Clarifying Murky Waters: Is observation enough? Head and Cervical - - PDF document

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Clarifying Murky Waters: Head and Cervical Spine Injuries in Children

Judith R. Klein, MD, FACEP Assistant Professor of Emergency Medicine UCSF-SFGH Emergency Services

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Objectives

Ø Is observation enough? Ø Whom to image? Ø How to image?

• Skull films vs. CT
• Role for ultrasound?
• C spine plain films vs CT

vs MRI

Ø Whom to admit? 3

Pediatric head trauma: what’s the big deal?

• #1 cause of death

age 1-14 years

 70% of fatal child

injuries

• >7K deaths
• 60K hospitalizations,
• >600K ED visits per

year

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Why worry?

• 3 to 6% incidence of

TBI post minor head trauma

• Up to 20% of kids < 2

years old with TBI are asymptomatic!

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Who gets imaged?

• 40-50% with CHI to ED get imaged!!
• Higher CT rates:

 white race  older  general vs pediatric hospital  emergent triage status  attending treated 5 6

Implications of imaging

• Cognitive development
• Lifetime cancer risk

from 1 head CT:

 1:1500 (1 yr old)  1:5000 (10 yr old)

• < 10% of CT’s have

any TBI

• 0.5% of CT’s with

clinically important (CI) TBI

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GCS>14: To CT or not To CT??

• Reduce # of CT’s

performed

 Radiation/brain dev  Sedation  $$$$

• Identify all TBI or just

CI TBI?

 NSU intervention  Hospital >2

nights/intubation>24 hrs

 Death/long term

neurological sequelae

Cancer Identify TBI IQ $$$ Sedation

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The Science

• Several CDRs available
• Only 2 included infants
• PECARN rule the best:

 Largest, 25 centers  Lots of young kids  Clear reference

standard for CI TBI

 Best validation 8 9

PECARN Minor Head Trauma Decision Rule

• Derivation and

validation study

• 42K kids GCS>14:

>10K under 2 yrs

• <2 years:

 100% NPV for CI TBI

and all TBI

• >2 years:

 99.9% NPV for CI TBI  98.4% NPV for all TBI

• CT by 20-25%

Kuppermann, Lancet 2009

Why identify all TBI: implications for sports/other activities?

Kuppermann et al. Lancet 2009

Under 2 years old

Why identify all TBI: implications for sports/other activities?

Kuppermann et al. Lancet 2009

Over 2 years old

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Severe Mechanism

• MVA with ejection, rollover or death of

another occupant

• Pedestrian or bike w/o helmet
• vs. car
• Fall >3 ft (<2 yr)
• r >5 ft (>2 yr)
• High impact object to

head

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Back to Baby Leo

• Imaging?

 A good idea..

• Imaging for <3

months with scalp hematoma + >3 ft fall

• Thin skulleasily

fracturedstrong correlation with TBI

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Well, can I just do a skull x-ray?

• Skull film cons:

 Hard to read  Not sensitive/specific

enough

 If (+) still need to do

CT

• CT cons:

 Radiation  Cost  Transport from ED  Sedation

Survey says: CT

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Ultrasound and skull fracture?

• Skull fx 4-20x likelihood of TBI
• 15-30% with skull fx TBI
• Prospective study*:

 55 patients  100% sensitivity  95% specificity

• Include in CDR for low risk?

 If US +, then CT? If US -,

• bserve?

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*Parri, J Emerg Med 2012.

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Baby Leo gets a CT

• How do I keep him

still?

 Swaddle  Dextrose H20  Acetaminophen

• CT shows a skull

fracture over posterior fossa

• Admit?

 YES 17

Admit criteria for skull fracture

• Very young-->higher

bleeding risk

• Depressed
• Widely diastatic
• High energy mechanism
• High risk location

(sutures, posterior fossa, dural sinus)

• Poor home situation

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Case #2: Wild Bill

• 20 month old rolls

down 12 stairs

• “Few seconds of

LOC” Cried. Ate.

• Physical Exam:

 GCS?  Talk his language  3 cm temporal

hematoma

• To CT or not to CT?

