Minor Head Injury In Children
Larry Kleiner
Medical Director, Dept of
Neurosurgery
The Children's Medical Center
Head Trauma
Definition of Mild head injury
Glasgow Coma Scale 13-15 • Prejudice against children
• doesn’t account for
• simple
asymetry
• reproducible
• prejudice against facial
• functional
injury/intubation
• valid predicteur
• doesn’t account for
brainstem reflexes
Modification of the GCS
• Eye opening:
spontaneous
to sound
to pain
none
4
3
2
1
Modification of the GCS
• Verbalization
• Appropriate for age
– fixes and follows
– social smile
• cries but consolable
• persistent irritability
• restless,lethargy
• none
5
4
3
2
1
Modification of the GCS
• Motor Response
•
•
•
•
•
•
Spontaneous
localizes to pain
withdraws
decorticate
decerebrate
none
6
5
4
3
2
1
Modification of GCS
Glasgow-Liege Scale
– includes brainstem reflexes
– increases prediction of outcome
from 76% to 90% with a .9 confidence level
Modification of the GCS
Brainstem reflexes/scoring the GLCS
fronto-orbicluar
5
vertical-oculocephalics
4
pupillary reaction to light
3
horizontal-oculocephalics
2
oculo-cardiac
1
none
0
Epidemiology
• 7-8 million “head injuries”/year
• 1.5-2.0 million/year with LOC/amnesia
- 80% considered minor
Epidemiology
• Trauma: leading cause of death age 1-19
• head injury direct cause in 30-50%
• major factor in 75%
in MVA’s:
75% have head injuries
20% have spinal cord injuries
Epidemiology
Head injury overview:
• 1:10 has loss of consciousness
• 250-500,00 hospitalizations/year
• 4,000 deaths/year
• 15-20,000 prolonged hospitalizations/year
Demographics
Compared to severe head injuries:
generally younger
• higher frequency of students
• percentage of males is less
• alcohol less frequently involved
Demographics
Pediatric head Injury
• higher death rate under the age of two
• bimodal distribution- bikes/cars
• 90% are closed, non-penetrating
• mortality; 1-5%
but rises to 17% if coma >12hr.
• 10% of the deaths are < ten years of age
Demographics
• Children aren’t little adults
• Infants aren’t little children
Physiology Unique to Children
•
•
•
•
•
Skull
relation to spine
deformability
thickness
open sutures
open fontanel
Physiology Unique to Children
Meninges
• wider subarachnoid space over
convexity(shear/tear), over all smaller
in proportion to brain (less buoyancy)
• dura adherently applied to bone
Physiology Unique to Children
Brain
• Increased water content
• autoregulatory mechanisms
• pressure/volume compliance shifted left
• contracoup
• post traumatic unconsciousness
Pediatric post-concussive
Syndrome
Characteristics:
• Stunned/unresponsive
• pupils dilated,fixed or
anisocoric
• bradycardia
• pallor
• perspiration
• vomiting
Mechanism:
1. most likely
vasovagal effect
2. some consider
post-traumatic
seizure effect
Treatment
Efficacy of head trauma sheets
• 66% referred to the document
• 84% found it answered all questions
Sequellae; at 48 hours
•
•
•
•
headaches
dizziness
sleepy
naus/vomit
51%
14%
14%
12%
•
•
•
•
•
behavioral changes
memory deficits
visual changes
hearing problems
pupillary change
7%
5%
3%
2%
1.5%
Sequellae
• At one week these signs and symptoms are
approximately halved
• 27% yet to return to normal function at
48hr, 13% at by one week
• 50% with residual complaints at 3 months
• recovery from cognitive deficits;1-3months
Sequellae
• 10-15% have surgical lesions
• EDH, SDH, ICH, Depressed skull Fx
• <1% demonstrate talk and die phenomena
sequellae
Post Traumatic Seizures
In isolation; impact or early sz (<1 week);
– not indicative of severe head injury
– not indicative of inc. risk for epilepsy
– 50% occurred in mild group with normal CT
– No role for anticonvulsants
Classification of Injury
•
•
•
•
Primary
scalp: laceration, avulsion
skull Fx: “ping-pong” linear , depressed
open/closed, comminuted, basilar
neck: soft tissue, bone, vascular
brain: focal, diffuse
Primary Head Injuries
Skull fractures of concern:
• open,depressed
• crosses suture lines
• crosses known vascular channels
– arterial
– dural sinuses
• enters into sinuses
• basilar
Classification of Head Injury
Secondary
•
•
•
•
•
•
•
swelling
hemorrhage
edema
vasospasm
seizures
hypotension
ischemia
• Metabolic
hypoxia/hypercarbia
hypo/hypernatremia
hyperglycemia
• hormonal dysregulation
• dysautonomia
• nutritional
CT Scans of Intracranial Hemorrhage
Mechanism of Injury
Translational
• linear
• focal
Accelerationdeceleration
• rotational
• concussive-shearing
forces
Mechanisms of injury
Age Related
• birth injury; skull fx via canal vs forceps, CN
posterior fossa SDH
• infant/toddler; falls, abuse
• children falls, bikes, pedestrian-MVA, bike-MVA
• teens; falls, MVA, assaults
Triage
Approach/attitude
• apparent stability DOES NOT=
insignificant injury
• stay directed, utilize protocols- avoid inertia
• repeat neurologic exam looking for change
• consider the mechanism of injury-think broadly
• alcohol level <.2 doesn’t alter neurologic much,
but consider drug effect
Triage
History
• mechanism of injury (should “fit” what you see)
• neurologic- recent, remote; baseline, SZ, HI
• general-medical, drugs
• psychological/educational
Triage
•
•
•
•
Physical Exam
CGLCS
• reflexes
– DTR
pupils
– cutaneous
respiratory pattern
• mental status
sensory modalities
SEARCH FOR FOCALITY!
