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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 Larry Kleiner Medical Director, Dept of Neurosurgery The Children's Medical Center
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
Eye opening: spontaneous 4 to sound 3 to pain 2 none 1 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 the GCS
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
Demographics Compared to severe head injuries: generally younger • higher frequency of students • percentage of males is less • alcohol less frequently involved
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
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
Treatment Efficacy of head trauma sheets • 66% referred to the document • 84% found it answered all questions
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
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
Secondary swelling hemorrhage edema vasospasm seizures hypotension ischemia Classification of Head Injury • Metabolic hypoxia/hypercarbia hypo/hypernatremia hyperglycemia • hormonal dysregulation • dysautonomia • nutritional
Translational linear focal Acceleration-deceleration rotational concussive-shearing forces Mechanism of Injury
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
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
Triage History • mechanism of injury (should “fit” what you see) • neurologic- recent, remote; baseline, SZ, HI • general-medical, drugs • psychological/educational
Physical Exam CGLCS pupils respiratory pattern sensory modalities SEARCH FOR FOCALITY! Triage • reflexes • DTR • cutaneous • mental status
decreased LOC headache vomiting visual changes pupilary change Signs of Rostro-caudal deterioration • 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
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
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 lesions Glasgow 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