Pediatrics minor head Pediatrics minor head traumatrauma

To Scan or not to scan?That is the question!!

ד"ר יורם בן יהודה, מנהל היחידה לרפואה דחופה ילדיםמרכז רפואי וולפסון, חולון

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

Evident Base?

Or

Rule of Thumb?

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

• Most researches on Pediatric MHT are on small sample size or retrospective.

• Old recommendations and guidelines were derived from adult data.

• There are no large pediatric studies such as the “Nexus II Investigation” or “The Canadian CT Head Rule Study…”

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

There is simply not enough data!!!!!!!!

So what do we do?• Commonsense? Brrrr!!

• Adult guidelines? Some cases.• Pediatric guidelines and a lot of

RESEARCH (Multi center, multi national)

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

• What are the questions:– Definition.– Who should be in charge?– Which patient can go home?

– Risk factors and low risk criteria.

– What do we fear? – What can help us reduce the risk?And if you can think of more questions – please let me know.

I Probably won’t have an answer for you, but I may have quite a few.

What is Minor Head Injury?What is Minor Head Injury?

• GCS 13-15– No real consensus to the definition

• Normal mental status, no focal or abnormal findings on neuro exam, no signs of skull #.– AAP 2000

• GCS >14– Israeli MOH 1998-1999

• Are there other factor to consider?

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

• History = 95% of diagnosis:– Age– Mechanism– LOC (duration)– Amnesia– Convulsion

• PE = 4% of diagnosis:– GSC– Neurological findings– Multiple Injuries

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

Who is in charge?

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

• Not a real problem in level 1, 2, & 3 trauma centers in the US of A.

•

• First year surgical resident?!• Pediatric surgery house physician?!• Intern?!

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

So who can go home? (what are we afraid of?)

Low risk for occult ICI**Intra Cranial Injury

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

• Risk for occult ICI:– The age factor:

• Most of the cases <6 m old• Hardly ever > 12 m old.• No record (in the literature) of

occult ICI over 2 y.

– Mechanism:• Fall- >5m or >3X child’s hight.• MVC- same as adults +

unrestrained infant in MVC.• Assault- with blunt object.• Pedestrian- child struck by car.• Other vehicle- fall from vehicle

struck by car.• Buttered child.

B Simon et al. Pediatric minor head trauma: indication for computed tomographic scanning revisited. The journal of TRAUMA Injury, Infection, and Critical Care. 2001;51(2): 231-238

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

• Low predictors for occult ICI:– Short LOC.– Short generalized seizure.– Vomiting.

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

• Risk for occult ICI (PE):– Focal or abnormal neurological signs.– Multiple injuries.– Scalp hematoma (except frontal).– Signs of skull #.– Craniofacial ST injury.

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

• Who can we send home relatively safe?– >5 y of age: same as adults .– 2 - 5 y old: If they meet low risk criteria:

• Provided that the child was evaluated by a qualified physician.

– <2 y of age: Should we send them home?

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

• How can the risk be reduced?– Admission.– Observation.– Imaging:

• Scalp radiography.• Head CT scan.• MRI.

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

• Imaging:– MRI:

+ very good modality for ICI.

- requires sedation or anesthesia.

- time consuming.

- not available.

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

• Skull radiography:+ sensitive for fractures in the very young.

+ low radiation dose.

+ available.

- Difficult to interpret (interpreter dependent).- Hardly ever result in change of management.

Skull Radiograph Interpretation of Children Younger Than Two Years: How Good Are Pediatric

Emergency Physicians? Chung et al. Ann Emerg Med.2004;43:718-722.

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

• CT Scan:– Reliable? Radiology Resident Evaluation of Head CT Scan Orders in the Emergency

Department William K.Erly,William G.Berger,Elizabeth Krupinski,Joachim F.Seeger,and John A.Guisto. AJNR Am J Neuroradiol 23:103–107,January 2002

– Available.– High sensitivity.

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

Why not scan everybody?

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

• Sedation or anesthesia.• expensive.

ANDAND

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

Risk of cancer from radiation!!

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

• Brenner,-D-J et al. Estimating cancer risks from pediatric CT: going from the qualitative to the quantitative. Pediatr-Radiol. 2002 Apr; 32(4): 228-3; discussion 242-4.

• Hall,-E-J et al. Lessons we have learned from our children: cancer risks from diagnostic radiology. Pediatr-Radiol. 2002 Oct; 32(10): 700-6.

• Brenner,-D et al. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR-Am-J-Roentgenol. 2001 Feb; 176(2): 289-96.

• Risks and benefits in pediatric CT. MR/CT Committee of the Society of Pediatric Radiology. Pediatr-Radiol. 2001 Jun; 31(6): 387; discussion 389-

91. • Donald P. Frush et al. Computed Tomography and Radiation Risks: What

Pediatric Health Care Providers Should Know, REVIEW ARTICLE. PEDIATRICS Vol. 112 No. 4 October 2003 951.

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

Than what shall we do?

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

• Some unanswered questions:– Well then, who should be in charge?– Admission for observation v/s the concept of

the golden hour.– The consequence of occult ICI.

And a few more!

