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Minor Head Injury In Children

Minor Head Injury In Children. Larry Kleiner Medical Director, Dept of Neurosurgery The Children's Medical Center. Head Trauma. Glasgow Coma Scale 13-15 simple reproducible functional valid predicteur. Prejudice against children doesn’t account for asymetry

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Minor Head Injury In Children

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  1. Minor Head Injury In Children Larry Kleiner Medical Director, Dept of Neurosurgery The Children's Medical Center

  2. Head Trauma

  3. 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 Definition of Mild head injury

  4. Eye opening: spontaneous 4 to sound 3 to pain 2 none 1 Modification of the GCS

  5. 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

  6. Motor Response Spontaneous 6 localizes to pain 5 withdraws 4 decorticate 3 decerebrate 2 none 1 Modification of the GCS

  7. Modification of GCS Glasgow-Liege Scale • includes brainstem reflexes • increases prediction of outcome from 76% to 90% with a .9 confidence level

  8. 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

  9. Epidemiology • 7-8 million “head injuries”/year • 1.5-2.0 million/year with LOC/amnesia - 80% considered minor

  10. 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

  11. 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

  12. Demographics Compared to severe head injuries: generally younger • higher frequency of students • percentage of males is less • alcohol less frequently involved

  13. 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

  14. Demographics • Children aren’t little adults • Infants aren’t little children

  15. Physiology Unique to Children Skull • relation to spine • deformability • thickness • open sutures • open fontanel

  16. 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

  17. Physiology Unique to Children Brain • Increased water content • autoregulatory mechanisms • pressure/volume compliance shifted left • contracoup • post traumatic unconsciousness

  18. 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 Pediatric post-concussive Syndrome

  19. Treatment Efficacy of head trauma sheets • 66% referred to the document • 84% found it answered all questions

  20. 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 48 hours

  21. 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

  22. Sequellae • 10-15% have surgical lesions • EDH, SDH, ICH, Depressed skull Fx • <1% demonstrate talk and die phenomena

  23. 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

  24. 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

  25. Primary Head Injuries Skull fractures of concern: • open,depressed • crosses suture lines • crosses known vascular channels • arterial • dural sinuses • enters into sinuses • basilar

  26. Secondary swelling hemorrhage edema vasospasm seizures hypotension ischemia Classification of Head Injury • Metabolic hypoxia/hypercarbia hypo/hypernatremia hyperglycemia • hormonal dysregulation • dysautonomia • nutritional

  27. CT Scans of Intracranial Hemorrhage

  28. Translational linear focal Acceleration-deceleration rotational concussive-shearing forces Mechanism of Injury

  29. 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

  30. Triage Approach/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

  31. Triage History • mechanism of injury (should “fit” what you see) • neurologic- recent, remote; baseline, SZ, HI • general-medical, drugs • psychological/educational

  32. Physical Exam CGLCS pupils respiratory pattern sensory modalities SEARCH FOR FOCALITY! Triage • reflexes • DTR • cutaneous • mental status

  33. decreased LOC headache vomiting visual changes pupilary change Signs of Rostro-caudal deterioration • Cushing Triad • loss of function • motor/sensory • respiratory pattern • change

  34. Triage As A Rule Any pupillary inequality> 1 mm in a head injured child must be attributed to an intracranial injury until proven otherwise

  35. Pathophysiology Monroe-Kellie doctrine • three compartments blood brain CSF • change in one requires reciprocal change in the others

  36. 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 Findings in 4500 pediatric head injuries

  37. 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

  38. Clinical profile Presence of Mass lesions Glasgow Coma Scale 15: 7.1 % Glasgow Coma Scale 14: 9.7 % Glasgow Coma Scale 13: 13.6 %

  39. 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%

  40. Identifying Risk Facteurs • GCGS and the patient’s MENTAL STATUS were the best predicteurs of potential deterioration or the presence of a mass lesion

  41. 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

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