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Pediatric Traumatic Brain Injury

Pediatric Traumatic Brain Injury. Janice L. Cockrell MD Medical Director, Pediatric Rehabilitation Legacy Emanuel Children’s Hospital. Incidence. Annual incidence 180/100,000 in 1-15 year olds (Kraus, 1995) Most common cause of mortality. Pediatric TBI. 81% mild 8% moderate 6% severe

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Pediatric Traumatic Brain Injury

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  1. Pediatric Traumatic Brain Injury Janice L. Cockrell MD Medical Director, Pediatric Rehabilitation Legacy Emanuel Children’s Hospital

  2. Incidence • Annual incidence 180/100,000 in 1-15 year olds (Kraus, 1995) • Most common cause of mortality

  3. Pediatric TBI • 81% mild • 8% moderate • 6% severe • 5% fatal

  4. Injury Severity • Mild – unconscious <15 min; GCS 13-15 • Mod – unconscious >15 min; GCS 9-12 • Severe – unconscious >6hr; GCS 3-8

  5. Etiology • Non-accidental trauma in infants • Falls in toddlers • Ped vs. MVA in school-age children • MVA in >16 year olds

  6. Types of Injuries • Trauma • Focal • Diffuse • Stroke • Hypoxia

  7. Trauma • Focal injuries • Prefrontal regions • Intracranial hematomas

  8. Anatomy of the Skull

  9. Trauma • Focal injuries • Prefrontal regions • Intracranial hematomas • Diffuse injuries • Diffuse axonal injury (DAI) • Hypoperfusion • Excitatory cascades of neurotransmitters producing free radicals

  10. Risk Factors • Age • Previous TBI • Socioeconomic deprivation • Premorbid behavior problems only a minor risk factor • (Demellweek et al, 2002)

  11. Effect of AANS Trauma Protocols • Implementation of the AANS protocols for TBI resulted in a 9.13 times higher odds ratio of a good outcome compared to prior outcomes in a community hospital. • Hospital charges increased by more than $97,000 per patient. (Palmer, Bader, Qureshi et al, 2001)

  12. Most Common Physical Problems (Hawley, 2003) • Headache • Blurred vision • Difficulty sleeping • Fatigue • Clumsiness • Seizures • Hearing problems • Change in appetite

  13. Sensory Problems • Blurry vision • Visual field cuts • Cortical blindness • Diplopia • Hearing loss/central auditory processing problems • Loss of smell

  14. Motor Problems • Spasticity • Ataxia • Clumsiness • Tend to improve markedly over time

  15. Outcomes measurement • Glasgow Outcome Score • IQ • Academic achievement • Motor skills • Adaptive skills • Problem solving • Executive function

  16. Glasgow Outcome Score • 1 - Expired • 2 - Vegetative • 3 - Severe disability • 4 - Moderate disability • 5 - Good outcome

  17. Most Common Sequelae • Intellectual • Academic • Personality/behavioral

  18. Cognitive Outcomes • Declines in • IQ • Attention and concentration • Memory • Language • Non-verbal skills • Executive functions

  19. Behavioral Outcomes • Impulsivity • Irritability • Agitation (overstimulation) • Apathy • Emotional lability

  20. Academic Outcomes • Declines in achievement • Declines in school performance • Decreased adaptability

  21. Problems Which Resolve Mild TBI • Clumsiness • Speech • Hearing

  22. Problems Which ResolveMod-Severe TBI • Sleep • Epilepsy

  23. Problems Which PersistMild • Attitude to siblings • Nightmares • Lost hobbies • Personality change • Temper

  24. Problems Which PersistModerate/Severe • Attitude toward siblings • Clumsiness • Concentration • Hearing • Mood fluctuations • Temper

  25. Adult Outcomes • Difficulty maintaining employment • Marital problems • Social isolation (adults described as less likable, less interesting, less socially skilled) • Involvement with criminal justice system

  26. Long-term Neuropsychological Outcomes • Family factors influence behavior and academic outcomes • Family factors did not moderate neuropsychological outcomes (Yeates, Taylor, Wade, et al 2002)

  27. Intellectual & Emotional Functioning in College Students with Hx of Mild TBI • Intellectually unimpaired • Significantly higher level of emotional distress (Marschark et al, 2000)

  28. Executive Functions • Modulated by frontal lobe and prefrontal circuits • Involve both monitoring and controlling behavior • Interact with declarative memory and processing speed but are distinct abilities

  29. Anatomy of the Skull

  30. Outcomes of Frontal Lesions • Children with unilateral frontal lesions regardless of severity had a higher frequency of maladaptive behaviors than those without, even if there was no difference in cognition. (Levin, Zhang, Dennis et al 2004)

  31. Mediating Factors • Age • Severity • SEC • Family functioning • Education • Economic resources • Premorbid personality

  32. Predictors of Social Outcome(Yeates, Swift, Taylor, et al, 2004) Executive function Social Problem Solving Social Outcome Pragmatic language

  33. SADHD • Omission vs commission errors • Omission errors immediately after TBI predicted SADHD • Children with ADHD have a high number of commission errors • SADHD is likely fundamentally different than ADHD. (Wassenberg, Max, Lindgren et al, 2004)

  34. What can the treating physician do? • Follow patient closely for the first few months • Evaluate hearing and vision • Monitor growth, nutrition • Monitor and treat sleep disorders • Educate patient and family regarding TBI • Refer family for counseling if needed

  35. Resources • Brain Injury Association of Oregon 1-800-544-5243 • Brain Injury Support Group of Portland 1-503-413-7707 • Brain Injury Assoc of the US www.biausa.org • Teaching Research, Western Oregon University 1-541-346-0573

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