged safely
within 24 hours without serious complications.33
November 2011 • www.ebmedicine.net
Some pediatric patients will not fit these discharge
criteria and will require admission for evaluation
and further treatment or close monitoring.
Such patients would have:
• Clinician concern of potential for change in
medical stability
• Severe headache
• Inability to tolerate fluid orally either by
refusal or with frequent vomiting
It is important to stress the need for cessation of
return to sports and need for medical clearance on
follow up visit with the family and discuss postconcussive syndrome as well as the risks for second
impact syndrome. The Centers for Disease Control
and Prevention has created an online resource called
“Heads Up: Concussion” for children and their
families as well as school personnel and health care
professionals to provide important information on
preventing, recognizing, and responding to a concussion.80 These materials can be utilized by the ED
clinician and referred to families.
Depending on the standard in your hospital, follow up care may involve reassessment by a neurologist, neurosurgeon, and/or sports medicine physician in addition to the PMD.
As demonstrated by prospective cohort by Polissar et al, there is a potential decline in eating and
living skills shortly after mTBI with further effects
on neurobehavioral skills initially and at 1 year.81 For
this reason, follow up in these pediatric patients is
imperative.
15
Pediatric Emergency Medicine Practice © 2011
Summary
Emergency clinicians are faced with the presenting
complaint of pediatric CHI on a regular basis. The
vast majority of these are manifestations of mTBI
with concussion. As discussed, this diagnosis can be
made with or without imaging. Due to the increasing concerns for ionizing radiation and the risks
of procedural sedation, ED clinicians must exercise stricter criteria for neuro-imaging and include
clinical acumen which may include ED observation
time in making the diagnosis of mTBI. As there are
discrepancies in the current literature as to what
exactly defines concussion and mTBI and as these
terms may be interpreted differently by caregivers, we must mindfully make these diagnoses and
discuss their implications with the families involved.
Aided by our knowledge of the potential for residual
neurobehavioral skills deficits, post concussive syndrome and second impact syndrome, we are responsible for educating patients and parents and ensuring that follow up is in place prior to discharge.
3. 4. 5. 6. 7. 8. Case Conclusion
9. It is a busy Saturday afternoon in the pediatric ED
and you have decided to PO trial and ambulate the
crying 2 year old girl who fell about 3 feet from a
swing sustaining a CHI. The height of her fall is defined as a severe injury mechanism by the PECARN
study. Though there is a small occipital cephalohematoma, there is no suggestion of skull fracture in
this patient and she denies headache. She is well
appearing in your ED and tolerates a popsicle without nausea or vomiting and speaks and ambulates
without neurologic deficit. It is now 4 hours post
injury and her parents are reliable and live nearby
the hospital.
At this point, your suspicion for significant intracranial pathology in this patient is low. However
discussion of the risks and benefits of CT with the
patient’s parents is still warranted as is ascertaining their comfort level with return precautions and
home monitoring. The little girl’s parents are worried for their daughter but do not want to expose
her to unnecessary radiation and assure you that
they will watch her closely at home. You confirm
the presence of their pediatrician and decide to
discharge this well appearing patient home with follow up with her regular doctor. A follow up phone
call from the ED on the next day confirmed that the
patient is doing very well.
10. 11. 12. 13. 14. 15. 16. 17. 18. References
1. 2. 19. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic brain
injury in the United States. In: CDC, ed. National Center For
Injury Prevention and Control, 2006. (Statistical Data)
Faul M, Xu L, Wald MM, et al. Traumatic brain injury in the
Pediatric Emergency Medicine Practice © 2011
16
United States: emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control
and Prevention, National Center for Injury Prevention and
Control; 2010. (CDC Statistics)
Dematteo CA, Hanna SE, Mahoney WJ, et al. “My child
doesn’t have a brain injury, he only has a concussion”. Pediatrics. 2010 Feb;125(2):327-334. (434 children; Prospective
cohort)
The management of minor closed head injury in children.
Committee on Quality Improvement, American Academy
of Pediatrics. Commission on Clinical Policies and Research,
American Academy of Family Physicians. Pediatrics. 1999
(Practice parameter)
Jagoda, AS. Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting.
