Dain Bramaged - Hackensack University Medical Center

Dain Bramaged:
Management of Pediatric Head Injury
Shira J. Gertz MD
Assistant Professor, Rutgers - NJMS
Attending Physician
Joseph M Sanzari Children’s Hospital
Hackensack University Medical Center
Hackensack, NJ
May 21, 2015
Hilton Head Island, SC
Disclosures
²  Site investigator for CALIPSO which gets its
investigational drug gratis from ONY Pharmaceuticals
²  Not related to this topic
Objectives
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Incidence of Pediatric Brain Injury
Recognition and treatment of:
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concussions
skull fractures
epidural hematomas
subdural hematomas
intraparenchymal hematomas
Prevention of pediatric brain injury
Traumatic Brain Injury
An estimated 2.5 million TBIs occurred in the United
States in 2010 resulting in:
2.2 million ED visits
280,000 hospitalizations
50,000 deaths
²  TBI is a contributing factor in 30.5% of all injury related
deaths
²  About 75% of TBIs that occur are concussions or other
mild forms of TBI
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www.cdc.gov ² Children 0 to 4 years, adolescents 15 to 19 years, and
adults > 65 years old are most likely to sustain a TBI.
TBIemergency department visits
² Almost half a million (473,947)
for TBI are made annually by children 0 to 14 years old.
² In 2009, an estimated 248,418 children (age 19 or younger)
were treated in U.S. EDs for sports and recreation-related
injuries that included a diagnosis of concussion or TBI.
² From 2001 to 2009, the rate of ED visits for sports and recreationrelated injuries with a diagnosis of concussion or TBI, alone or in
combination with other injuries, rose 57% among children (age 19
or younger).
² Adults aged 75 years and older have the highest rates of
TBI-related hospitalization and death.
www.cdc.gov
Etiology
² More than half (55%) of TBIs among children 0 to 14
years were caused by falls.
² Close to a quarter (24%) of all TBIs in children less than
15 years of age were related to blunt trauma
² motor vehicle crashes were the third overall leading
cause of TBI (14%).
² Assaults were the leading cause of death for children
ages 0-4.
Concussion
•  Mild Traumatic Brain Injury
•  Precise definition debatable
•  International Conference on Concussion in Sports (ICCIS):
Ice Hockey Federation
Federation of Intranationale de football
International Olympic Committee Medical Commission
“complex pathophysiological process affecting the brain,
induced by traumatic biomechanical forces”
Five Major Features of
Concussion
²  May be caused by blow to head, face, neck, or elsewhere on body with
a force transmitted to the head
²  Typically results in short-lived impairment of neurological function that
resolves spontaneously
²  May result in neuropathological changes, but the acute clinical
symptoms largely reflect a functional disturbance rather than structural
injury
²  Results in a set of clinical symptoms that may or may not involve LOC.
Resolution of the clinical and cognitive symptoms typically follows a
sequential course; however, it’s important to note that in a small
number of cases, postconcussive symptoms may be prolonged
²  No abnormality on standard structural neuroimaging is seen in
concussion
Biomechanisms of injury may
include:
omechanics
² During trauma, the brain moves, twists, and
experiences forces that cause movement of brain
matter
² This sudden movement or direct force applied to the
head can set the brain tissue in motion even though
the brain is well protected in the skull
² This motion squeezes, stretches and sometimes tears
the neural cells.
² The effects of these forces can change how the brain
processes information.
Biomechanics
² This results in biochemical changes related to
perfusion, energy demand, and utilization at
the site of injury and are not well understood
² Although the stretching and swelling of the
axons may seem relatively minor or
microscopic, the impact on the brain’s
neurological circuits can be significant. Even
a “mild” injury can result in significant
physiological damage and cognitive deficits.
