Peds In A Pod: My Child Fell & Hit His Head, HELP!

Mild Traumatic Brain Injury in Children

You’re working in the peds ED and the weather outside is just starting to get warmer.  Your first patient of the day is a young 2 yo girl with no PMH as per the parents, that was playing in the park when she fell off the jungle gym and landed on the dirt ground hitting her head.  They estimate the height to be about 3 feet off the ground and report about 5 mins of LOC followed by crying.  There was no vomiting and she currently appears to be acting like her usual self.  PE is remarkable for a small occipital cephalohematoma.  The child is playful in mom’s arms but crying on your exam.  What do you do?  Does she need a CT or is observation enough at this time?

Traumatic brain injury accounts annually for 3000 deaths, 29,000 hospitalizations, and 473,947 ED visits in the US in children 14 years and younger.  Children aged 0 to 4 years and adolescents aged 15 to 19 years are most likely to sustain a TBI.  Although TBI is the leading cause of death in this population, 75% of pediatric closed head injuries (CHIs) may be classified as concussions due to mild traumatic brain injury (MTBI).  The decision to image children is oftentimes challenging as ionizing radiation and its risk for potential malignancy in young patients as well as the risks of sedation that might be needed to obtain imaging are concerns that emergency clinicians should consider.

DEFINITION: The Mild Traumatic Brain Injury Committee of the American Congress of Rehabilitation Medicine (yes apparently this is a real committee) has defined MTBI as a “traumatically induced physi­ological disruption of brain function, as manifested by a least 1 of the following:

1. Any period of loss of consciousness

2. Any loss of memory for events immediately before or after the accident

3. Any alteration in mental state at the time of the accident (eg feeling dazed, disoriented or confused)

4. Focal neurological deficit(s) that may or may not be transient, but where the severity of the injury does not exceed the following:

• Posttraumatic amnesia not greater than 24 hours

• After 30 minutes, an initial GCS score of 13 to 15

• Loss of consciousness of approximately 30 minutes or less

The 2003 Children’s Hospital of Philadelphia pediatric MTBI practice guidelines rejected incorporating a GCS score of < 13 into the MTBI algorithm as a large review had shown that 33.8% of patients with a GCS score of 13 had an intracranial lesion and 10.8% required emergency surgery. Therefore, CHOP Prac­tice Guidelines further defined pediatric MTBI as children with a GCS score of 14 to 15 at the initial examination without focal neurologic deficits.

ED MANAGEMENT:  Much of our evidence-based data comes from studies by the Pediatric Emer­gency Care Applied Research Network (PECARN)30 as well as a large meta-analysis by Dunning in 2004 describing the findings of 16 papers to assess factors in the presentation of ICH in children with CHI. Dunning went on to publish the children’s head injury algorithm for the prediction of im­portant clinical events (CHALICE).

• The CHALICE study examined 14 clinical variables and  did not exclude patients with moderate or severe head injury; hence, the algorithm is most valuable for its negative predictive value.
• Variables include: LOC > 5 minutes, Amnesia > 5 minutes , Drowsiness , Vomiting > 2 times , Suspicion of NAT , Seizure , GCS score < 14, or < 15 if under 1 year old , Suspicion of penetrating or depressed skull injury or tense fontanelle , Signs of basilar skull fracture , Neurologic deficit , Cephalohematoma or laceration > 5 cm in children < 1 year old , High-speed accident , Fall > 3 meters, High-speed injury from projectile.
• They defined clinically important TBI as “death from TBI, neurosurgery, intubation for more than 24 hours due to TBI, or hospital admission of 2 nights or more associated with TBI on CT.”
• The study evaluated over 40,000 children presenting to the ED within 24 hours of CHI and with a GCS score of 14 to 15.
• It assessed the following potential predictors: severity of injury mechanism, history of LOC, duration of LOC, head­ache, severity of headache, vomiting and number of times, acting abnormally according to parent, altered mental status, signs of basilar skull fracture, palpable skull fracture, and scalp hematoma and its location.
• In children less than 2 years of age, the validated predictors for clinically important TBI in­cluded: altered mental status, scalp hematoma, LOC, severe mechanism of injury, palpable skull fracture, and acting abnormally per parents. If none of these predictors were present, the patient had a 0.02% or less risk of clinically important TBI, with 100% specificity and sensitivity.
• In children 2 years of age and older, the validated predictors for clinically important TBI included: altered mental status, LOC, history of vomiting, severe mechanism of injury, signs of basilar skull fracture, and severe headache. If none of these predictors were present, the patient had a 0.05% or less risk of clinically important TBI, with a negative predictive value of 99.95% and sensitivity of 96.8%.
• In 2009, PECARN derived and validated clinical prediction rules for children at very low risk of clinically important TBI.