Annals of Emerg Med. 2008;52(6):714-748. (Clinical Policy)
Kamerling SN, Lutz N, Posner JC, et al. Mild traumatic brain
injury in children: practice guidelines for emergency department and hospitalized patients. The Trauma Program, The
Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine. Pediatr Emerg Care. 2003;19(6):431440. (Practice Guidelines)
American Academy of Pediatrics. Clinical report--sportrelated concussion in children and adolescents. Halstead
ME, Walter KD; Council on Sports Medicine and Fitness.
Pediatrics. 2010;126(3):597-615. (Practice Guidelines)
Mild Traumatic Brain Injury Committee of the Head Injury
Interdisciplinary Special Interest Group of the American
Congress of Rehabilitation Medicine. J Head Trauma Rehabil
1993:8(3):86-87.(Practice Guidelines)
Practice parameter: the management of concussion in sports.
Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology.1997;48 :581-585.
(Summary Statement)
Gordon KE, Dooley JM, Fitzpatrick EA, et al. Concussion or
mild traumatic brain injury: parents appreciate the nuances
of nosology. Pediatr Neurol. 2010;43(4):253-257. (Prospective
Cohort; 1734 parents)
Hahn YS, McLone DG. Risk factors in the outcome of children with minor headinjury. Pediatr Neurosurg. 1993;19:135142. (Prospective cohort; 937 children)
National Institutes of Health. Conference on Sports Injuries
in Youth: Surveillance Strategies, 1991. Bethesda, MD: National Institutes of Health; 1992. (NIH publication)
Nonfatal Traumatic Brain Injuries from Sports and Recreation Activities -United States, 2001—2005. MMWR Weekly.
2007;56(29):733-737. (CDC publication)
Powell JW, Barber-Foss KD. Traumatic brain injury in high
school athletes. JAMA. 1999;282(10):958-963. (Observational
cohort; 1219 patients)
Williamson IJ, Goodman D. Converging evidence for the
under-reporting of concussions in youth ice hockey. Br J
Sports Med. 2006;40(2):128-132; discussion 128-132. (Retrospective Case Series; 44 children)
Browne GJ, Lam LT. Concussive head injury in children
and adolescents related to sports and other leisure physical
activities. Br J Sports Med. 2006;40(2):163-168. (Retropsective
Case Series; 592 children)
Boden BP, Tacchetti RL, Cantu RC, et al. Catastrophic head
injuries in high school and college football players. Am J
Sports Med. 2007;35(7):1075-1081. (Retropsective Case Series;
94 cases)
Field M, Collins MW, Lovell MR, et al. Does age play a role
in recovery from sports-related concussion? A comparison of
high school and collegiate athletes. J Pediatr. 2003;142(5):546553. (Prospective comparative study; 554 patients)
Signoretti, S. Biochemical and neurochemical sequelae
following mild traumatic brain injury: summary of experimental data and clinical implications. Neurosurgical Focus.
2010;29(5):E1. (Review; 554 patients)
www.ebmedicine.net • November 2011
2004;113(6):e507-513. (Prospective cohort; 2043 children)
38. Dayan P, Holmes JF, Atabaki S, et al. for the PECARN TBI
Study Group. Association of Traumatic Brain Injuries (TBI)
in Children after Blunt Head Trauma with Degree of Isolated
Headache or Isolated Vomiting. Presented at the Pediatric
Academic Societies meeting, Honolulu, Hawaii, 2008. Abstract only. Acad Emerg Med. 2008;15:S175-176. (Prospective
cohort;43485 children)
39. Nee PA, Hadfield JM, Yates DW, et al. Significance of
vomiting after head injury. J Neurol Neurosurg Psychiatry.
1999;66:470-473. (Prospective cohort; 5416 patients)
40. Lewis RJ, Yee L, Inkelis SH, et al. Clinical predictors of posttraumatic seizures in children with head trauma. Ann Emerg
Med. (Retrospective Cohort; 194 children)
41. Dietrich AM, James CD, King DR, et al. Head trauma in children with congenital coagulation disorders. J Pediatr Surg.
1994;29:23-32. (Retrospective Cohort; 109 children)
42. Lee LK, Dayan PS, Gerardi MJ, et al. Traumatic Brain Injury
Study Group for the Pediatric Emergency Care Applied Research Network (PECARN). J Pediatr. 2011;158(6):1003-1008.
(Prospective cohort; 43,904 patients)
43. Leiblich, A. Emergency management of minor head injury in
anticoagulated patients. Emerg Med Jour. 2011;28(2):115-118.