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Wild Bill: CT or Observation?

• Rule: CT or 6 hour obs for

all < 2 years with non-frontal scalp hematoma

 Location, location…:

• Temporal > parieto-
• ccipital > frontal

 Severe mechanism?:

• Stairs vs. straight fall

 LOC too brief to count

but...

• Verdict: Very careful
• bservation or CT

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Keeping Bill Still

• Sedation choices:

 Ketamine is OK  Rectal methohexital  Dexmedetomidine  IV/IM pentobarbital  Etomidate  Avoid versed

• CT (+) epidural:

Admit

Brutane

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Case #3: The Car’s a Mess...

• 5 year old helmeted

bike vs low speed MV

• No LOC
• V x 3 en route
• Mild headache
• PE:

 Playing  Small parietal scalp

hematoma

• To CT or not to CT?

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Let’s talk observation

• > 2 years
• Isolated vomiting
• No LOC
• Non-severe

mechanism

• Mild headache
• Consider observation

if parents comfortable

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Discharge home?

• Criteria:

 Normal MS  Vomiting controlled  No abuse suspected  Responsible home/

reliable transportation

 Normal head CT*

• Confused after neg

CT?

 Observe x 4-6 hrs

• ->admit if still abnl

Holmes, Annals EM, 2011. 24

Case #4: Tell me again what happened to Jane?

• 18 mo old BIB father
• Vomiting x 3 days
• “Tripped at daycare”

4 days ago

• PE: somnolent
• CT by criteria: +SAH!
• What do you do?

 Neurosurgery  Admit

 Child Protective

Services (CPS)

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Epidemic: Non-accidental trauma (NAT)

• 6-10% of pediatric

trauma: NAT

• #1 NAT mortality: head

injury

• Suspect NAT:

 (+) CT: minor/no

reported trauma

 Delayed presentation  Changing history  Other injuries

inconsistent with reported mechanism

 Retinal hemorrhages*

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Nutshell:

• Whom to CT after trauma?

 <2 years:

• AMS
• Sx skull fracture
• Non frontal scalp hematoma
• >5 seconds LOC
• Not acting normally per parent
• Severe mechanism

 > 2 years:

• AMS
• Sx basilar skull fracture
• Vomiting
• Severe HA
• LOC
• Severe mechanism

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Nutshell (cont):

• Whom to admit?:

 All TBI  High risk skull fractures

• Depressed
• Wide diastasis
• Very young
• High energy mechanism
• High bleeding risk

 Persistent AMS after observation  Poor social/transport situation  Suspected abuse  Neurosurgery discretion

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Return to sports post concussion

• Grading systems not

useful

• Stepwise return to

play based on sx:

 No activity  Light aerobic  Sports specific

exercise

 Non contact drills  Contact practice  Return to play

Halstead, Pediatrics 2010

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Case #5: Do you have neck pain??

• 6 month old rear car-

seat passenger MVA- rear-ended

• Car-seat/patient in

place

• PE: VS nl. Happy, no

signs of trauma

• How do I clear the c-

spine?

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Some background on pediatric c-spine injuries

• Uncommon injury

(3x more common in adults)

• More common in
• lder kids (> 8 years)
• Leading causes:

 MVA (<8 yrs)  Sports (>8 yrs)  PVA

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Kids aren’t just little adults…

• Unique anatomy:

 Large head high

fulcrum

 Higher injuries more

common in < 8 year old

 Horizontal facets

slippage/dislocation

 Less neck muscle  More pre-vertebral soft

tissue

• > 8 years more like

adult

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Clearing little c-spines

• NEXUS:

 3065 kids  30 CS injuries:

• Only 4 injuries 2-8

years

• None < 2 years

 Criteria: (100% sens)

• No neck tenderness
• No focal neuro sx
• No distracting injury
• Normal MS
• No intoxication

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Applying NEXUS criteria

• 187 kids with c-spine

injury-->NEXUS rules applied:

 32 kids < 8 yrs: 94%

sensitivity

 155 kids > 8 yrs:

100% sensitivity

• *Garton, Neurosurgery, 2008.