TIMING OF INJURY:  Timing of CHI is important to ascertain. A delay in seeking medical care for a head injury in a pediatric patient should alert the clinician to the possibility of non-accidental trauma (NAT) or medical neglect.  The AAP practice parameters for minor CHI recommended 24 hours of observa­tion in the hospital, ED, doctor’s office, respon­sible home environment, or any combination of the above for patients with suspected MTBI.

MECHANISM OF INJURY:

• PECARN –> severe CHI mechanisms are: motor vehicle crash with patient ejection, death of another passenger, or roll­over; pedestrian or bicyclist without helmet struck by a motorized vehicle; falls of more than 3 feet in children less than 2 years old or more than 5 feet in children 2 years and older; or head struck by a high-impact object.
• CHALICE –> severe injury mechanisms include high-speed accidents or projectiles and falls > 3 meters.

LOC: It has been reported that traumatic brain injury occurs more commonly in children with a history of LOC than those without.

• CHAL­ICE –> recommends CT imaging in children with LOC greater than 5 minutes.
• PECARN –> In their abstract of secondary analysis of isolated LOC following blunt head injury, it was reported that the risk of TBI is very small; 4 of 790 children with isolated LOC had positive CT findings with only 1 requiring intervention. The authors concluded that LOC should not drive the decision to obtain imaging when it occurs in isolation.

VOMITING:

• CHALICE –> recommend CT in children with CHI and history of vomiting 3 or more times.
• PECARN –> data suggested that 1.7% of children with isolated vomiting had TBI on CT, while 0.2% required intervention.   In this study, the risk of TBI did not seem to increase with increased number of vomiting episodes.

HISTORY OF SEIZURE:  Posttraumatic seizures occur in less than 10% of pedi­atric head injuries, most commonly with severe TBI, but can occur after minor CHI.

• CHALICE –> CT imaging is recommended in children without a history of epilepsy who sustain a seizure after CHI.

PMH:  Seizure disorders, history of syncope, or stroke could be the underlying cause of trauma due to fall. A history of previous head injury or symptoms of concussion should heighten the emergency clinician’s concern for TBI sequelae such as second impact syndrome.

• Patients with congenital or acquired bleeding disorders (including those on anticoagulants) are at increased risk of ICH after minor head injuries. However, it is important to note that most of these patients will be symptomatic if ICH is present (I still would be more cautious in these children, personally).
• There is paucity of literature and recommenda­tions regarding the management of moderately to severely cognitively impaired children who sustain CHI.
• However, these patients are similar to patients less than 2 years of age in that they have poor verbal skills and are at higher risk for NAT.
• In addition, these patients may have abnormal baseline neuro­logic examinations that make clinical evaluation of MTBI very difficult. For these reasons, when there is any suspicion of ICH or skull fracture, head CT should be obtained.

CEPHALOHEMATOMA:

• PECARN –> concluded that there is a low risk (0.5%) of clinically important TBI in children less than 2 years of age with isolated scalp hematomas. However, it was noted that the likelihood of TBI on CT was higher in those children less than 3 months (20%, with 1.9% requiring intervention) and those with large tem­poral-parietal cephalohematomas.
• CHALICE –> recommends CT in patients less than 1 year of age with the presence of a bruise, swelling, or lacera­tion > 5 cm after CHI.

SKULL FRACTURE:

• CHALICE rules defined signs of basilar skull fracture to include blood or cerebrospinal fluid (CSF) from ear or nose, periorbital ecchymosis, Battle sign, hemotympanum, facial crepitus, or serious facial injury.
• Both CHALICE and PECARN reported that the presence of skull fracture increases the risk of intracranial injury by 4 times.

GCS:

• CHALICE –> recommends imag­ing in children less than 1 year with a GCS score < 15 or 1 year and older with a GCS score < 14.

TREATMENT:  Symptom control is the main objective in MTBI when the concern for ICH or skull fracture has been effectively ruled out via imaging or clinical exami­nation and observation.

