CRANIUM; IT’S NOT JUST A GAME:
MILD & MODERATE TRAUMATIC
BRAIN INJURIES IN CHILDREN
Andrew W. Kiragu, MD, FAAP
Interim Chief of Pediatrics
Medical Director, PICU
Hennepin County Medical Center
Assistant Professor of Pediatrics
University of Minnesota
FACES OF TBI
Disclosures
•
I have no relevant financial relationships with the
manufacturers of any commercial products and/or
commercial services discussed in this CME activity
•
I do not intend to discuss any unapproved
commercial product/device in this presentation
GOALS OF THE
PRESENTATION
•
Discuss a representative case of pediatric TBI
•
Review epidemiology, evaluation and initial
management of traumatic brain injury
•
Briefly review pathophysiology of TBI
•
Review other aspects of TBI management including
follow-up, family-centered care and injury prevention
GOALS OF THE
PRESENTATION
•
Discuss a representative case of pediatric TBI
•
Review epidemiology, evaluation and initial
management of traumatic brain injury
•
Briefly review pathophysiology of TBI
•
Review other aspects of TBI management including
follow-up, family-centered care and injury prevention
CASE REPORT
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Patient FP is an 11 year-old boy who presented to the ED
after being struck by a vehicle while riding his bicycle.
•
He was out riding with his friends and they had been going
fairly fast downhill when he swerved to avoid an object on
the road.
•
Swerved into the path of a slow moving truck, was struck
and flung off his bike.
•
Landed on the pavement and struck his unhelmeted head.
He was observed to lose consciousness for about 2-3
minutes.
CASE REPORT
•
The driver called 911 and
paramedics arrived to find him
still lying on the sidewalk
somnolent but rousable
•
He opened his eyes to voice,
was able to talk but was
confused and could only
localize pain
CASE REPORT
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Initial GCS 12 (E3, V4, M5)
•
He was transported to the ED
for additional evaluation and
treatment
CASE REPORT
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Initial Vital signs: T36.7 C, HR124, RR20, BP110/56, SpO2
98% on RA
•
Gen: more awake and somewhat combative. Bruise and
swelling noted over forehead and large abrasion noted of
right forearm
•
HEENT: NC, swelling and bruising of forehead, PERRL, no
nasal dc,
•
Chest: CTA B
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CV: nl S1S2, RR increased heart rate
CASE REPORT
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Abdomen: soft, NT, NABS, no HSM
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Ext: abrasion of R forearm, MAE, WWP
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Neuro: awake but somewhat combative, intermittently following
commands, GCS 14(E4, V4, M6)
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Taken for head CT which significant for two small punctate
hemorrhage in frontal lobe. Soft tissue swelling of forehead seen.
No fracture
•
Labs in ED including electrolytes and CBC normal
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Sent to PICU for overnight observation
EPIDEMIOLOGY
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There are approximately 1.7 million traumatic brain
injuries sustained in the US annually
•
50,000 die;
•
235,000 are hospitalized; and
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1.1 million are treated and released from an
emergency department.
EPIDEMIOLOGY
•
Over 85% of the 1.7 million TBI’s occurring annually in
the US are considered mild.
•
The average incidence of mild TBI was 503.1 per 100,000
population, with a peak among American Indians/Alaska
Natives (1026/100,000 population) and in children
younger than 5 years old (1115.2/100,000 population).
•
The mechanisms by which children sustain head injury
vary by activity, age, helmet use, and geographic location.
EPIDEMIOLOGY
•
Among children aged 0 to 14, TBI results in over
400,000 ED visits, 2685 deaths and 37,000
hospitalizations each year. Injury rates are highest
among children 0 to 4.
•
Approximately 50% of patients hospitalized with TBI
are younger than 20
INTRODUCTION
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The term concussion has been used
interchangeably with mild traumatic brain injury (TBI)
•
Defined as a trauma-induced alteration in mental
status that may or may not involve the loss of
consciousness (LOC).
•
Cerebral concussion is considered a diffuse brain
injury and is associated with widespread disruption
of brain function.