Concussion
² Why children are at more risk than adults is not
well understood
² Thought to be secondary to:
² ongoing development making the brain more
sensitive to metabolic and neurochemical changes
² axons not myelinated
² less developed shoulder and cervical musculature
leading to inability to absorb energy
² improper technique when playing sports
Signs of concussion
² Features of concussion frequently
observed
² Vacant stare
² Delayed verbal and motor responses
² Confusion and inability to focus attention
² Disorientation
² Slurred or incoherent speech
² Observable incoordination
² Emotions out of proportion to circumstances
² Memory deficits
² Any period of loss of consciousness
Symptoms of concussion
²  Early (minutes and hours)
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Headache
Dizziness or vertigo
Lack of awareness of surroundings, disorientation
Nausea or vomiting
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Persistent low grade headache
Poor attention and concentration
neurocognitive deficits
Light-headedness
Memory dysfunction
Easy fatigability
Irritability and low frustration tolerance
Intolerance of bright lights or difficulty focusing vision
Intolerance of loud noises, sometimes ringing in the ears
Reduced reaction time and impaired processing of info
Anxiety and/or depressed mood
Sleep disturbance
²  Late (days to weeks)
Concussion Evaluation
² Mental status testing
² Orientation
²  Time, place, person, and situation (circumstances of injury)
² Concentration
²  Digits backward, Months of the year in reverse order
² Memory
²  Recall of 3 words and 3 objects at 0 and 5 minutes; Recent
newsworthy events; Details of the game (plays, moves,
strategies, etc.)
Concussion Evaluation
² Neurologic tests:
²  Pupils Symmetry and reaction
²  Coordination: Finger-nose-finger, tandem gait
²  Sensation: Finger-nose (eyes closed)
²  Romberg
² External provocative tests (on the field):
²  40-yard sprint; 5 push ups; 5 sit ups; 5 knee bends; (any
appearance of associated symptoms is abnormal, e.g.
headaches, dizziness, nausea, unsteadiness, photophobia,
blurred or double vision, emotional lability, or mental status
changes)
Medical Workup
² Neurologic Examination
² Neurosurgical evaluation or transfer to a trauma
center if:
²  Prolonged unconsciousness, persistent
mental status alterations, worsening
postconcussion symptoms, or abnormalities on
neurologic examination
Neuroimaging
² May include:
² CT or MRI scanning
² Recommended in all instances where headache or
other associated symptoms worsen or persist longer
than one week.
² A meta-analysis of variables that predict significant
intracranial injury in minor head trauma
² There was a statistically significant correlation between
intracranial hemorrhage and skull fracture, focal
neurological deficit, LOC, and GCS (<15) abnormality.
Headache and vomiting were not found to be predictive.
Dunning Et al Arch Dis Child. 2004 Jul;89(7):653-9.
Skull Fracture
² Observation if linear and non-depressed
² If depressed needs to be elevated
Epidural Hematoma
² Lucid interval followed by loss of consciousness
² 15-20% are fatal
² Treatment is Surgical Drainage
² Famous people who have died from an epidural
hematoma:
² Robert Atkins
² Natasha Richardson
² Gary Coleman
Sanders MJ and McKenna K. 2001. Mosby’s Paramedic Textbook,
2nd revised Ed. Chapter 22, "Head and Facial Trauma." Mosby.
Subdural Hematoma
² Acute, subacute or chronic
² Non-accidental trauma patients may have acute on
chronic
² Acute subdurals have a 60 – 80% mortality
² Treatment is surgical drainage if large enough
Dawodu S. 2004. “Traumatic Brain Injury: Definition, epidemiology ,
pathophysiology”. Emedicine.com.
Intraparenchymal bleed
² Supportive Care
² May drain if possible
Return to Activities
² If pt visits the ED they may not return to sports that day
² If there are any abnormalities on imaging studies sports
need to be terminated for the season.
What about all the other
Concussions?
² If you have no changes on neuroimaging or you haven’t done
any neuroimaging now what?
² If injury occurs during athletic practice/game the patient needs
to be pulled from participation for the rest of the day
² A licensed health care professional whose scope of practice
includes being properly trained in the evaluation and
management of concussion, must clear the athlete before
returning to play. This includes sports recognized by high
school athletic associations as well as youth and recreational
leagues
www.aan.com/guidelines
Management of Concussion
² No more grading system
² Individualized management based on symptoms
² Return to activity when free from all symptoms and back to baseline
² Supplemental information, such as neurocognitive testing or other tools, to
assist in determining concussion resolution. This may include but is not
limited to resolution of symptoms as determined by standardized checklists
and return to age-matched normative values or an individual’s preinjury
baseline performance on validated neurocognitive testing
² Err on the side of caution – especially with younger children
MANAGEMENT
² Rest, Rest, then rest some more
² While symptomatic. Recent article showed no benefit and
possible harm for forced rest when asymtomatic
² Resting the brain means no school, no screens, no
texting,etc
² Symptoms, severity and length of time of recovery
can not be predicted
Benefits of strict rest after acute concussion: a randomized controlled trial.
Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T.Pediatrics.
2015 Feb;135(2):213-23.
Recovery
² May be slow
² Rest. May need time away from school
² Avoid doing anything that could cause another blow or
jolt to the head.
² Reaction time slower
² Should not drive, ride a bike, etc
² Write things down if you have a hard time remembering.
² May need help to re-learn skills that were lost.
² May need CBT (cognitive behavior therapy)
Recommendations
² Until child has fully recovered, the following supports
may be recommended:
² No return to school until symptoms resolved
² Shortened day
² Shortened classes (i.e., rest breaks during classes).
² Allow extra time to complete coursework/assignments
and tests.
² Lessen amount of homework
Recommendations
² No significant classroom or standardized testing
² Check for the return of symptoms when doing
activities that require a lot of attention or concentration.
² Request meeting of School Management Team to
discuss plan and needed supports.
² Refer to: Neurosurgery/Neurology/Sports Medicine/
Physiatrist/Psychiatrist
² Neuropsychological testing
Outcomes
² TBI can cause a wide range of functional short- or
long-term changes affecting thinking, sensation,
language, or emotions.
² Thinking (i.e., memory and reasoning);
² Sensation (i.e., touch, taste, and smell);
² Language (i.e., communication, expression, and
understanding); and
² Emotion (i.e., depression, anxiety, personality changes,
aggression, acting out, and social inappropriateness).
Outcomes
² TBI can also cause epilepsy
² Increase the risk of Alzheimer’s disease, Parkinson’s
disease, and other brain disorders that become more
prevalent with age.
² Repeated mild TBIs occurring over an extended period of
time (i.e., months, years) can result in cumulative
neurological and cognitive deficits.
² At risk for second-impact syndrome
Second Impact Syndrome
(SIS)
² In rare cases, repeat concussions can result in edema (brain
swelling), permanent brain damage, and even death.
² The second hit can occur days, weeks or minutes after an initial
concussion – usually within 10 days.
² Even the mildest concussion can lead to SIS.
² Often fatal, and almost everyone who is not killed is severely
disabled.
² Cause of SIS is uncertain, but it is thought that the brain's blood
vessels lose their ability to regulate their diameter, and therefore
lose control over cerebral blood flow, causing cerebral edema.
Prevention of TBI
² Car Seats
² Wear a seat belt every time you’re in a vehicle.
² Never drive while under the influence of alcohol or drugs.
² Wear a helmet and make sure children wear helmets
when:
² Riding a bike, motorcycle, snowmobile, scooter, or all-terrain vehicle
² Playing a contact sport, such as football, ice hockey, or boxing
² Using in-line skates or riding a skateboard
² Batting and running bases in baseball or softball
² Riding a horse
² Skiing or snowboarding
² NO HELMET is CONCUSSION
PROOF!
www.cdc.gov
Prevention of TBI
² Making living areas safer for seniors, by:
² Removing tripping hazards such as throw rugs and clutter in
walkways;
² Using nonslip mats in the bathtub and on shower floors; Installing
grab bars next to the toilet and in the tub or shower;
² Installing handrails on both sides of stairways;
² Improving lighting throughout the home; and
² Maintaining a regular physical activity program, if your doctor agrees,
to improve lower body strength and balance.
www.cdc.gov
Prevention of TBI
² Making living areas safer for children, by:
² Installing window guards
² Using safety gates at the top and bottom of stairs
² Making sure the surface on playgrounds is made of
shock-absorbing material, such as hardwood mulch or
sand.
Resources
² www.aan.com
² www.cdc.gov
² “Concussion Quick Check” app
² Preventingconcussions.com
Questions?
Dain Bramaged:
Management of Pediatric Head Injury
Shira J. Gertz MD
Assistant Professor, Rutgers - NJMS
Attending Physician
Joseph M Sanzari Children’s Hospital
Hackensack University Medical Center
Hackensack, NJ
May 21, 2015
Hilton Head Island, SC