• Nausea and vomiting- Zofran is ok, just make sure to not mask vomiting in a child before you adequately determine if imaging is necessary.
• Pain control of headache associated with direct blow, cephalohematoma, and concussion should be initiated and achieved in the ED –> There is no evidence that acetaminophen or nonste­roidal anti-inflammatory drugs (NSAIDs) alleviate or shorten the duration of concussive symptoms.
• If symptoms of severe concussion persist despite pain control and antiemetics, admission to an inpa­tient ward for further therapy is warranted.

Some other key things to remember.

Postconcussive Syndrome

• Potential sequelae of TBI in which the symptoms of concussion persist longer than 7 to 10 days.
• Somatic, cognitive, and af­fective symptoms may be present such as headache, sleep disturbance, dizziness, nausea, fatigue, attention problems, irritability, anxiety, depression, and emo­tional lability.
• A recent study assessed for postcon­cussive symptoms in children with MTBI compared to children with uncomplicated orthopedic injuries found that LOC, acute CT scan abnormality, parenchymal lesion on MRI, hospitalization, and injuries to body regions other than the head predicted higher levels of postconcussive symptoms.

Second Impact Syndrome

• Catastrophic brain injury occurring after an initial TBI, generally before the symptoms of concussion have resolved.
• The hypothesized pathology involves cerebral vascu­lar congestion with progression to diffuse cerebral swelling and death.
• All reported cases have been in patients less than 20 years of age.
• It is important to elicit any history of recent head trauma (eg athlet­ics, motor vehicle accidents, or simple play) in the patient presenting with CHI to evaluate for second impact syndrome.

*It is important to stress the need for cessation of return to sports and need for medical clearance on follow up visit with the family and discuss post­concussive syndrome as well as the risks for second impact syndrome.

DISPOSITION: The pediatric patient with MTBI may be observed in the ED or an observation unit, admitted for inpatient hospitalization, or discharged home.

• PECARN evaluated over 13,000 children with a GCS score of 14 or 15 and normal ED head CT scan.
• The study stated that this popu­lation is at very low risk for traumatic findings on neuroimaging and extremely low risk of needing neurosurgical intervention.
• The authors con­cluded that hospitalization of this population for neurologic observation is generally unnecessary.
• However, neurologic observation is not the only reason why such patients would be admitted to the hospital – protracted vomiting, severe pain, and inability to tolerate fluids orally would be reasons to admit children with a GCS score of 14 to 15 and normal head CT.

Children must pass the following in order to be sent home:

1. Hemodynamic stability with clinician expec­tation of persisting stability

2. No alteration in mental status

3. Resolved or tolerably mild headache

4. Tolerating oral fluids

5. Reliability of follow up with primary care physician, neurologist, neurosurgeon, or sports medicine physician to re-evaluate symptoms of MTBI

6. Family communication and understanding of discharge instructions

So back to our case:  You watch her for 4 hours, she is playful with her parents and tolerates juice.  Although her mechanism is severe by PECARN, your suspicion of TBI is low.  The parents are educated about concerning signs and symptoms to look for and they have immediate follow-up with a PMD and close access to the hospital ER if needed.  You decide to send her home and on follow-up with her PMD the next day, she is doing well.

Resources

1)       Kuppermann N, Holmes JF, Dayan PS, et al, for the PECARN TBI Study Group. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170.

2)       Dunning J, Daly JP, Lomas JP, et al. Derivation of the children’s head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child. 2006;91(11):885-891.

3)       Maguire JL, Boutis K, Uleryk EM, et al. Should a head- injured child receive a head CT scan? A systematic review of clinical prediction rules. Pediatrics. 2009;124;e 145-e154.

4)       Jagoda A, Riggio S. Mild traumatic brain injury and the postconcussive syndrome. Emerg Med Clin North Am. 2000;18(2):355-363.

5)       McCrory P. Does second impact syndrome exist? Clin J Sport Med. 2001;11(3):144-149.

6)       Holmes JF, Borgialli DA, Nadel FM, et al. Do children with blunt head trauma and normal cranial computed tomog­raphy scan results require hospitalization for neurologic observation? Ann Emerg Med. 2011;58(4)315-322.

7)       Langlois JA, Rutland-Brown W, Thomas KE. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. CDC website. http://www.cdc. gov/ncipc/pub-res/TBI_in_US_04/TBI-USA_Book-Oct1. pdf.

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