Ep 153 Pediatric Minor Head Injury and Concussion

We see about 750,000 pediatric patients annually with traumatic head injury in EDs across North America. That’s a lot of kids. While most of these kids will be fine regardless of what we do in the ED, even minor pediatric head injury may require neurosurgical intervention, investigating is not without serious risk, there may be long term consequences even with trivial bonks and the signs can be devilishly subtle. Recent literature suggests that pediatric patients take longer to recover from mild traumatic brain injury compared to adults and persistent post-concussive symptoms (PPCS) after 1 month occur in up to 30% of children after minor head injury. These children can and should be identified in the ED based on the PPCS clinical risk score. In this EM Cases main episode podcast "Pediatric Minor Head Injury and Concussion" Dr. Sarah Reid and Dr. Roger Zemek discuss how best to incorporate the PECARN and CRASH2 decision tools into your practice, the role of Fast MRI, how to identify children who are at risk for long term sequelae after a minor head injury and how to manage persistent concussion symptoms when a child returns to the ED after a minor head injury.... Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Winny Li, edited by Anton Helman March, 2021 Cite this podcast as: Helman, A. Reid, S. Zemek, R. Pediatric Minor Head Injury and Concussion. Emergency Medicine Cases. March, 2021. https://emergencymedicinecases.com/pediatric-minor-head-injury-concussion. Accessed [date] Emergency physicians should have a rock-solid approach to identify high-risk patient with minor head injury; to identify those at risk for long term sequelae, to use imaging responsibly, and to ensure ongoing appropriate care for the concussed child after they leave the ED. Classification of pediatric head injury The classification of pediatric head trauma is divided into minor, moderate and severe which are defined by GCS cut offs on first assessment in the ED. GCS 14 to 15: Minor head trauma GCS 9 to 13: Moderate head trauma GCS ≤8: Severe head trauma Minor head injury is defined as injury within the past 24 hours associated with one of the following: * Witnessed loss of consciousness * Definite amnesia * Witnessed disorientation * persistent vomiting (> 1 episode) or * persistent irritability (< 2 years old) * and a GCS score of 14–15 Fortunately, only 5% of children with minor head injury will have an intracranial abnormality and about 1% will have a clinically important outcome. It is important that we use our history and physical exam to identify the patients at high risk for a clinically important outcome. Key features on history to identify children at risk for an intracranial lesion requiring imaging Mechanism of injury PECARN: severe mechanism (MVC with ejection, death another passenger, rollover, pedestrian or bicyclist w/o helmet struck by motorized vehicle, fall 0.9m or 3ft, head struck by high-impact object) CATCH2: high risk mechanism (fall ≥3ft or 5 stairs, bicycle with no helmet), worsening headache, persistent irritability if under 2 years old) Recurrent vomiting Isolated vomiting in the absence of other high-risk factors is rarely associated with significant traumatic brain injury (TBI). Recurrent vomiting (≥ 4 episodes, at least 15min apart) is a significant risk factor for intracranial injury  in children after minor head injury. The addition of ≥ 4 episodes of vomiting to CATCH2 increased sensitivity to 100% for neurosurgical intervention and 99.5% for any brain abnormality. Age and persistent irritability Not acting normally as per parent or persistent irritability i...