Signs of Rostro-caudal
deterioration
•
•
•
•
•
decreased LOC
headache
vomiting
visual changes
pupilary change
• Cushing Triad
• loss of function
– motor/sensory
• respiratory pattern
change
Triage
As A Rule
Any pupillary inequality> 1 mm in a head
injured child must be attributed to an
intracranial injury until proven otherwise
Pathophysiology
Monroe-Kellie doctrine
• three compartments
blood
brain
CSF
• change in one requires reciprocal change in
the others
Clinical Findings in 4500
pediatric head injuries
• Initial LOC
normal
confused
%
56.0
30.2
major impairment
• Vomiting
• Skull Fx
linear
depressed
compound
13.8
30.3
26.6
72.8
27.2
19.7
•
•
•
•
•
•
•
•
Seizures
paralysis
pupil abn
retinal hem
subdural hem
epidural hem
major sequellae
mortality
7.4
3.8
3.6
2.6
5.2
0.9
5.9
5.4
Clinical Profile from 937
Pediatric Head Injuries
•
•
•
•
•
•
•
•
84% CGCS 13-15
Mean age 5.5
Males>females 2:1
Falls>pedestrian/MVA
75% “alert” on admission
13% had surgical lesions
0.3% with CGCS died
avg. length of stay ; 2.8 days
Clinical profile
Presence of Mass lesions
Glasgow Coma Scale 15: 7.1 %
Glasgow Coma Scale 14: 9.7 %
Glasgow Coma Scale 13: 13.6 %
Identifying Risk Facteurs
• LOC >16 minutes =>45X>risk of poor outcome
• small punctate hem/ contusion on CT did not
adversely effect outcome compared to normal CT.
• Linear,basilar,depressed skull Fxs did Not effect
outcome
• Diastatic and compound depressed skull Fxs had
poor outcomes respectively 50% vs 14%
Identifying Risk Facteurs
• GCGS and the patient’s MENTAL
STATUS were the best predicteurs of
potential deterioration or the presence
of a mass lesion
Identifying risk facteurs
Skull X-ray; what role if any??
• Not essential for decision making process
HOWEVER
–
–
–
–
presence=>inc risk of lesion\deterioration
useful in penetrating injuries
useful in Non-accidental trauma
useful in following growing Fx of childhood
Etiologies of delayed detoriation
•
•
•
•
Mass lesions: EDH/SDH/ICH
electrolyte imbalance
cerebral edema
seizures
Recommendations
• Glasgow Coma Scale 13-14:
CT scan and admit for observation
• Glasgow Coma Scale 15 with normal
neurologic exam/mental status, and
normal CT; discharge with home
observation . CT optional?
• Relevance of duration/presence of
LOC- varied opinion.
Recommendations;Concussion
and Sports
• Confusion w/o amnesia/LOC
asymptomatic; observation 1/2 hr
• confusion with amnesia , no LOC
observe 24 hr, asymptomatic
return to activity after one week
• LOC; formal medical evaluation
asymptomatic return to activity in 2-4 wks
Fail-Safe vs the Doomsday EDH
• Small percentage(<1%) will develop
a delayed lesion with Normal original CT
– In patients with abnormal CT scans:
30% of patients:
• develop a delayed lesion not present on
first CT or worsening of original lesion
• Most will occur within the first 24-36 hrs
Bicycle Facts
•
•
•
•
400,000 Rx/yr 1/3 HI
300deaths/yr 80% HI
annual cost:$8 billion
2200/yr sustain
permanent disability,
helmets would
prevent 1700
• helmets reduce risk of
injury85%
• Helmet laws have
reduced mortality 80%
• Bikes are assoc with
more childhood injury
than any other
consumer product
operated by children
• Universal use of
helmets would prevent
one HI every 4 min
and save a life DAILY
Is it a crap shoot?
KNOWLEDGE
IS
POWER