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Mild Traumatic Brain Injury: Primary Care from an Intensivist’s Perspective

Mild Traumatic Brain Injury: Primary Care from an Intensivist’s Perspective. Mark W Uhl, MD, FAAP Pediatric Critical Care Carolinas Medical Center. Overview of Mild TBI. Scope and Etiology Diagnosis and Disposition (AAP Guidelines) 2 to 20 years old Less than 2 years old Sports Injuries

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Mild Traumatic Brain Injury: Primary Care from an Intensivist’s Perspective

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  1. Mild Traumatic Brain Injury:Primary Care from an Intensivist’s Perspective Mark W Uhl, MD, FAAP Pediatric Critical Care Carolinas Medical Center

  2. Overview of Mild TBI • Scope and Etiology • Diagnosis and Disposition (AAP Guidelines) • 2 to 20 years old • Less than 2 years old • Sports Injuries • Second Impact Syndrome • Post Concussive Syndrome (PCS) • Prevention

  3. Head Trauma • Leading cause of death in children • 80% of pediatric trauma deaths • 650,000 ED visits (325,000 CT scans) • >50,000 admissions • 550,000 hospital days (> $1 billion) • 200-300 cases per 100,000 per year

  4. Etiology • Obvious: • MVCs: driver, passenger, pedestrian or cyclist • Falls: bikes, skateboards, ATVs, walkers, windows • Missiles: lawn darts, pellets, bullets

  5. Etiology • Less obvious: • Sports injuries • Delayed deterioration (EDH) • Hidden: • Child abuse

  6. Classification of TBI • Severe TBI • Regional Trauma Systems, Level One Trauma centers, ATLS, PICU / TICU • Moderate TBI • Level Two, +/- PICU • Mild, Minor, Trivial CHI = Mild TBI • Office, Urgent Care, School, Field of play • The great majority

  7. Severe Traumatic Brain Injury • 4% of all TBI • Glasgow Coma Score 3-8: • Often prolonged LOC • Focal neurologic signs • Unequal pupils • Inadequate respiratory effort • Penetrating skull injury, fractures

  8. Moderate Traumatic Brain Injury • 14% of TBI • GCS 9-12(13): • Often LOC > 1 minute • Progressive lethargy, persistent headache • Amnesia • Repeated seizures • Protracted vomiting • Depressed skull fracture

  9. Mild Traumatic Brain Injury • 82% of all TBI • Glasgow Coma Score (13?) 14-15: • Asymptomatic, or… • Headache • Vomiting • Seizure • Brief LOC

  10. GCS and Brain Injury Relationship between baseline mental status (GCS) and risk of intracranial injury: • GCS 15 TBI 2-3% • GCS 14 TBI 7-8% • GCS 13 TBI 25%

  11. Focused Neuro Exam • Mental Status • AVPU • GCS: M, V, E • Brief Cranial Nerve Exam • Pupils (III) • EOM (IV and VI) • Corneals (V and VII) • Gag (X) • DTRs

  12. Mechanisms of Injury • Direct trauma to vessels or brain • Contusion, hemorrhage, hematoma • Mass lesions »» surgery • Inertial forces (acceleration/deceleration) • Concussion, diffuse axonal injury (DAI or “shear”) • Coup-contrecoup • Hypoxia / ischemia, hypoperfusion

  13. Coup Contrecoup Injury • Injury at site of impact and opposite due to inertial forces (“jello in a bowl”)

  14. Epidural Hematoma • Bleeding between skull and dura • Arterial or venous origin • Peak 6-8 hours after injury, up to 24 hrs • Temporal, frontal, occipital lobes • Especially with fracture over middle meningeal artery

  15. Subdural Hematomas • Between dura and cortical surface of brain • Tearing of bridging veins or laceration of parenchyma during acceleration / deceleration forces • May have profound or progressive neurologic deterioration

  16. Subarachnoid Hemorrhage • Most common ICH associated with head trauma • Disruption of small vessels on cerebral cortex • Nausea, vomiting, headache, nuchal rigidity

  17. Contusion • Area of bruising or tearing • Temporal and frontal lobes • May have progressive neurologic deterioration • edema, infarction, hematoma

  18. Concussion • Mild insult with transient LOC • Anorexia, vomiting, pallor • Amnesia • Often normal neuro exam • CT normal

  19. Diffuse Axonal Injury • Result of rapid acceleration/deceleration forces • Disruption of long axons • Basal ganglia, thalamus, corpus callosum • Marked discrepancy between neurologic exam and CT findings • Prognosis for full recovery guarded

  20. Mild TBI Definition • Applied force that causes: • Any period of LOC < 30 minutes, OR • Any loss of memory of the events immediately before or after the injury (amnesia less than 24 hrs duration), OR • Any alteration of mental state at time of injury (dazed, dinged, confused, etc) American Congress on Rehabilitation Medicine

  21. Mild TBI Symptoms • Physical • Nausea, vomiting, headache, dizziness, blurred vision, lethargy, sleep disturbance, etc • Cognitive deficits • Attention, concentration, perception, memory, speech and language, executive functions • Behavioral changes • Irritability, anger, disinhibition, emotional lability

  22. Consequences of Mild TBI • Immediate • Somatic problems • Cognitive impairment • Behavioral changes • Life Threatening • Intracranial hemorrhage • Second Impact Syndrome • Long term • Post concussive syndrome • PTSD

  23. AAP Guidelines, 1999 • Mild Traumatic Brain Injury • Inclusion Criteria: • previously healthy (neurologically) • age 2 years to 20 years • isolated minor closed head injury • evaluated within 24 hrs