(Review)
44. Claudia, C. Minor head injury in warfarinized patients: Indicators of risk for intracranial hemorrhage. Journ of Trauma.
2011;70(4):906-909. (Retrospective cohort; 1410 patients)
45. Dayan PS, Holmes JF, Schutzman S, et al for the TBI Study
Group of PECARN. Association of traumatic brain injuries
with scalp hematoma characteristics in patients younger
than 24 months who sustain blunt head trauma. Abstract
presented at the AAP National Conference, Boston, MA,
October 2008. Pediatr Emerg Care. 2008;24:727. (Prospective
cohort; 43,995 children.)
46. Simon B. Pediatric minor head trauma: indications for
computed tomographic scanning revisited. J Trauma. 2001
Aug;51(2):231-237. (Systematic review; 569 patients)
47. Palchak M, Holmes JF, Vance CW, et al. A decision rule for
identifying children at low risk for brain injuries after blunt
head trauma. Ann Emerg Med. 2003;42:493-506. (Observational cohort; 2043 children)
48. Stein, SC. Minor head injury: 13 is an unlucky number. Journ
of Trauma. 2001;50(4):759-760. (Systematic Review; 1047
patients)
49. Dietrich A, Bowman MJ, Ginn-Pease ME, et al. Pediatric
Head Injuries: Can Clinical Factors Reliably Predict an
Abnormality on Computed Tomography? Ann Emerg Med.
1993;22(10)1535-1540. (Prospective cohort; 322 patients)
50. Marr A, Coronado V. Central nervous system injury surveillance data submission standards—2002. Atlanta, GA: CDC,
National Center for Injury Prevention and Control, 2004.
51. Harty E. CHALICE head injury rule: An implementation
study. Emerg Med Journ. 2010;27(10):750-752. (Case review;
464 patients)
52. Crowe L. Application of the CHALICE clinical prediction rule for intracranial injury in children outside the UK:
Impact on head CT rate. Arch Disease Child. 2010;95(12):10171022. (Restrospective cohort; 1091 children)
53. Brody AS, Frush DP, Huda W, et al; American Academy of
Pediatrics Section on Radiology. Radiation risk to children
from computed tomography. Pediatrics. 2007;120(3):677-82.
(Guideline)
54. Frush DP, Donnelly LF, Rosen NS. Computed tomography
and radiation risks: what pediatric health care providers
should know. Pediatrics. 2003;112(4):951-957. (Review)
55. Slovis TL. Children, Computed Tomography Radiation
Dose, and the As Low As Reasonably Achievable (ALARA)
Concept. Pediatrics. 2003; 112:4 971-972. (Commentary)
56. National Cancer Institute. Radiation risks and pediatric
computed tomography (CT): a guide for healthcare provid-
20. De Beaumont L, Tremblay S, Poirier J, et al. Altered Bidirectional Plasticity and Reduced Implicit Motor Learning in
Concussed Athletes. Journal of Neurotrauma. 2011;28(4):493502. doi:10.1089/neu.2010.1615. (Retrospective Case Series;
26 cases)
21. Anderson JC, Courson RW, Kleiner DM, et al. National
Athletic Trainers’ Association position statement: emergency
planning in athletics. J Athl Train. 2002;37:99–104. (Position
Statement)
22. American Academy of Pediatrics. Guidelines for emergency
medical care in school. Committee on School Health. Pediatrics. 2001;107: 435–436. (Guideline)
23. Olympia, RP. Emergency planning in school-based athletics: a national survey of athletic trainers. Pediatric Emergency
Care. 2007;23(10):703-708. (Survey; 643 athletic trainers)
24. Collopy KT, Friese G. High school sports injuries. Prehospital assessment and management of traumatic carotid artery
dissection and mild traumatic brain injuries. EMS Mag. 2010;
Sep;39(9):60-65. (Review)
25. National Emergency Medical Services Education Standards.
Paramedic Instructional Guidelines. U.S. Department of
Transportation National Emergency Medical Services Education Standards. January 2009. http://www.ems.gov/education/nationalstandardandncs.html. Accessed 10/10/2011.
(Guidelines)
26. Kelly, JP. Diagnosis and management of concussion in sports.
Neurology. 1997;48(3), 575-580. (Summary statement)
27. Dunning J, Batchelor J, Stratford-Smith P, et al. A meta-analysis of variables that predict significant intracranial injury
in minor head trauma. Arch Dis Child. 2004; 89:653–659.
