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ABEM LLSE 2005:Peds Head Trauma

This quiz covers essentials of the paper by Schutzman & Greenes, Ann Emerg Med 2001 37(1): 65-74. Remember, this quiz isn't just about "teaching to the test," it's about the paper itself.

Sorry about the semicolons.

AB
T or F: Head trauma is one of the less common childhood injuries; but its severity and cost make it important.F: Head trauma is one of the most common childhood injuries; accounting for 500;000 annual ED visits; 95;000 admits; 7;000 deaths and a billion dollars in hospital costs.
Where can the clinician make the biggest impact on patients with head trauma?The largest reduction in mortality results from preventing deterioration and secondary brain injury in patients with mild-mod head injury who initially appear to be at low risk.
Give the authors; date of publication and journal.Shutzman and Greenes; Annals of EM; January 2001.
T or F: Minor head trauma causes a large number of intracranial injuries.True. In some studies; >50% of all intracranial injuries were in patients who were awake and alert.
T or F: According to the authors; limiting “unnecessary” imaging studies is a not a priority in the evaluation of the head-injured child.F. The authors maintain that imaging of all children with minor head injury is wasteful; and also entails the risk of sedation in some cases.
Give the standard definition for minor head trauma.Good luck. There IS no standard definition; the literature has variously used GCS of 15 to as low as 13 (!).
Give the AAP definition of minor head truama.“Those who have normal mental status at the initial examination; who have no abnormal or focal findings on neurological examination; and who have no physical evidence of skull fracture.”
In all cases; the physician should approach a well-appearing head-injured child as having _____________ mild head trauma.APPARENT mild head trauma. Any head-injrued child may harbor potentially life-threatening intracranial hematomas.
The literature shows that the prognosis after epidural hematoma is directly related to ____________________.The patient’s neurological status before surgical evacuation.
T or F: the literature indicates that few pediatric patients with minor head trauma require surgical intervention.True. The literature shows that between 0.4% and 1.5% of such patients require surgical intervention; some studies report surgical intervention rates approaching zero.
T or F: Several studies describing pediatric patients with minor head trauma have directly demonstrated an improvement in outcome associated with early diagnosis of intracranial hematoma.False. No such data exists; which has led some (stark raving mad) authors to question the value of radiographic imaging in these patients.
T or F: The same insane authors who question the value of radiographic imaging in PMHI are able to point to studies showing that patients with minor head trauma and radiographic evidence of intracranial injury will have a benign prognosis.False. Most studies include very few patients with intracranial injuries—so we don’t know how such patients do as a population. (And ask yourself: to what extent do patients initially classified; on clinical grounds; as being “MHI” get RE-classified when their CT comes back with a goombah? Post-hoc pigeonholing is a perennial bugaboo in the clinical literature.)
T or F: Radiographic evidence of intracranial injury is uncommon in patients with minor head injury.False. Up to 6% of pediatric patients with head injury and normal neurologic status have findings on CT
T or F: No study of PMHI has been able to identify a single criterion; or a small set of clinical criteria; that identify all patients with radiographic lesions.True.
What is the value of a history of loss of consciousness in the evaluation of PMHI?Highly doubtful. LOC has poor sensitivity and specificity for identifying patients with radiographic lesions. Quayle et al found that LOC correlated with intracranial injury only if the LOC was for more than 20 min.
What is the value of a history of vomiting in the evaluation of PMHI?Highly doubtful. Poor sensitivity and specificity.
What is the value of a history of seizures in the evaluation of PMHI?Doubtful. Poor sensitivity and specificity.
Few data exist on CT findings in asymptomatic pediatric patients with head injuries. Why?Because these cases have either been specifically excluded from or underrepresented in large series.
What is the true incidence of radiographic evidence of intracranial injury in children with ASYMPTOMATIC head injury?Unknown.
What is the most important difference between children < 2 yo and older children; vis-à-vis MHI?Younger children have a higher risk of intracranial injury and skull fracture. More importantly; younger children and infants present more difficulty in clinical detection of inctracranial lesions. The younger the patient; the higheer the risk of intracranial injury and the more difficult to assess.
T or F: Infants are particularly difficult to assess in the setting of PMHI.True. Very true. Frighteningly true. Infants have a limited behavioral repertorie and an esp. high incidence of injury after minor mechanisms. Infants may have serious intracranial injury in the absence of clinical findings
Most intracranial injuries in asymptomatic infants are diagnosed because_________The infant has an associated skull fracture. Skull fracture is clearly a risk for associated intracranial injury; Quayle reported that it increased the risk by a factor of 20.
Most cases of skull fracture are associated with a finding of ______________on exam.Scalp hematoma. Larger hematomas and parietal hematomas convey an especially high risk of intracranial injury.
