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• simple• reproducible• functional • valid predicteur

• Prejudice against children• doesn’t account for

asymetry• prejudice against facial

injury/intubation• doesn’t account for

brainstem reflexes

• Eye opening: spontaneous 4

to sound 3

to pain 2

none 1

Modification of the GCS

Modification of the GCS

• Verbalization • Appropriate for age 5– fixes and follows – social smile

• cries but consolable 4• persistent irritability 3• restless,lethargy 2• none 1

Modification of the GCS

• Motor Response • Spontaneous 6• localizes to pain

5• withdraws

4• decorticate 3• decerebrate 2• none 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

Compared to severe head injuries: generally younger

• higher frequency of students

• percentage of males is less

• alcohol less frequently involved

Demographics

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 51%• dizziness 14%• sleepy 14%• naus/vomit 12%

• behavioral changes 7%• memory deficits 5%• visual changes 3%• hearing problems 2%• pupillary change 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

• Metabolic

hypoxia/hypercarbia

hypo/hypernatremia

hyperglycemia• hormonal dysregulation• dysautonomia• nutritional

Classification of Head Injury

Secondary • swelling• hemorrhage• edema• vasospasm• seizures• hypotension• ischemia

CT Scans of Intracranial HemorrhageCT Scans of Intracranial Hemorrhage

Mechanism of Injury

Translational• linear• focal

Acceleration-deceleration

• 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

TriageApproach/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

• pupils

• respiratory pattern

• sensory modalities

SEARCH FOR FOCALITY!

• reflexes – DTR– cutaneous

• mental status

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 56.0

confused 30.2

major impairment 13.8

• Vomiting 30.3• Skull Fx 26.6

linear 72.8

depressed 27.2

compound 19.7

• Seizures 7.4

• paralysis 3.8

• pupil abn 3.6

• retinal hem 2.6

• subdural hem 5.2

• epidural hem 0.9

• major sequellae 5.9

• mortality 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 lesionsGlasgow 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?

KNOWLEDGEIS

POWER