minor head trauma in children and adolescents
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Minor Head Trauma in Children and Adolescents. Bill Ahrens The University of Illinois at Chicago. MHT. An extraordinarily common problem Obvious sequelae are uncommon Recommendations characterized by lack of standard definition lack of prospective studies . MHT. - PowerPoint PPT PresentationTRANSCRIPT
Minor Head Trauma in Minor Head Trauma in Children and Children and AdolescentsAdolescents
Bill AhrensBill AhrensThe University of Illinois at The University of Illinois at
ChicagoChicago
MHTMHT►An extraordinarily common problemAn extraordinarily common problem►Obvious sequelae are uncommonObvious sequelae are uncommon►Recommendations characterized byRecommendations characterized by
lack of standard definitionlack of standard definition lack of prospective studies lack of prospective studies
MHTMHT►For the purposes of this lecture MHT For the purposes of this lecture MHT
will be considered to involve:will be considered to involve: a relatively trivial mechanism of injurya relatively trivial mechanism of injury a patient with a GCS of 15 on arrival to a patient with a GCS of 15 on arrival to
the EDthe ED no evidence of skull fracture no evidence of skull fracture Retrograde/posttraumatic amnesiaRetrograde/posttraumatic amnesia ??? Brief LOC ??? ??? Brief LOC ???
MHTMHT►Key questions for the evaluating Key questions for the evaluating
physician include:physician include: What is the appropriate evaluation?What is the appropriate evaluation? What radiographic studies are necessary?What radiographic studies are necessary? What is the disposition of the patient?What is the disposition of the patient? When can the patient resume activity?When can the patient resume activity? Are there sequelaeAre there sequelae
MHTMHT►Radioimaging in the ED: the goal is to Radioimaging in the ED: the goal is to
diagnose neurosurgical emergenciesdiagnose neurosurgical emergencies Skull FilmsSkull Films CT ScanningCT Scanning
MHTMHT►What is known (more or less)What is known (more or less)
Intracranial lesions ( per CT scanning) are not Intracranial lesions ( per CT scanning) are not rare in pediatric patients with MHTrare in pediatric patients with MHT
A normal neurologic exam does not exclude A normal neurologic exam does not exclude an injury—especially in infantsan injury—especially in infants
The overwhelming majority of intracranial The overwhelming majority of intracranial lesions in children with MHT are nonoperativelesions in children with MHT are nonoperative
MHTMHT►Skull X-Rays:Skull X-Rays:
Intracranial injuries are associated with Intracranial injuries are associated with skull fracturesskull fractures
Skull fractures are usually associated with Skull fractures are usually associated with swellingswelling
The parietal bone is the most common The parietal bone is the most common site of a skull fracturesite of a skull fracture
Whether skull films can be used as a Whether skull films can be used as a screening tool is controversialscreening tool is controversial
MHTMHT► Infants are different:Infants are different:
Both skull fractures and intracranial Both skull fractures and intracranial injuries are more common in patients less injuries are more common in patients less than 2 years oldthan 2 years old
Infants less than 6 months of age are Infants less than 6 months of age are probably exceptionally vulnerable to probably exceptionally vulnerable to injuryinjury
MHTMHT► Indications for CT scanning:Indications for CT scanning:
Any patient with altered mental status or an Any patient with altered mental status or an abnormal neurological examabnormal neurological exam
Patients less than 2 years of age with Patients less than 2 years of age with symptoms such as vomiting or irritabilitysymptoms such as vomiting or irritability
Patients less than 2 years old with large Patients less than 2 years old with large scalp hematomas, especially non-frontal scalp hematomas, especially non-frontal swellingswelling
Infants less than 3 months—especially if a Infants less than 3 months—especially if a scalp hematoma is presentscalp hematoma is present
MHTMHT►Disposition: Patients with minor head Disposition: Patients with minor head
trauma and a normal CT scan may be trauma and a normal CT scan may be safely discharged– delayed bleeds are safely discharged– delayed bleeds are extremely rareextremely rare
MHT: ConcussionMHT: Concussion►““a clinical syndrome characterized by a clinical syndrome characterized by
the immediate and transient post-the immediate and transient post-traumatic impairment of neural traumatic impairment of neural function such as alteration of function such as alteration of consciousness, disturbance of vision or consciousness, disturbance of vision or equilibrium etc. due to brainstem equilibrium etc. due to brainstem involvement”involvement”
MHT: ConcussionMHT: Concussion►Results from acceleration-deceleration Results from acceleration-deceleration
forces applied to a moving brainforces applied to a moving brain►Shearing forces disrupt normal Shearing forces disrupt normal
neurological elementsneurological elements►Axonal injury, biochemical Axonal injury, biochemical
abnormalities, or microvascular injury abnormalities, or microvascular injury may resultmay result
MHT: ConcussionMHT: Concussion►Prospectively Validated Signs and Prospectively Validated Signs and
Symptoms:Symptoms: Loss of Consciousness ( less than 10%)Loss of Consciousness ( less than 10%) Amnesia (Retrograde---Posttraumatic)Amnesia (Retrograde---Posttraumatic) Attention DeficitAttention Deficit Headache, Dizziness, Blurred VisionHeadache, Dizziness, Blurred Vision
MHT: ConcussionMHT: Concussion►Subjective findings:Subjective findings:
Vacant Stare, Impaired CoordinationVacant Stare, Impaired Coordination Emotional Lability, Sleep DisturbanceEmotional Lability, Sleep Disturbance Lethargy, Behavioral DisturbanceLethargy, Behavioral Disturbance Altered Sense of Taste or SmellAltered Sense of Taste or Smell
MHT: ConcussionMHT: Concussion►Grading the Severity of Injury:Grading the Severity of Injury:
There are 25 published injury severity There are 25 published injury severity scales; many are “sport-specific”scales; many are “sport-specific”
Many rely on history of and duration of Many rely on history of and duration of LOC and duration of Posttraumatic LOC and duration of Posttraumatic AmnesiaAmnesia
More severe injuries would not qualify as More severe injuries would not qualify as MHT and would mandate aggressive MHT and would mandate aggressive evaluationevaluation
MHT: ConcussionMHT: Concussion►““Mild Concussion:”Mild Concussion:”
No Standardized Definition butNo Standardized Definition but 1) Usually characterized by no LOC1) Usually characterized by no LOC 2) Normal neurological examination2) Normal neurological examination 3) Normal “sideline tests” evaluating 3) Normal “sideline tests” evaluating orientation, memory, concentration orientation, memory, concentration
MHT: ConcussionMHT: Concussion►Sequelae of “Mild” Concussion:Sequelae of “Mild” Concussion:
There is evidence for neuropsychiatric There is evidence for neuropsychiatric deficits during the first week following deficits during the first week following mild concussive injury in some patientsmild concussive injury in some patients
After one week there is no consensus After one week there is no consensus regarding time frame for full neurologic regarding time frame for full neurologic recoveryrecovery
Risk of Second Impact Syndrome (SIS)Risk of Second Impact Syndrome (SIS)
MHT: ConcussionMHT: Concussion►Second Impact SyndromeSecond Impact Syndrome
Thought to occur when an athlete sustains a Thought to occur when an athlete sustains a second head injury prior to recovery from an second head injury prior to recovery from an initial head injury, usually a mild concussioninitial head injury, usually a mild concussion
Severe cerebral swelling occurs, which has Severe cerebral swelling occurs, which has been reported to be fatalbeen reported to be fatal
May be similar in pathology to “malignant May be similar in pathology to “malignant brain edema” that is know to occur in children brain edema” that is know to occur in children and adolescents after mild head traumaand adolescents after mild head trauma
MHT: ConcussionMHT: Concussion►Second Impact Syndrome (cont)Second Impact Syndrome (cont)
The pathology of malignant brain edema The pathology of malignant brain edema is though to involve disordered cerebral is though to involve disordered cerebral autoregulationautoregulation
Fear of SSI guides current Fear of SSI guides current recommendations regarding the recommendations regarding the management of concussionmanagement of concussion
In fact the role of repeated concussion as In fact the role of repeated concussion as a cause of SSI is questionablea cause of SSI is questionable
MHT: ConcussionMHT: Concussion►Postconcussion SyndromePostconcussion Syndrome
Clinically characterized by multiple Clinically characterized by multiple physical and cognitive complaintsphysical and cognitive complaints
Etiology is controversial: physical damage Etiology is controversial: physical damage vs emotional sequelae– also possible vs emotional sequelae– also possible genetic vulnerabilitygenetic vulnerability
Cannot be predicted in the immediate Cannot be predicted in the immediate postconcussion periodpostconcussion period
MHT: ConcussionMHT: Concussion►Sequelae of Multiple Concussions:Sequelae of Multiple Concussions:
There is evidence that there is cumulative There is evidence that there is cumulative impairment from repeated mild head impairment from repeated mild head trauma, especially in cognitive functiontrauma, especially in cognitive function
Damage may be subtle and can involve Damage may be subtle and can involve deficits in verbal skills, memory processing, deficits in verbal skills, memory processing, and spatial relationships, coordinationand spatial relationships, coordination
Do some patients have a predestined Do some patients have a predestined trauma reserve?trauma reserve?
MHT: ConcussionMHT: Concussion►There is a growing trend toward There is a growing trend toward
neuropsychologic testing in the neuropsychologic testing in the evaluation of concussion in athletesevaluation of concussion in athletes There are many different types of examsThere are many different types of exams Knowing a baseline is crucialKnowing a baseline is crucial The primary goal is to prevent the return The primary goal is to prevent the return
to competition before the brain has to competition before the brain has healedhealed
MHT: ConcussionMHT: Concussion►New Radiologic Modalities in New Radiologic Modalities in
ConcussionConcussion The CT scan is rarely a useful toolThe CT scan is rarely a useful tool Promising Modalities includePromising Modalities include 1) Functional MRI1) Functional MRI 2) Spect Scanning2) Spect Scanning
MHT: CasesMHT: Cases►A 6 month old boy with a chief A 6 month old boy with a chief
complaint of fever, and by the way he complaint of fever, and by the way he hit his head against the coffee table.hit his head against the coffee table. PE remarkable for:PE remarkable for: 1) left parietal swelling– no palpable fx1) left parietal swelling– no palpable fx 2) normal neurological exam2) normal neurological exam
MHT: CasesMHT: Cases►A 3 year old boy presents with A 3 year old boy presents with
forehead swelling after a fall sustained forehead swelling after a fall sustained when he tripped; no loc; vomited x when he tripped; no loc; vomited x one.one. PE remarkable forPE remarkable for 1) An alert happy child1) An alert happy child
2) A forehead contusion2) A forehead contusion 3) A normal neurological exam3) A normal neurological exam
MHT: CasesMHT: Cases►A 17yo male presents because he A 17yo male presents because he
needs a note to return to baseball; he needs a note to return to baseball; he had a concussion one week prior.had a concussion one week prior. PE remarkable forPE remarkable for 1) An alert oriented patient1) An alert oriented patient 2) Normal neurological exam2) Normal neurological exam