Which physical finding was reported by the authors to be the most sensitive predictor of intracranial injury; compared to any of the other clinical predictors they studied?Scalp hematoma; indicative of underlying skull fracture.
T or F: Children with MHI who have normal CTs do not go on the develop short-term complications.False. Such children may rarely develop complications; including the dreaded “second impact syndrome.”
Describe the “second impact syndrome.”These cases all describe football players who developed irreversible brain injury; apparently triggered by a fairly routine second head impact after a prior concussion had occurred. Thought to be due to derangements in autoregulation.
Comment on the sensitivity of CT for intracranial injury.CT is not completely sensitive to radiographically detectable intracranial injury; MRI will pick up some subtle lesions that CT will miss. However; CT does seem to be sensitive to those injuries that require intervention. Several studies report that the risk of deterioration after normal head CT is negligible.
Discuss the problem of delayed intracranial bleeding after normal CT scan.Several such cases have been published; virtually all; however; involve pts who either had other intracranial abnormalities on initial head CT or who had an abnormal neuro status on presentation. Delayed bleeding after normal CT with a normal neuro presentation appears to be very rare.
Discuss the impact (so to speak) of MHI on cognitive function.“Taken together; the strenght of the data suggests that minor head trauma MAY be associated with subtle but measurable differences in cognitive function. There are very limited data specifically examining the consequences of minor head trauma in pediatrics.”
T or F: Identifying skull fractures per se is of little importance in the setting of PMHI—what’s important is to find intracranial injury.False. It is true that identifying intracranial injury is the primary focus; but identifying skull fractures is also important; because fractures are predictors for intracranial injury and because fractures themselves can lead to complications.
What is the most commonly fractured skull bone?The parietal; followed by the occipital; frontal and temporal bones.
What is the most common type of skull fracture?Linear fractures; followed by depressed and basilar skull fractures.
T or F: most linear skull fractures do not have an overlying hematoma.False. In most studies; >90% of skull fractures have an overlying hematoma; although swelling may not be detectable if the child is evaluated shortly after trauma of the swelling is obscured by hair.
True or False: most linear skull fractures do not present with a palpable bony abnormality.True.
Clinical findings such as hemotympanum; Battle’s sign; cerebrospinal fluid rhinorrhea; or CN palsy are present in about ______% of basilar skull fractures.80%
Growing skull fractures a. result from a tear in the dura b. produce a cranial defect that tends to close up over time. c. usually require surgical correction d. typically occur in preteens or adolescents e. a and c f. b and dAnswer: e. Growing skull fractures usually occur in infants or young children with diastatic fracures; and can present months after injury with skull defect; swelling; seizure or neuro deficit.
Aside from intracranial hemorrhage; what are other complications of depressed skull fracture?Dural laceration; compression of brain parenchyma; parenchymal bone fragements; and cosmetic deformity.
What is the rate of CSF otorrhea or rhinorrhea in children with basilar skull fracture?15 to 30%
T or F: CT has a higher sensitivity for skull fracture than plain skull radiography.False. Radiography has a sensitivity of 94-99%; while CT sensitivity ranges from 47 to 94%.
What are the pros and cons of skull radiographs; relative to CT; in the diagnosis of skull fracture?PRO: radiographs have higher sensitivity; are more universally available; and generally do not require sedation. CON: Radiographs have limited utility because they give little to no information about intracranial injury.
T or F: The authors report that between 6-24% of pediatric patients with head trauma may have suffered abuse; however a paper by Jenny et al shows that almost all such cases are detected by physicians once the child presents for care.False. Jenny et al found that 31% of cases were missed at initial visit; and 28% of those were reinjured before child abuse was diagnosed.
What are some of the physical findings that suggest abuse?1. Signs of blunt impact to the head – swelling; contusion; bony abnormality; swollen fontanel. 2. Retinal hemorrhages. 3. Extracranial abnormalities (fracture; burn; visceral injury).
T or F: Retinal hemorrhage is always associated with abuse.False; although its association with accidental trauma is quite rare; and generally occurs in situations resulting from mechanisms of enormous force.
Which intracranial lesions are common in abuse but uncommon in the setting of accidental pediatric head trauma (high-force injuries notwithstanding)?Subarachnoid hemorrhage; subdural hemorrhage; interhemispheric blood; and cerebral edema.
Which skull fracure is pathognomonic for inflicted trauma?None. Any skull fracture resulting from abuse can also occur with accidental trauma. However; fractures from abuse are more commonly multiple; bilateral; corssing suture lines; diastatic; nonparietal; and associated with intracranial subdural hematomas.
The recommendations of this paper are intended for___________________.Children with acute closed head trauma who are alert or easily aroused to voice or light touch. These recommendations are not for children with birth trauma; penetrating injury; existing neurologic disorder; bleeding diathesis; prior intracranial surgery; or multiple trauma.