INTRODUCTION
Wing, R & James, C; Emerg Med Clin N Am 31 (2013) 653–675
INTRODUCTION
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Not usually associated with visible lesions that can
be detected by current imaging techniques.
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The primary injury mechanism for a concussion is
thought to be from a rotational acceleration force .
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No head injury should be considered minor.
EPIDEMIOLOGY
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Falls
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Motor vehicle crashes
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Sports and recreational injuries
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Violence including child abuse and child on child
violence
EPIDEMIOLOGY
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Severity
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Mild 80-85%
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Moderate to Severe 12-15%
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Fatal 4-5%
EPIDEMIOLOGY
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Average cost of hospitalization for a child with mild TBI
$10,000 up to $3+ million for severe TBI leading to PVS.
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The annual cost of hospitalization for TBI estimated in
the US at $100 billion.
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Immeasurable price to individual and family and to
society as a whole.
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Head injury the single greatest cause of lost potential
productivity in children.
EVALUATION
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History
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Physical Examination
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Laboratory evaluation
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Imaging
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Cognitive evaluation/Neuropsychology
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PT/OT/SLP
EVALUATION
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Primary Survey
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Neurologic Assessment
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Airway
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Pupillary response
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Breathing
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Responsiveness
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Circulation
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Glasgow Coma Scale
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Disability
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Modified Glasgow
Coma Scale
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Exposure
EVALUATION
Wing, R & James, C; Emerg Med Clin N Am 31 (2013) 653–675
EVALUATION
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Head CT imaging an important tool in the management
of TBI.
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Provides valuable information regarding the type,
location, and severity of intracranial injuries, skull
fractures, and cervical spine injuries.
•
Newer improved technology allows faster and more
detailed imaging to be obtained.
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Unfortunately, increased CT use leads to increased
radiation exposure as well as increased costs
EVALUATION
Advances in Imaging: MRI
DTI Tractography
RISK FACTORS FOR
DELAYED
COMPLICATIONS
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Age of less than 2 years a moderate risk factor for
ICI after head trauma.
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Lower threshold for imaging studies of younger
children because historical and clinical factors may
not be available or present for assessment
PECARN Guidelines
Kupperman, n et al. Lancet 2009; 374: 1160–70
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
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Impact -head striking a surface
or being struck by object
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Inertial (translational, rotational
or both)
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Penetrating
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Anoxic
PATHOPHYSIOLOGY
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Are potentially preventable and are caused by:
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Hypoxia/ischemia
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Energy failure
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Brain swelling/edema
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Excitotoxicity
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Necrosis/Apoptosis
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Inflammation
SPORTS CONCUSSIONS
SPORTS CONCUSSIONS
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High concussion risk organized sports such as
wrestling and boxing described as early as 776 BC
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Sports related concussions recognized historically
but remain a frequent and controversial topic
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Increased concern, awareness and prevention
efforts including at the legislative level
SPORTS CONCUSSIONS
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Differences between sports
concussions and concussions
from other etiologies
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Sports concussions a particular
problem in pediatrics
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Children at increased risk
SPORTS CONCUSSIONS
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More than 300 000 sport-related concussions occur
annually in the United States
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More than 60 000 cases of concussions occur at the
high school level, with football accounting for the
majority of these.
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Approximately 4% of high school and collegiate football
players sustain concussions during each season.
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1 250 000 student-athletes participating at the high
school level
SPORTS CONCUSSIONS
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Recent concerns over the health of athletes who
sustain concussions.
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Practice guidelines and parameters for evaluating
and managing the head-injured athlete have been
developed.
