2/1/2013

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Clarifying Murky Waters: Head and Cervical Spine

Injuries in Children

Judith R. Klein, MD, FACEPAssistant Professor of Emergency Medicine

UCSF-SFGH Emergency Services

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Objectives

Ø Is observation enough?Ø Whom to image?Ø How to image?Skull films vs. CTRole for ultrasound?C spine plain films vs CT

vs MRIØ Whom to admit?

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Pediatric head trauma: what’s the big deal?

#1 cause of death age 1-14 years 70% of fatal child

injuries >7K deaths 60K hospitalizations, >600K ED visits per

year

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Why worry?

3 to 6% incidence of TBI post minor head trauma

Up to 20% of kids < 2 years old with TBI are asymptomatic!

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Who gets imaged? 40-50% with CHI to ED get imaged!!Higher CT rates:

white race older general vs pediatric hospital emergent triage status attending treated

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Implications of imaging

Cognitive development Lifetime cancer risk

from 1 head CT: 1:1500 (1 yr old) 1:5000 (10 yr old)

< 10% of CT’s have any TBI

0.5% of CT’s with clinically important (CI) TBI

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GCS>14: To CT or not To CT?? Reduce # of CT’s

performed Radiation/brain dev Sedation $$$$

Identify all TBI or just CI TBI? NSU intervention Hospital >2

nights/intubation>24 hrs

Death/long term neurological sequelae

CancerIdentify TBIIQ

$$$Sedation

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The Science

Several CDRs availableOnly 2 included infants PECARN rule the best:

Largest, 25 centers Lots of young kids Clear reference

standard for CI TBI Best validation

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PECARN Minor Head Trauma Decision Rule

Derivation and validation study

42K kids GCS>14: >10K under 2 yrs

2 years:

99.9% NPV for CI TBI 98.4% NPV for all TBI

CT by 20-25%Kuppermann, Lancet 2009

Why identify all TBI: implications for sports/other activities?

Kuppermann et al. Lancet 2009

Under 2 years old

Why identify all TBI: implications for sports/other activities?

Kuppermann et al. Lancet 2009

Over 2 years old

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Severe MechanismMVA with ejection, rollover or death of

another occupant Pedestrian or bike w/o helmet

vs. car Fall >3 ft (5 ft (>2 yr)High impact object to

head

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Back to Baby Leo

Imaging? A good idea..

Imaging for 3 ft fall

Thin skulleasily fracturedstrong correlation with TBI

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Well, can I just do a skull x-ray?

Skull film cons: Hard to read Not sensitive/specific

enough If (+) still need to do

CT

CT cons: Radiation Cost Transport from ED Sedation

Survey says: CT

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Ultrasound and skull fracture?

Skull fx 4-20x likelihood of TBI 15-30% with skull fx TBI Prospective study*:

55 patients 100% sensitivity 95% specificity

Include in CDR for low risk? If US +, then CT? If US -,

observe?15

*Parri, J Emerg Med 2012. 16

Baby Leo gets a CT How do I keep him

still? Swaddle Dextrose H20 Acetaminophen

CT shows a skull fracture over posterior fossa

Admit? YES

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Admit criteria for skull fracture

Very young-->higher bleeding risk

Depressed Widely diastatic High energy mechanism High risk location

(sutures, posterior fossa, dural sinus)

Poor home situation

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Case #2: Wild Bill

20 month old rolls down 12 stairs

“Few seconds of LOC” Cried. Ate.

Physical Exam: GCS? Talk his language 3 cm temporal

hematoma To CT or not to CT?

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Wild Bill: CT or Observation?

Rule: CT or 6 hour obs for all < 2 years with non-frontal scalp hematoma Location, location…:

• Temporal > parieto-occipital > frontal

Severe mechanism?: • Stairs vs. straight fall

LOC too brief to count but...

Verdict: Very careful observation or CT

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Keeping Bill Still

Sedation choices: Ketamine is OK Rectal methohexital Dexmedetomidine IV/IM pentobarbital Etomidate Avoid versed

CT (+) epidural: Admit

Brutane

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Case #3: The Car’s a Mess...

5 year old helmeted bike vs low speed MV

No LOC V x 3 en route Mild headache PE:

Playing Small parietal scalp

hematoma To CT or not to CT?

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Let’s talk observation

> 2 years Isolated vomiting No LOC Non-severe

mechanism Mild headache Consider observation

if parents comfortable

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Discharge home?

Criteria: Normal MS Vomiting controlled No abuse suspected Responsible home/

reliable transportation Normal head CT*

Confused after neg CT? Observe x 4-6 hrs

-->admit if still abnlHolmes, Annals EM, 2011.

