10/15/2015 Driscoll Children’s Hospital Presents When Elsa Slips…. More Than Brain Freeze: Pediatric Head Trauma Alicia Hart, MD, FACEP, FAAFP CCMC Trauma Medical Director Del Mar EMS Medical Director Why Are We Here? • Develop a strategy for the evaluation of pediatric head trauma. • Learn the types of pediatric head injuries. • Discuss the management of minor head injury. • Discuss the management of moderate and severe head trauma. • Identify risk factors and signs of non-accidental trauma. • Head injuries account for ~500,000 ED visits, 37,000 hospitalizations, and >2000 deaths every year in the United States 1
10/15/2015 Olaf • Olaf is a delightful and active 2 year old boy. He loves warm hugs and summertime. His grandma came over to visit. In his excitement to run to grandma, he slipped and fell. He hit his occiput on the tile floor of his home. There was no LOC. • When you enter the exam room, Olaf is playing with a toy and drinking from a sippy cup. Minor Head Trauma • Healthy child that is over 2 years old. • GCS of 14-15 at initial exam. • No abnormal or focal neuro findings. • No sign of skull fracture. • No severe mechanism. • No vomiting. PECARN • Pediatric Emergency Care Applied Research Network • Studied 42,412 children in 25 North American pediatric ED • Who do we need to image to detect CLINICALLY SIGNIFICANT head injuries? 2
10/15/2015 Olaf’s Disposition • After a thorough physical exam.... – We will discuss head injury precautions and recommend follow up with the patient’s doctor. – Discuss reasons to return to the ED. – We will advise AGAINST imaging. – Discharge Olaf home. 3
10/15/2015 Kristoff and Sven Kristoff is an adventurous 7 y/o boy and Sven is his 5 y/o tag-a-long brother. They were riding through the neighborhood on the spiffy new motorized scooter he got for Christmas. He ran into a parked car. Neither child was wearing a helmet. There was no LOC in either child. Sven has been vomiting and has been acting “whiny” according to mom. Kristoff is complaining of a mild headache. Sven-Physical Exam • An adorable 5 y/o male that is developmentally appropriate. • He is vomiting during the exam. He tells you “my head hurts”. • You note a 3 cm hematoma to the occiput. No focal neuro deficits. • Mother is anxious and appropriate. She reports that dad is a trial attorney and is on his way to the hospital. Intermediate Risk Patients • Seizures • LOC • Amnesia • Vomiting • Age less than 2 years • Nonfrontal scalp hematoma in children younger than one year of age • Persistent or worsening headache • Significant trauma mechanism 4
10/15/2015 What do we do with the Intermediate Risk Patient? • Neuroimaging? – The lifetime risk of death due to cancer caused by radiation from one head CT • 1 in 1500 in a one year old infant • 1 in 5000 in a 10 year old child • Shared Decision Making – Observation for 4-6 hours Discharge Criteria • No suspicion of inflicted injury • Easily arousable with light touch with normal GCS • Return to baseline • If vomiting, able to tolerate fluids • No other injuries requiring admit • Competent caregivers who can follow discharge instructions Discharge Instructions • Return if – Persistent or worsening headaches – Vomiting – Change in mental status or behavior – Unsteady gait – Seizure or LOC – Bloody/clear rhinorrhea or otorrhea – Focal weakness or numbness – Irritability – Difficulty staying awake or being aroused 5
10/15/2015 Elsa • Elsa is a sweet 8 y/o girl who loves playing dress up. She put on her mom’s heels and was playing with her sister. She tripped and fell down one flight of stairs. She landed on tile. Her mother found her unconscious after hearing the fall. • 911 was notified and the child arrived fully immobilized. She has a large temporal hematoma. She is vomiting. Her GCS is 9. Types of Brain Injury • Diffuse brain injury – Occurs from acceleration or deceleration injuries – Mildest form-concussion • Diffuse axonal injury – Severe form of diffuse brain injury – Shearing at the interface of the gray and white matter • Focal injuries – Contusions or intracranial hemorrhages • Epidural hematoma • Subdural hematoma • Subarachnoid hemorrhage Subdural Hematoma 6
10/15/2015 Epidural Hematoma Subarachnoid Hemorrhage Intracranial Hemorrhage 7
10/15/2015 Management of Severe Brain Injury • Airway and breathing – Consider RSI • Fluid Management • Head positioning – 30 degrees • Sedation • Seizure prophylaxis • Avoid hyperthermia/hypothermia • Hyperosmolar therapy • Neurosurgery consultation and transfer to trauma center Who do we have to image? • History – Witnessed LOC >5 minutes – History of amnesia >5 minutes – Abnormal drowsiness – Three or more episodes of vomiting – Suspicion of non accidental trauma – Seizure in a patient with no history of epilepsy Who do we have to image? • Examination – GCS <14 or GCS <15 if <1 year old – Penetrating trauma or depressed skull injury – Tense fontanelle – Signs of a basilar skull fracture – Focal neuro deficits – Bruise, swelling, or laceration >5 cm if <1 year old 8
10/15/2015 Who do we have to image? • Mechanism – High speed traffic accident >40 mph – Fall >3 m – High speed injury from a projectile or an object Anna Anna is an 8 month old infant who is brought in by her foster parents. She was brought in for vomiting and “sleeping too much.” Foster mom reports the baby rolled off the couch a few days ago. Vaccines are not up to date. The baby’s parents were killed in a boating accident and she was placed in foster care about 6 weeks ago. Physical Exam • Child is lethargic and irritable. She is dirty. • Multiple areas of bruising in various stages of healing. • She has tenderness to her upper arms and legs. • She appears to have retinal hemorrhages. 9
10/15/2015 Evaluation of suspected nonaccidental trauma • High level of suspicion • Laboratory studies – CBC, coags, electrolytes, liver function panel • Imaging – CT, MRI, skeletal survey • Ophthalmologic exam Retinal Hemorrhages Posterior Rib Fractures 10
10/15/2015 Shaken Baby Findings on MRI Management • Stabilize critical issues. • Multidisciplinary team to address the concerns and document concerns of abuse. • Protect the child. Prevention of Head Injuries • Helmet Education • Car safety Seat checks • Public education about head injuries • Public education about shaken baby syndrome. • Home visitation to high risk homes. 11
10/15/2015 LET IT GO!! • No more CT imaging of low risk head injuries • Use of clinical decision rules to help decide who really needs imaging • Use of extended observation to reduce imaging • Use of shared decision making 12
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