Lecture 5 - TBI Paeds Flashcards
(47 cards)
Are the vast majority of Paediatric TBIs mild, moderate or severe?
Mild - 90%
What is the prevalence of TBI is Paeds?
Approx 745 per 100,000 children in any year. (Mitra et al 2007, Australian study)
How does the TBI vary based on age and Gender?
Age affects type:
Infants (inflicted injuries)
Toddlers (falls)
Primary school (pedestrian, bicycle, sport)
Secondary school (MVA related, sport, falls)
Overall, Males more likely to have severe TBI. But interaction between age and gender….
Preschool occurring 1.5:1 male-female - by school age the ratio is 2:1 male-female.
What are some of the pre-injury characteristics associated with increased risk of TBI?
Up to 23% of children met criteria for ADHD pre-injury
Social disadvantage also associated with TBI.
What indices of severity are commonly used?
Level of consciousness - Glascows coma scale and Children’s Coma scale (for young children [age less than 5] with limited verbal abilities)
+
Post-traumatic amnesia - westmead PTA scale
+ MRI/CT information, undertaken acutely for medical management
Describe the Glasgow coma scale and the typical categories used to classify TBI severity.
Made up of 3 parts, scores range from 3-15. eye-opening(4), verbal response (5), Motor response (6).
13-15 = mild
9-12 = moderate
lessthan 8 = severe
Why might you use the ‘children coma scale’ for young children?
Because the children may have limited verbal abilities to begin with and this measures has a changing verbal scale based on age.
Describe the verbal scale of children’s coma scale.
0-23 months: smiles, coos, orientated to sound/ cries but not consolable/ persistent writers / grunts / no verbal response
2-5 years: app words/inapprop words/cries/grunts/no verbal response
> 5 years: orientated/confused/inapprop words/incomprehensible sounds / no verbal response
Can the westmead PTA scale be used reliably in children? are there alternative PTA scales?
Can be used reliably in children over 8 years of age, some modified Questions for 6-7 year olds (though not well normed).
Starship PTA scale for 4-6 year olds is an alternative, but is not routinely used in Aus.
Describe the levels of severity using the westmead PTA scale
Most use: less than 5mins = very mild 5-60mins = mild 1-24hours = moderate 1-7days = severe more than 4 weeks = extemely severe
Used at Westmead: less than 5mins = very mild 1-6days= Moderate 1-4 weeks = severe 4+ weeks = extremely severe (Westmead group, Khan and Baguley, 2003)
What is a primary TBI injury, give examples (2 types of injuries):
caused by contact forces
e.g.,:
Linear: skull fractures, contusions, lacerations, and contre-coup
Rotational: aceleration-deceleration resulting in DAI
What is a secondary injury, give examples:
Initiated at the time of injury and develops over time.
Vascular: extradural, subdural, or intracerebral haemorrhage, raised ICP, hydrocephalus, cerebral oedema, hypoxia, infection and/or metabolic and respiratory changes.
Diffuse axonal injury also occurs from changes in metabolism (presence of free radicals and excitatory amino acids, changes in glucose metabolism)
What are late effects (of TBI, pathophysiology), give examples:
Any effects occurring outside primary and secondary effects. E.g., white matter degeneration and cortical thinning, cerebral atrophy and ventricular enlargement.
What brain areas are particularly vulnerable to the primary contact force injury of TBI?
Prefrontal cortex and fronto-temporal cortex particularly.
Are skull fractures more common in older or younger children?
Younger ages (infant and toddler) - thinner skulls.
Are mass lesions (incl. haematoma, contusions) more frequent in younger or older children?
Less frequent in younger children (infant and toddlers), than adolescents and adults.
Are secondary injuries such as brain swelling, hypoxia, and diffuse axonal injury more common in children or adults?
More common in children.
Describe the general pattern of physical and then neuropsychological outcomes to mod-severe TBI (not specific domains, just the general pattern)
- Physical issues often resolve in the short term
- Cognitive and behavioural difficulties common and likely to significantly impact on participation and progress
- Considerable variation beween cognitive and behavioural outcomes within mod-sec tbi - this reflects the contribution of multiple factors.
Multiple factors affect cognitive outcome after paediatric TBI, what are four main categories of factors?
- Biological insult: nature, severity, dose-response effect
- Development of a child: age at injury, age at ax
- Time since onset: Acute phase v chronic, post-injury
- Reserve/resilience: pre-injury factors (child and family), mental health, family stress and functioning, school & social supports.
What is the concept of a ‘double hazard’?
That multiple factors compound the effects of any one factor – to affect cognitive outcome after paediatric TBI
Briefly describe how early TBI can affect later development?
Slowed developmental progress. Raw scores increase but not at an age appropriate rate, therefore abilities fall further behind peers over time.
What cognitive problems may affect later development?
Children who suffer a significant neurological event have a range of cognitive problems. e.g., attention, memory, executive deficits that compromise their ability to maintain their normal intellectual/developmental trajectory.
How does TBI affect intellectual development?
A unique TBI IQ profile not identified!
- age at injury and severity relate to overall IQ ability level. e.g., Younger age at time of injury results in reduced IQ relative to injuries sustained in late childhood or adolescence. AND
Greater injury severity >IQ impairment
HOWEVER….very general clinical findings:
- verbal IQ resillient to changes in early stages, but can find a widening gap emerging in these areas over time
- performance based IQ and processing speed, vulnerable acutely, but more likely to show recovery.
Is IQ a good indicator of general functioning following TBI? why not?
No. as IQ can remain in low avg to avg range following moderate to severe TBI, but that does not mean the child is functioning well. May have many other cognitive issues or fatigue etc.