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The various guidelines released have raised
controversy since not enough data on concussion
grades and return-to-play criteria
SPORTS CONCUSSIONS
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Baseline and post concussion neuropsychological
testing
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ImPACT testing (Immediate Post-Concussion
Assessment and Cognitive Testing)
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Return to play guidelines
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Return to school guidelines
SPORTS CONCUSSIONS
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Heads Up Campaign-CDC
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Information for coaches,
parents and student athletes
regarding concussions
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Guidelines for recognition and
treatment
SPORTS CONCUSSIONS
SPORTS CONCUSSIONS
Thiessen, ML & Woolridge, DP; Pediatr Clin N Am 53 (2006) 1 – 26
SPORTS CONCUSSIONS
Thiessen, ML & Woolridge, DP; Pediatr Clin N Am 53 (2006) 1 – 26
OUTCOMES OF MTBI
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Related to:
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Severity of injury
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Severity of intracranial hypertension
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Secondary brain injuries
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20% of mild brain injury have some deficit
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90-100% of moderate to severe will have deficit
OUTCOMES OF MTBI
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Neurologic sequelae
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motor deficits
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sensory deficits
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hearing and vision should be formally tested
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Communication difficulties
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Cognitive deficits
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Behavioral problems
OUTCOMES OF MTBI
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The short- and long-term complications of mild TBI
in children are poorly understood.
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Postconcussive syndrome refers to the constellation
of acute symptoms after a mild TBI.
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These symptoms can be somatic (headache,
dizziness, blurriness), emotional (irritability, anxiety),
and cognitive (concentration and memory)
POST-CONCUSSION
SYNDROME
POST-CONCUSSION
SYNDROME
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Studies have assessed physical, behavioral, and
cognitive outcomes across the severity continuum of
head injuries.
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Speech and feeding difficulties associated with an
increasing severity of head injury, but not walking.
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Headaches are among the most common
postconcussive symptoms reported
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Also, temper outbursts, dizziness, mood swings, anxiety,
and aggressive behavior have been reported.
POST-CONCUSSION
SYNDROME
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Children with mild TBI do well in their recovery, but
studies have found that not all mildly injured children
recover completely.
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In one study 50% of the study group made a good
recovery, but only 18.4% made a full recovery
without discernible sequelae.
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Unclear what the threshold of injury severity below
which the risk of late morbidity could be discounted.
CTE
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Concerns about effects of repetitive head trauma
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Recent professional athlete cases
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NFL money for research etc.
Rehabilitation
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Treatment directed at maximizing functional
independence by reducing impairment, disability and
handicap.
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Early intervention.
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Interdisciplinary team effort/organization.
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Short-term rehabilitation- consider intra-facility resources
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Long-term rehabilitation-specialized facility(note agerestrictions)
RETURN TO SCHOOL
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When children with head injury return to school, they
may be expected to assimilate immediately with the
class.
•
The child’s teacher may not understand the head injury
or even know the child suffered a MHI, which could
affect how the child is treated, observed, or graded.
•
In one study, teachers knew of the child’s head injury in
only 39.8% of the children, and there was a significant
linear trend across injury severity groups.
RETURN TO SCHOOL
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Special educational needs were provided for only
65% of the children identified with such needs.
•
At follow-up, 18.7% of the children were currently
having difficulties with schoolwork
•
Interestingly, 18% of the children had been
disciplined by the school for problem behavior after
sustaining their head injury
Return to Play
Wing, R & James, C; Emerg Med Clin N Am 31 (2013) 653–675
FOLLOW-UP
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Pediatric Traumatic Brain Injury Clinic
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Mild/Moderate TBI Clinic
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Primary care Physicians
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Return to school
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Return to sports
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PT/OT/Neuropsychology/SLP
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Brain Injury Association of Minnesota
PREVENTION
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All head trauma is potentially preventable.
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Ensure a safe environment for kids.
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Educate regarding motor safety.
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Emphasize helmet use, age-appropriate MV restraints
to prevent or attenuate injury.
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Educate about guns (limit access).
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Educate about prevention of inflicted head injuries.
PREVENTION
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Heads Up Campaign by CDC
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National and regional injury
prevention programs
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Role of pediatricians
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State and federal legislation
RESEARCH
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Need for ongoing research into
brain injury treatment
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Need for increased federal and
foundation funding for
traumatic brain injury.
Conclusions
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Traumatic brain injuries are a common cause of morbidity and
mortality in children
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Damage to the brain cannot be reversed
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Sports related concussions are a continued problem for the
pediatric population
•
Advances in management of MTBI offer hope for improved
outcomes
•
Research into the pathophysiology of MTBI crucial
•
PREVENTION IS KEY
QUESTIONS?