(Metanalysis of 16 articles; 22,420 children)
28. Dunning, J. Derivation of the children’s head injury
algorithm for the prediction of important clinical events
decision rule for head injury in children. Archives of disease
in childhood. 2006;91(11): 885-891. (Prospective cohort; 22772
children)
29. Osmond M H. CATCH: a clinical decision rule for the use of
computed tomography in children with minor head injury.
Canadian Medical Association journal. 2010;182(4):341-348.
(Prospective cohort; 3866 children)
30. Kupperman N, et al. Identification of children at very low
risk of clinically-important brain injuries after head trauma:
a prospective cohort study. Lancet. 2009;(374) 9696:1160-1170.
(Prospective cohort; 42,412 children.)
31. Krugman, RD. Fatal child abuse: analysis of 24 cases. Pediatrician. 1983;12(1):68-72. (Case analysis)
32. Hamilton M. Incidence of delayed intracranial hemorrhage
in children after uncomplicated minor head injuries. Pediatrics. 2010;126:e40-45. (Retrospective Cohort; 17,962 children)
33. Holsti M, Kadish HA, Sill BL, et al. Pediatric closed head
injuries treated in an observation unit. Pediatr Emerg Care.
2005;21(10):639-644. (Retrospective Cohort Review; 285
children)
34. Nigrovic LE, Schunk JE, Foerster A, et al. The Effect of Observation on Crainial Computed Tomography Utilization for
Children After Blunt Head Trauma. Pediatrics. 2011;127:10671073. (Prospective cohort; 40,113 children)
35. Gruskin KD, Schutzman SA. Head trauma in children
younger than 2 years: are there predictors for complications?
Arch Pediatr Adolesc Med.1999;153:15–20. (Case Series;278
children)
36. Kuppermann N, Holmes JF, Dayan P, et al. for the PECARN
TBI Study Group. Does Isolated Loss of Consciousness
Predict Traumatic Brain Injury in Children after Blunt Head
Trauma? Presented at the Pediatric Academic Societies meeting, Honolulu, Hawaii, 2008. Abstract only. Acad Emerg Med.
2008;15:S82. (Prospective cohort; 43,485 children.)
37. Palchak MJ, Holmes JF, Vance CW, G, et al. Does an isolated
history of loss of consciousness or amnesia predict brain
injuries in children after blunt head trauma? Pediatrics.
November 2011 • www.ebmedicine.net
17
Pediatric Emergency Medicine Practice © 2011
57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. ers. Bethesda, Maryland; 2002. http://www.cancer.gov/
cancertopics/causes/radiation/radiation-risks-pediatric-CT.
(accessed 10/10/11)
Maguire JL, Boutis K, Uleryk EM, et al. Should a headinjured child receive a head CT scan? A systematic review
of clinical prediction rules. Pediatrics. 2009;124;e 145- e 154.
(Systematic review; 3357 titles and abstracts)
Sun BC, Hoffman JR, Mower WR. Evaluation of a modified prediction instrument to identify significant pediatric
intracranial injury after blunt head trauma. Ann Emerg Med.
2007;49(3):325–332, 332e1. (Retrospective cohort; 1666 children)
Oman JA, Cooper RJ, Holmes JF, et al; NEXUS II Investigators. Performance of a decision rule to predict need for computed tomography among children with blunt head trauma.
Pediatrics. 2006;117(2). (Retrospective cohort; 1666 children)
Da Dalt L, Marchi AG, Laudizi L, et al. Predictors of intracranial injuries in children after blunt head trauma. Eur J Pediatr.
2006;165(3):142-148. (Prospective cohort; 3806 children)
Haydel MJ, Shembekar AD. Prediction of intracranial injury
in children aged five years and older with loss of consciousness after minor head injury due to nontrivial mechanisms.
Ann Emerg Med. 2003;42(4):507–514. (Prospective cohort; 175
children)
Sigmund GA, Tong KA, Nickerson JP, et al. Multimodality
comparison of neuroimaging in pediatric traumatic brain
injury. Pediatr Neurol. 2007;36(4):217-26. PubMed PMID:
17437903. (Prospective cohort; 40 pediatric patients)
Schrader H, Mickeviciene D, Gleizniene R, et al. Magnetic
resonance imaging after most common form of concussion.