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PECARN: Risk factors for CSI

• 540 CSI cases/1060 controls
• Risk factors:

 AMS/focal neuro sx  Neck pain/torticollis  Significant torso injury  High risk condition  Diving/high risk MVA

• 98% sensitive
• CT use by 25%

34 Leonard, Annals EM, 2011. 35

Modified NEXUS: Clearing younger c-spines

• Age appropriate MS/no

LOC/no focal neuro sx

• No distracting

injury/significant torso injury

• No neck tenderness or

pain/muscle spasm

• Low force

mechanism....

• Let them look around

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Case # 6: Johnny Walker

• 5 yr old 20 mph PVA
• BIBA with (+) LOC
• Now awake/alert
• No c/o of neck pain or

neurological sx

• Open leg fracture
• Image: YES

 LOC  Distracting injury  High force mechanism

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Choosing an imaging modality

• Retrospective study:

 206 kids with CSI  Plain XR:

• <7yrs: 83% sensitive (add C1-

C1-C3 CT 94-97%)

• >7yrs: 93% sensitive

 Missed:

• AMS
• Intubated
• Focal sx

37 Nigrovic Peds Emerg Care 2012

AMS? Focal neuro sx? Intubated? Hx/PE concerning (torticollis/major torso injury)? Full cervical spine CT

• r MRI

yes

<8 years

Attempt clinical clearance:

• Age appropriate mental status
• No history of LOC
• No neck pain or tenderness
• Normal neurological exam
• No distracting injury
• Low force mechanism

THEN let them look around left/right/flex/extend pass clinically clear fail Consider AP/Lat plain XR PLUS Occiput to C3 CT

>8 years

Attempt clinical clearance with NEXUS criteria

• Normal mental status/no intoxication
• No neck pain or tenderness
• Normal neurological exam
• No distracting injury

pass clinically clear fail Start with 3 view plain X-rays abnl or inadequate Full cervical spine CT

Pediatric Cervical Spine Clearance

normal attempt clinical clearance normal attempt clinical clearance *Low force mechanism:

• Fall <3-5 feet vertical
• Lower speed MVA where patient/car-seat all stay in place

Fail Fail Persistent pain/tenderness/neuro sx MRI no no

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Rorschach tests: reading pediatric c-spine x-rays

• ABC’S

 Alignment  Bones  Cartilage/Physes  Spaces

• Pre-dental

 Child: < 4 mm  Adolescent: < 2-3 mm

• Pre-C2

 Child: < 7 mm  Adolescent: < 5 mm

• Pre-C6

 Child: < 14 mm  Adolescent: < 21 mm

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More on pediatric c-spine films…

• Psuedo-subluxation:

 < 4-5 mm of C2 on C3  Up to 40% < 8 yrs  C1-3 spinolaminar line

alignment

• SCIWORA:

 Injury visible on MRI  NL CT does not =

clinical clearance

 If neuro sx/guarding/

pain and (-) CTget MRI/call neurosurgery

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Final case: Suzy Q

• 8 year old diving from

board

• Struck head on

bottom of pool

• C/O neck pain and

hand paresthesias

• BIBA in full C-spine

precautions

• PE: tender, mild hand

weakness

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Suzy’s got a fracture

• Start with CT

 High pretest probability

• Vertebral burst C5
• Image whole spine
• Management:

 Strict immobilization: highly

unstable

 Steroids? No data on kids

• 30 mg/kg solumedrol

bolus 5.4 mg/kg/hr x 24 to 48 hours

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Nutshell:

• Whom to image?

 Neck pain/tenderness/spasm  Focal neurological

symptoms /signs

 Distracting injury/significant

torso injury

 AMS/LOC/intoxication  High force mechanism  Unwilling to look around/

“guarding” neck

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Nutshell (cont):

• Try to avoid reflex CT in

kids

• How to image?

 CT first if:

• Very positive history/PE
• Significant AMS

 Otherwise:

• Consider AP/Lat XR plus
• cciput to C3 CT if <8 yrs
• 3 view XR alone if >8 yrs

 If one fracture, image whole

spine

• How to manage?

 Immobilization/NSU  Steroids-your call

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