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Case #4: Tell me again what happened to Jane?

18 mo old BIB father Vomiting x 3 days “Tripped at daycare”

4 days ago PE: somnolent CT by criteria: +SAH! What do you do?

Neurosurgery Admit Child Protective

Services (CPS)

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Epidemic: Non-accidental trauma (NAT)

6-10% of pediatric trauma: NAT

#1 NAT mortality: head injury

Suspect NAT: (+) CT: minor/no

reported trauma Delayed presentation Changing history Other injuries

inconsistent with reported mechanism

Retinal hemorrhages*

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Nutshell: Whom to CT after trauma?

5 seconds LOC• Not acting normally per parent• Severe mechanism

> 2 years:• AMS• Sx basilar skull fracture• Vomiting• Severe HA• LOC• Severe mechanism

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Nutshell (cont): Whom to admit?:

All TBI High risk skull fractures

• Depressed• Wide diastasis• Very young• High energy mechanism• High bleeding risk

Persistent AMS after observation Poor social/transport situation Suspected abuse Neurosurgery discretion

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Return to sports post concussion

Grading systems not useful

Stepwise return to play based on sx: No activity Light aerobic Sports specific

exercise Non contact drills Contact practice Return to play

Halstead, Pediatrics 2010

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Case #5: Do you have neck pain??

6 month old rear car-seat passenger MVA-rear-ended

Car-seat/patient in place

PE: VS nl. Happy, no signs of trauma

How do I clear the c-spine?

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Some background on pediatric c-spine injuries

Uncommon injury (3x more common in adults)

More common in older kids (> 8 years)

Leading causes: MVA (8 yrs) PVA

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Kids aren’t just little adults… Unique anatomy:

Large head high fulcrum

Higher injuries more common in < 8 year old

Horizontal facets slippage/dislocation

Less neck muscle More pre-vertebral soft

tissue > 8 years more like

adult

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Clearing little c-spines NEXUS:

3065 kids 30 CS injuries:

• Only 4 injuries 2-8 years

• None < 2 years Criteria: (100% sens)

• No neck tenderness • No focal neuro sx• No distracting injury• Normal MS• No intoxication

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Applying NEXUS criteria

187 kids with c-spine injury-->NEXUS rules applied: 32 kids < 8 yrs: 94%

sensitivity 155 kids > 8 yrs:

100% sensitivity

*Garton, Neurosurgery, 2008.

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PECARN: Risk factors for CSI 540 CSI cases/1060 controlsRisk factors:

AMS/focal neuro sx Neck pain/torticollis Significant torso injury High risk condition Diving/high risk MVA

98% sensitive CT use by 25%

34Leonard, Annals EM, 2011.

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Modified NEXUS: Clearing younger c-spines

Age appropriate MS/no LOC/no focal neuro sx

No distracting injury/significant torso injury

No neck tenderness or pain/muscle spasm

Low force mechanism....

Let them look around 36

Case # 6: Johnny Walker 5 yr old 20 mph PVA BIBA with (+) LOC Now awake/alert No c/o of neck pain or

neurological sx Open leg fracture Image: YES

LOC Distracting injury High force mechanism

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Choosing an imaging modality Retrospective study:

206 kids with CSI Plain XR:

• 7yrs: 93% sensitive Missed:

• AMS• Intubated• Focal sx

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Nigrovic Peds Emerg Care 2012

AMS?Focal neuro sx?

Intubated?Hx/PE concerning

(torticollis/major torso injury)?

Full cervical spine CT or MRI

yes

8 years Attempt clinical clearance with NEXUS

criteria-Normal mental status/no intoxication

-No neck pain or tenderness-Normal neurological exam

-No distracting injury

pass

clinically clear

fail

Start with 3 view plain X-rays

abnl or inadequate

Full cervical spine CT

Pediatric Cervical Spine Clearance

normal

attempt clinical clearance

normal

attempt clinical clearance

*Low force mechanism:-Fall

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Nutshell:

Whom to image? Neck pain/tenderness/spasm Focal neurological

symptoms /signs Distracting injury/significant

torso injury AMS/LOC/intoxication High force mechanism Unwilling to look around/

“guarding” neck

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Nutshell (cont): Try to avoid reflex CT in

kids How to image?

CT first if:• Very positive history/PE• Significant AMS

Otherwise:• Consider AP/Lat XR plus

occiput to C3 CT if 8 yrs

If one fracture, image whole spine

How to manage? Immobilization/NSU Steroids-your call

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