BMC Med Imaging. 2009;(17)9:11. (Prospective cohort; 20
patients)
McCrory P. Should we treat concussion pharmacologically?
The need for evidence based pharmacologic treatment for
the concussed athlete. Br J Sports Med. 2002; 36(1):3-5. (Review)
Browne KD, Iwata A, Dutt ME, Smith DE. Chronic ibuprofen
administration worsens cognitive outcome following traumatic brain injury in rats. Exp Neurol. 2006;201(2):301–307.
(Control Trial; Animal model)
Jagoda A. Mild traumatic brain injury and the postconcussive syndrome. Emerg Med Clin N Amer. 2000;18(2):355-363.
(Review)
Taylor HG. Post-concussive symptoms in children with mild
traumatic brain injury. Neuropsychology. 2010;24(2):148-159.
(Prospective cohort; 285 children)
McCrory P. Does second impact syndrome exist? Clin J Sport
Med. 2001;11(3):144-49. (Review)
Mueller FO. Catastrophic head injuries in high school and
collegiate sports. J Athl Train. 2001;36(3):312–315. (Review)
Saunders RL, Harbaugh RE. The second impact in catastrophic contact sports head trauma. JAMA 1984;252:538-539.
(Case report)
Berger RP, Beers SR, Richichi R, et al. Serum Biomarker
Concentrations and Outcome after Pediatric Traumatic Brain
Injury. Journ Neuro. 2007; 24(12):793-1801. (Prospective
cohort; 152 children)
Geyer C, Ulrich A, Gräfe G, et al. Diagnostic value of S100B
and neuron-specific enolase in mild pediatric traumatic brain
injury. J Neurosurg Pediatr. 2009 Oct;4(4):339-344. (Prospective Clinical Study;148 children)
Bechtel, K. Relationship of serum S100B levels and intracranial injury in children with closed head trauma. Pediatrics.
2009;124(4), e697-e704. (Prospective cohort;152 children)
Castellani C, Bimbashi P, Ruttenstock E, et al. Neuroprotein
s-100B -- a useful parameter in paediatric patients with mild
traumatic brain injury? Acta Paediatr. 2009;98(10):1607-1612.
(Prospective cohort;109 children)
Fraser DD, Close TE, Rose KL, et al. for the Canadian Critical
Care Translational Biology Group. Severe traumatic brain
Pediatric Emergency Medicine Practice © 2011
76. 77. 78. 79. 80.
81.
82. 83.
84.
injury in children elevates glial fibrillary acidic protein
in cerebrospinal fluid and serum. Pediatr Crit Care Med.
2011;12(3):319-324. (Prospective cohort; 27 children)
Berger, R. Trajectory analysis of serum biomarker concentrations facilitates outcome prediction after pediatric traumatic
and hypoxemic brain injury. Develop Neuro. 2011;32(5-6):396405. (Meta-analysis)
Swanson, C. Low plasma d-dimer concentration predicts
the absence of traumatic brain injury in children. The Journal
of trauma, 2010;68(5), 1072-1077. (Retrospective cohort; 57
children)
Holmes JF, Borgialli DA, Nadel FM, et al. Do Children With
Blunt Head Trauma and Normal Cranial Computed Tomography Scan Results Require Hospitalization for Neurologic
Observation? Ann Emerg Med. 2011;58(4)315-322 Epub 2011
June 6. (Prospective Cohort; 13,543 children. )
Adams J, Frumiento C, Shatney-Leach L, et al. Mandatory
admission after isolated mild closed head injury in children:
is it necessary? J Pediatr Surg. 2001;36(1):119-121. (Retrospective Cohort; 1033 children)
Centers for Disease Control. Heads Up: Concussion. Injury
Prevention and Control: Traumatic Brain Injury. http://
www.cdc.gov/concussion/headsup/index.html (accessed
10/10/11). (Patient Guideline)
Polissar NL, Fay GC, Jaffe KM, et al. Mild pediatric traumatic brain injury: adjusting significance levels for multiple
comparisons. Brain Inj. 1994;8(3):249-263. (Review)
Selbst SM. Pediatric emergency medicine: legal briefs. Pediatr
Emerg Care. 2010;26(10):778-781. (Case Review)
Selbst, S. Standards for clinical evaluation and documentation by the emergency medicine provider. Ped Rad.