  24. AAP Guidelines, 1999 • Exclusion Criteria: • multiple trauma • unobserved LOC • known or suspected C-spine injury • bleeding diathesis • CNS risk factors (AVM, VP shunt, etc) • suspected intentional injury • language barrier

  25. AAP Guidelines, 1999 • Definition of Mild TBI: • normal mental status • normal neurologic exam • including fundoscopic exam • no evidence of skull fracture • no hemotympanum • no Battle’s Sign • no palpable depression

  26. AAP Guidelines, 1999 • Mild TBI may include: • LOC < one minute • immediate post-traumatic seizure • vomiting • headache • lethargy

  27. AAP Guidelines Algorithm, 1999 • 2-20 years old • stabilized • history and physical exam • no exclusion criteria • normal neuro, eye, and skull exam • brief LOC?

  28. AAP Guidelines Algorithm, 1999 • No LOC options • is home observation appropriate? AND • parent(s) competent to observe? • Observe at home • Written guidelines for follow-up

  29. AAP Guidelines Algorithm, 1999 • Brief LOC options • Observe? • Home • ED, Clinic, Office • Hospital • Image? • CT scan available? • no >>> refer or transfer • yes >>> scan

  30. AAP Guidelines Algorithm, 1999 • Negative CT scan • home observation? • hospital observation? • Appropriate written guidelines • Appropriate follow-up

  31. AAP Guidelines Algorithm, 1999 • Abnormal neuro exam, or • Abnormal eye exam, or • Signs / symptoms of intracranial problems develop: • Emergent consult of appropriate specialist, and • Consider emergent CT scan, and/or • Transfer to facility with neurosurgical care

  32. Predictive Value of LOC or Amnesia • Age < 18 y • Prospective, Level 1 Trauma center ED • Outcome variables: • TBI on CT • TBI requiring intervention (Rx) • Neurosurgical procedure • AED for > 1 week • Persistent neuro deficits • Hospitalized ≥ 2 nights Palchak, et al Pediatrics 2004;113:e507

  33. TBI and Hx of LOC Palchak, et al Pediatrics 2004;113:e507

  34. TBI with LOC and/or Amnesia

  35. Predictive Value of LOC or Amnesia • Isolated LOC and/or Amnesia: • 0 of 142 had TBI on CT • 0 of 164 required acute intervention • Conclusion: • Isolated LOC and/or Amnesia not predictive of either TBI on CT or TBI requiring acute intervention • May decrease unnecessary CT use

  36. Mild TBI (infants less than 2 yr) • Asymptomatic infants still have moderate risk of ICI • Assessment more difficult • Increased risk of NAT • Incidence of skull fracture higher • Leptomeningeal cysts (growing fractures) • Need for and risks of sedation greater

  37. Sedation Risks • Hypoxia • Apnea • Prolonged depressed consciousness • Aspiration • Respiratory failure • Intubation, mechanical ventilation

  38. Mild TBI, infants < 2 yrs(proposed guidelines, Pediatrics 2001; 107:983) • Apparently minor head trauma • Alert or awakens to voice or light touch • Excludes: • Birth trauma, multiple trauma • Penetrating injury • Existing neurologic disorder, neurosurgery • Bleeding diathesis • Significant concern for abuse or neglect

  39. Mild TBI, infants < 2 yrs(proposed guidelines, Pediatrics 2001; 107:983) • HIGH RISK? • Depressed MS, focal neuro, depressed or basilar skull fx, seizure, irritability, bulging fontanel, persistent vomiting (5X or >6hrs), LOC > 1 min • YES >>>>> CT scan

  40. Mild TBI, infants < 2 yrs(proposed guidelines, Pediatrics 2001; 107:983) • INTERMEDIATE RISK? • LOC < 1 min, vomiting 3-4X, lethargy or irritability resolved, concerned caretakers, nonacute skull fx, high force mechanism, scalp hematoma, fall onto hard surface, vague or unwitnessed trauma • YES >>>>> CT scan (or skull radiograph)

  41. Mild TBI, infants < 2 yrs(proposed guidelines, Pediatrics 2001; 107:983) • LOW RISK? • Low energy mechanism (fall < 3 ft) • No signs or symptoms • More than two hours since injury • Age > 12 months • YES >>>>> Discharge

  42. Concussion in Sports • Media attention • High profile cases (return to play or retire?) • Second impact syndrome • Amenable to study • Concern about safe participation of children and adolescents

  43. Concussion in Sports • Indirect blow to head can cause concussion • Imaging studies usually normal • More a functional than structural disturbance or injury

  44. Concussion in Sports • NCAA Football Study • 2905 NCAA football players (1999-2001) • 6.3% concussion • Of those, 6.5% repeat concussion • Hx of concussion increased risk of repeat concussion • Headache in 85% • Sxs resolved by one week

  45. Rates of Concussion (NCAA) • Helmets • Ice Hockey 0.27 • Football 0.25 • Lacrosse 0.19 • Softball 0.11 • No Helmets • Soccer 0.24-0.25 • Filed Hockey 0.20 • Wrestling 0.20

  46. Return to Play • Grade 1 15 min • Multiple Grade 1 1 week • Grade 2 1 week • Multiple Grade 2 2 weeks • Grade 3, brief 1 week • Grade 3, long 2 weeks • Multiple Grade 3 > 1 month (or retire)

  47. Second Impact Syndrome • Catastrophic outcome (50% mortality) • Malignant brain edema, herniation • Refractory to Rx • Age < 21 y • All survivors with impairment

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