What are the authors’ recommendations with regard to CT imaging; in light of the literature they present?Obtain CT imaging for any child with even mildly altered mental status (ie; GCS of 13-14); focal deficit; or evidence of skull fracture. Consider CT for children with LOC; amnesia; seizure; headache; persistent vomiting; irritability or behavioral change. Children who are awake; alert and asymptomatic (including no LOC) do not require imaging.
What are the authors’ specific recommendations with regard to CT imaging in infants; in light of the literature they present?Maintain a much lower threshold for imaging in younger patients—consider CT even for asymptomatic pts under 3 mos; particularly in the presence of scalp hematoma or significant mechanism. The younger the patient; the more strongly one should consider imaging. The authors suggest that skull radiographs may be a useful screen (no sedation) in otherwise well-appearing infants.
What are the authors’ specific recommendations with regard to consideration of abuse?Inflicted injury should be considered in the infant or young child with head trauma who presents with no history of injury; inconsistencies or changes in the hisotry; a delay in seeking medical care; history of repeated injury or hospitalization; mismatch of history and findings; or when the child exhibits multiple injuries; injuries in various stages of healing; or overall poor care.
What are the authors’ specific recommendations with regard to imaging and evaluation in patients with suspected abuse?Radiographic imaging is important both for identiyfing injuries as well as documenting and diagnosing abuse. CT is indicated for any child at risk of intracranial injury; and skel survey is indicated if suspicion of trauma exists. Strongly consider ophthalmologic exam. The physician is mandated to report abuse to authorities.
What are the authors’ specific recommendations with regard to disposition in children with a dx of skull fx or or intracranial injury?In general; a neurosurgeon should be consulted for intracranial injury or skull fracture that is depressed; basilar; or widely diastatic. Most will require admission. Admission should also be considered for pts with persistent neuro deficits (despite nl CT); significant extracranial injury; unremitting vomiting; unreliable caretakers; or suspicion of accidental trauma.
What are the authors’ specific recommendations with regard to analgesia and return to activities?Pts may be given acetaminophen for headache; but more potent analgesics are best avoided. IF the child has no significant symptoms; quiet play or activities can be allowed. Athletes with concussion should have activity restrictions in line with the recommendations of the American Academy of Neurology.
What are the authors’ specific recommendations with regard to follow up?Children with symptoms or isolated skull fxs should follow up with their physican within 24 hours. Infants and and young children with skull fx require followup at 2 months to evaluate for signs of growing skull fracture.
An athlete with head trauma has transient confusion; no LOC; and mental status abnormalities lasting < 15 min. Grade his concussion and state his activity restriction; if any.Grade 1 concussion. Return to sports activity same day only if all symptoms resolve within 15 minutes. If a second grade 1 concussion occurs; no activity until asymptomatic for one week. (According to The American Academy of Neurology guidelines; as stated in Schutzman and Greenes; Annals 2001)
An athlete with head trauma has transient confusion; no LOC; and mental status abnormalities lasting >15 min. Grade his concussion and state his activity restriction; if any.Grade 2 concussion. No sports until asymptomatic for one full week; if a grade 2 concussion occurs on the same day as a grade 1 concussion; no sports activity until symptomatic for 2 weeks. (According to The American Academy of Neurology guidelines; as stated in Schutzman and Greenes; Annals 2001)
An athlete with head trauma has a history of transient LOC of about 5-10 seconds. Grade his concussion and state his activity restriction; if any.Grade 3 concussion with brief LOC. No sports activity until asymptomatic for one week. (According to The American Academy of Neurology guidelines; as stated in Schutzman and Greenes; Annals 2001)
An athlete with head trauma has a history of transient LOC of about 5-10 minutes. Grade his concussion and state his activity restriction; if anyGrade 3 concussion with prolonged LOC. No sports activity until asymptomatic for two weeks. (According to The American Academy of Neurology guidelines; as stated in Schutzman and Greenes; Annals 2001).
An athlete with head trauma has a history of transient LOC. He suffered a similar injury six months ago; in which he had a transient LOC. Grade his concussion and state his activity restriction; if any.Repeat Grade 3 concussion. No sports activity until asymptomatic for one month. If intracranial pathology detected on CT or MRI; no sports activity for remainder of season and the athlete should be discouraged from future return to contact sports.
How do Shutzman and Greenes’ guidelines differ from those of the AAP (1999)?1. S&G do not use a history of LOC as the main determinant for which children should undeergo CT imaging. 2. S&G allow the clinician to consider hed CT in pts with no LOC but with worsening or persistent symptoms such as HA; dizziness; or vomiting.


aka Dr. Dog
Departments of Emergency Medicine and Physiology

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