• Sara A. Schutzman et al. Evaluation and Management of Children Younger Than Two Years Old With Apparently Minor Head Trauma: Proposed Guidelines. PEDIATRICS Vol. 107 No. 5 May 2001 983.

• Michael J. Palchak et al. A Decision Rule for Identifying Children at Low Risk for Brain Injuries After Blunt Head Trauma. Ann Emerg Med. 2003;42:492-506.

• Head Injury: Triage, Assessment, Investigation and Early Management of Head Injury in Infants, Children and Adults is available at www.nice.org.uk.

• David S. Greenes et al. Clinical Indicators of Intracranial Injury in Head-injured Infants. PEDIATRICS Vol. 104 No. 4 October 1999 861.

• David S. Greenes. Decisionmaking in Pediatric Minor Head Trauma. Ann Emerg Med. 2003;42:515-518.• William R. Mower et al. Developing a Clinical Decision Instrument to Rule Out Intracranial Injuries in Patients With Minor Head Trauma:

Methodology of the NEXUS II Investigation. Ann Emerg Med. 2002;40:505-514.• Michael J. Palchak et al. Does an Isolated History of Loss of Consciousness or Amnesia Predict Brain Injuries in Children After

Blunt Head Trauma? PEDIATRICS Vol. 113 No. 6 June 2004 e507. • Charles J. Homer, Lawrence Kleinman. AMERICAN ACADEMY OF PEDIATRICS Technical Report: Minor Head Injury in Children.

PEDIATRICS Vol. 104 No. 6 December 1999 1 of 7.• Greenes DS, Schutzman SA: Occult intracranial injury in infants. Ann Emerg Med December 1998;32:680-686.• Schutzman SA, Greenes DS. Pediatric minor head trauma. Ann Emerg Med. January 2001;37:65-74.• Micelle J. Haydel, Amit D. Shembekar. Prediction of Intracranial Injury in Children Aged Five Years and Older With Loss of

Consciousness After Minor Head Injury Due to Nontrivial Mechanisms. Ann Emerg Med. 2003;42:507-514.• William K. Erly et al. Radiology Resident Evaluation of Head CT Scan Orders in the Emergency Department. AJNR Am J

Neuroradiol 23:103–107, January 2002.• Sarita Chung et al. Skull Radiograph Interpretation of Children Younger Than Two Years: How Good Are Pediatric Emergency

Physicians? Ann Emerg Med. 2004;43:718-722.• Stiell IG et al. for the Canadian CT Head and C-Spine Study Group. The Canadian CT Head Rule Study for patients with minor head

injury: rationale, objectives, and methodology for phase I (derivation). Ann Emerg Med. August 2001;38:160-169.• Committee on Quality Improvement, American Academy of Pediatrics Commission on Clinical Policies and Research, American Academy

of Family Physicians. AMERICAN ACADEMY OF PEDIATRICS. The Management of Minor Closed Head Injury in Children. PEDIATRICS Vol. 104 No. 6 December 1999 1407.

• Clare Atzema et al. Defining ‘‘Therapeutically Inconsequential’’ Head Computed Tomographic Findings in Patients With Blunt Head Trauma. Ann Emerg Med. 2004;44:47-56.

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

Pediatric MHT*Pediatric MHT**Minor Head Trauma*Minor Head Trauma

??חבלת ראש קלה מה היאחבלת ראש קלה מה היא

• מנגנון• מצב הכרה• סימנים נוירולוגיים• סימני פגיעה חיצוניים• פציעות או פגיעות

נוספות• גיל

GCS 13-15

??מה החשיבותמה החשיבות

• .את מי ניתן לשחרר הביתה

• .מי לא זקוק להדמיה

• Low risk criteria

• !!!ICI לא להחמיץ

!!!!החששהחשש

• Occult intra) פגיעות תוך גולגולתיות סמויותcranial injuries).

• פגיעות סמויות נדירות מאוד מעל גיל שנה (למעשה כמעט .לא קיימות בילדים או במבוגרים)

• .כמעט רק בתינוקות מתחת לגיל שנה• .כמעט תמיד מלווות בשבר בגולגולת• .בדרך כלל ללא התדרדרות נוירולוגית או צורך בהתערבות• אין להסתמך על העדר סימנים קליניים בתינוקות מתחת

.ICI לגיל שנה לשלילת

!!!!החששהחשש

• העדר סימנים נוירולוגיים אינו שולל פגיעה תוך :גולגולתית סמויה– במידה וקיים מנגנון היפגעות בסיכון גבוה קיים סיכון יתר ל

ICI גם בהעדר סימנים קליניים:• . מגובה הילד3 מטר או פי 5נפילה מגוב מעל • .תקיפה ע"י חפץ כהה• התנגשות בין מכוניות (כמו במבוגרים – התנגשות חזיתית במהירות

. קמ"ש) או ילד לא חגור בתאונת מכוניות50העולה על • .הולך רגל – ילד נפגע ע"י מכונית• .רוכב אופניים – נפגע ממכונית נוסעת• .נפל מרכב ונפגע ממכונית

B Simon et al. Pediatric minor head trauma: indication for computed tomographic scanning revisited. The journal of TRAUMA Injury, Infection, and Critical Care. 2001;51(2): 231-238