2008;38:645-650.
Wong, A. A survey of emergency physicians’ fear of malpractice and its association with the decision to order computed
tomography scans for children with minor head trauma.
Pediatric emergency care, 2011;27(3):182-185. (Prospective
survey; 246 doctors)
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1. A 3-year-old female comes to the emergency
department with vomiting and headache after
a closed head injury 1 hour ago. These symptoms are indicative of:
a. Mild traumatic brain injury
b. Moderate traumatic brain injury
c. Concussion
d. Altered mental status
18
www.ebmedicine.net • November 2011
2. Which of the following is true regarding concussion?
a. It involves a trauma induced alteration in mental status
b. It requires a loss of consciousness
c. It is always associated with amnesia
d. It only occurs in patients with a GCS of 13 or above
7. A 5-year-old girl fell down a flight of stairs 12
hours ago and had a 5 second loss of consciousness but has been well since. What statement is
true regarding this ED patient?
a. She does not have moderate or severe traumatic brain injury
b. She does not require further monitoring
c. She is at risk for post concussive syndrome and second impact syndrome
d. She should have a head CT due to severe mechanism of injury
3. An 8-year old boy fell from a 10 ft. ladder
while stringing Christmas lights 1 hour ago.
He had a 5 second loss of consciousness. He
did not vomit, there is no cephalohematoma,
and he is back to his baseline mental status.
What is the best management for this patient?
a. Immediate head CT
b. ED monitoring for several hours
c. DC home with older sister
d. Morphine for pain and Ativan for agitation
8. A 2-month-old infant is brought to the ED because of a frontal cephalohematoma and bruise
to his left shin noted by his mother when she
picked him up from daycare. The daycare provider reported that the infant rolled off the bed
approximately 2 feet to carpeted ground and
the baby appears well. What is your next step?
a. Observe in the ED for 6 hours
b. Obtain a head CT
c. Obtain a head CT and skeletal survey
d. Obtain a head ultrasound and skeletal survey
4. A 17-year-old boy sustained a mild traumatic
brain injury while playing hockey. Four days
later, he slips and falls on the ice while wearing his helmet and develops a large cerebral
contusion. Which of the following is true
regarding second impact syndrome?
a. It occurs when symptoms of concussion last more than 10 days.
b. A patient must have a minimum of 1 week between injuries to define a second impact.
c. It typically occurs after a moderate to severe initial brain injury.
d. It has only been reported in children and young adults.
9. A 14-year-old boy hit a tree while skiing. He
was wearing a helmet but lost consciousness
for 5 minutes. In the ED he has a GCS of 12
and has vomited 3 times. This patient most
likely has what type of injury?
a. Mild traumatic brain injury
b. Second impact syndrome
c. Moderate-severe brain injury
d. Moderate-severe brain injury and concussion
5. A 2-year old female came to the ED after
falling from a second story window. She has
vomited 3 times and her parents are concerned
because she is fussy. What is the best course of
action?
a. Immediate head CT
b. 2-to-4 hours of ED monitoring
c. Discharge with parents for home monitoring
d. Administer anti-emetic
11. A 4-year-old female fell from the monkey bars
sustaining a 2 minute loss of consciousness
without any external signs of injury. She is
well appearing in the ED and you decide to observe her for 4 hours including PO and ambulatory trial. Which of the following statements
regarding ED observation post head injury is
true?
a. Children observed in the ED post head injury are less likely to obtain a head CT.
b. ED observation times should not exceed 2 hours.
c. There is a 30% chance of delayed
presentation of intracranial injury in this patient.
d. The AAP recommends 8 hours of medical observation post head injury.
6. An 8-year old boy sustained a mild traumatic
brain injury 2 weeks ago after being hit in the
head with a hockey puck and losing consciousness for 5 seconds. He has had persisting headache and difficulty concentrating at school.
What is the best diagnosis of these symptoms?
a. Concussion
b. Post-concussive syndrome
c. Second impact syndrome
d. Migraine
November 2011 • www.ebmedicine.net
19
Pediatric Emergency Medicine Practice © 2011
Coming In Future Pediatric Emergency
Medicine Practice Issues
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Pharyngitis
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Intussusception
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Constipation
•
Managing The Pediatric Airway
•
Sinusitis
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Appendicitis
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Croup
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The Limping Child
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