Now, what about kids?
I already told you that the Canadian C-Spine rules
excluded anybody under the age of 16.
And there’s been a lot of interest
among pediatric trauma specialists
in limiting the exposure of children to radiation.
We don’t wanna take young brains
and irradiate them unnecessarily
'cause that can lead to downstream complications
like increased rates of cancer.
So the PECARN network
which stands for Pediatric Emergency Care
Applied Research Network
came up with a decision rule.
There are two separate guidelines.
One for children over two and one for children under two.
And they’re both highly sensitive with specificity
that’s comparable to the Canadian rules.
So basically, it’s the pediatric equivalent
of the Canadian head CT rules.
The rules only apply to kids who have GCS of 14 to 15.
So if the child has a GCS of 13 or less,
you have to go ahead and CT them.
So this is only for kids
with either normal GCS' or one point off.
If they have two or more points off,
they have to get a CAT scan.
The PECARN guidelines for kids under 2
basically tell us that if the GCS is 14,
if the child is altered in any way,
or if they have signs of skull fracture,
they should go ahead and get CTed
because they have a significant risk
of having a traumatic brain injury, 4%
By contrast, if they don’t have any of those findings,
you then look for further symptoms. You search for
occipital or parietal or temporal scalp hematoma.
You also ask about loss of consciousness that was
equal or greater than five seconds, about the severity
of mechanism of the injury, and you ask the parent if
the kid is acting normally. If you get a yes on any of those
things you move on and see if there are multiple findings, or
a worsening of symptoms, or if the age of the kid is less
than 3 months. Again if yes a C T scan is recommended.
if you get a no in this step observation in hospital is recommended.
Although, in most developed world settings where CAT scans
are readily available, these kids are typically gonna go ahead and get head C T.
For kids whose answer is no to all of those questions,
the risk of significant TBI is less than 1%
it’s actually less than 0.1%
it’s very, very small,
and there’s no indication for CT.
So these children should not be exposed
to the radiation and discomfort associated with the scan.
They should just be permitted to go on about their business.
Over the age of two, the guidelines are similar.
Here, we have for high risk features,
GCS of 14,
altered mental status or basal or skull fracture.
If you suspect any of those things, go ahead and scan.
If you get a no in the first step, move on and look for
a loss of consciousness, or vomiting, or the severity
of mechanism of the injury or if there is a severe headache.
If you have multiple of those findings or a worsening
of symptoms then a C T scan is recommended.
If not then an observation is recommended.
But if they don’t have any of those findings
again, less than 0.1 percent risk of having a head injury,
no scan is warranted.
If you do go ahead and get a scan
because your patient required it
based on a validated decision rule,
you wanna know of course,
if the scan is positive and negative.
So for positive scans,
there are specific diagnoses
based on the findings on the scan
and your patient’s gonna be managed
according to those specific diagnoses
which we’ll talk about in more detail in another lecture.
If the scan is negative,
then your diagnosis is mild traumatic brain injury
which in conventional language in the U.S. is a concussion.
So what are we gonna do for these patients
who have concussion?
Well, it’s really important to remember
that “mild traumatic brain injuries”
are not actually all that mild.
They can cause significant neurologic sequelae
in both a short and long term,
and it’s really important to recognize
the significance of these,
educate our patients about them,
and manage them appropriately.
So patients who have concussions
should expect some degree of slight cognitive impairment
for several weeks after the event.
This is not uncommon.
But it’s important to indicate
that this impairment should be slight.
They might have difficulty concentrating.
They might have difficulty with memory.
They might be irritable or anxious about things
that wouldn’t normally irritate them or make them anxious,
but they shouldn’t be really significantly impaired.
If they can’t complete their normal daily activities.
If they’re really forgetful.
If they’re really not able to perform basic tasks.
Then, we should be concerned
that a more significant injury was missed.
These patients will often have a lot of symptoms.
So headaches, nausea, insomnia, irritability,
these things are all very, very common
and just even letting the patient know
to expect those things
and to understand that they are common
and they are expected is really helpful.
And then, to the extent that we can,
we should try to control those symptoms,
because sleep disturbance
can really exacerbate the cognitive impairment
that patients have following these injuries.
We wanna prescribe brain rest for our patients
and I think a lot of us
might enjoy having brain rest prescribed from time to time.
What that really means is that patients
should not be engaged in really challenging mental tasks.
So this is a time to tell your patient,
“Hey, you probably don’t wanna be taking your MCAT
or your USMLE exam
while you’re recovering from a mild traumatic brain injury.
Go ahead and delay that exam.”
This is not the time to pick up another AP course in school.
This is not the time to start a really challenging new job.
You wanna give yourself time to heal
before you take on really complicated cognitive tasks.
For athletes, we wanna make sure
that they don’t just jump back on the field
and return to play right away after their injury.
They should have a graded return to play
where they can start working out with the team
for short periods
and then longer periods before they compete.
And they definitely should be protected
from recurrent injuries
because repeated traumatic brain injuries,
especially among athletes are actually associated
with significant long term neurologic sequelae.
So we wanna make sure that we’re telling the patients,
“Hey, you know what?
If you’re engaged in a contact sport,
you can’t get back on the field this season,
because we don’t want this to happen to you again
before you’ve recovered from the first one.”
The other thing you wanna think about
is what caused the injury in the first place.
Now, it might have been something that’s not preventable
like a motor vehicle collision or a sports injury.
But especially in our elderly patients,
sometimes, these events are caused by falls,
and we wanna think about what caused the patient to fall
in the first place.
Do they have some sensory difficulties
that have rendered them imbalanced?
Do they have safety issues in their homes?
We wanna do anything that we can to prevent them
from having another incident just like this one.
So don’t just stop asking questions once you decide
that the patient hasn’t had a major brain injury,
think about what got them into this situation
and what you can do to keep it from happening again.
And then lastly, we wanna make sure
that all of our patients have follow-up.
That they have primary care providers
who they can link up with
if they are having significant symptoms down the line
and need additional testing or treatment.
So take home points on traumatic brain injury.
One, most of them are mild but even mild ones
can cause significant symptoms
and we wanna take them seriously.
GCS is the most widely used tool to stratify severity
and it’s very helpful for determining
need for imaging in our patients.
History and physical exam
is gonna give us a lot of clues
as to whether or not your patient needs to be imaged.
We have validated decision rules that can guide
our decision about whether or not to obtain CT scans.
But I do wanna emphasize,
these rules don’t substitute for our own clinical judgement.
So if you’re really, really worried about a patient,
even if they don’t meet the criteria for scan,
you should go ahead and image them.
You always wanna make sure that you feel comfortable
with the clinical decisions that you’re making.
And then, mild traumatic brain injuries
can be managed conservatively,
but you do wanna make sure to prepare
these patients for downstream sequelae
and let them know what to expect,
and keep them from hurting themselves again.
Thank you very much.
I hope this was helpful.