minor head trauma: what a headache! joshua rocker, md director of education, pem dept cohen...

Minor Head Trauma:Minor Head Trauma:What a headache!What a headache!

Joshua Rocker, MDJoshua Rocker, MD

Director of Education, PEM DeptDirector of Education, PEM Dept

Cohen ChildrenCohen Children’’s Medical Center/LIJs Medical Center/LIJ

Disclosure: Joshua Rocker, MDDisclosure: Joshua Rocker, MD

I have no relevant financial relationships or I have no relevant financial relationships or conflicts of interest to disclose conflicts of interest to disclose

This presentation will not involve This presentation will not involve discussion of unapproved or off-label, discussion of unapproved or off-label, experimental or investigational use experimental or investigational use medications or devices. medications or devices.

Minor Head TraumaMinor Head Trauma

Definition:Definition:– A patient who experiences an impulsive force A patient who experiences an impulsive force

to the head from a direct or indirect blow, but to the head from a direct or indirect blow, but is currently conscious and responsive. is currently conscious and responsive.

– A GCS of (13) 14 or 15.A GCS of (13) 14 or 15.

Not this…Not this…

But this…

And don’t forget this…

ObjectivesObjectives

What are the stats?What are the stats?

Review the literature.Review the literature.– Where we have been and where we are nowWhere we have been and where we are now

Other concernsOther concerns

Why do we care?Why do we care?

Just look at the Just look at the

numbers!!numbers!!

Why do we care?Why do we care?

Traumatic Brain Injury (TBI) Traumatic Brain Injury (TBI) – leading cause of pediatric leading cause of pediatric death/disabilitydeath/disability

– > 7000 deaths> 7000 deaths– > 60k hospitalizations> 60k hospitalizations– > 600,000 ED visits> 600,000 ED visits

Sports RelatedSports Related

National Electronic Injury Surveillance National Electronic Injury Surveillance System--All Injury Program (NEISS-AIP) System--All Injury Program (NEISS-AIP)

– Overall, >200k EM visits for SR- TBIOverall, >200k EM visits for SR- TBI

– Highest rates for 10-14 y/oHighest rates for 10-14 y/o

– ExtrapolationExtrapolation: 1.6 - 3.8M SR-TBIs annually: 1.6 - 3.8M SR-TBIs annually

TBI: common and serious…TBI: common and serious…what we also knowwhat we also know

In Canada: PEDs CT use for minor head In Canada: PEDs CT use for minor head traumas increased from 15% in 1995 to traumas increased from 15% in 1995 to 53% in 2005.53% in 2005.

US similar increaseUS similar increase

Why?Why?

Why not?Why not?

Its simple, just CT everyone!!! Its simple, just CT everyone!!!

Why not?Why not?

Its simple, just CT everyone!!! NIKHIL???? Its simple, just CT everyone!!! NIKHIL????

How did this happen?How did this happen?

What motivated this drastic increase?What motivated this drastic increase?

Yes, CT technology improved Yes, CT technology improved – FasterFaster– More detailedMore detailed– More accessibleMore accessible

BUT….BUT….

LetLet’’s look at the literature?s look at the literature?

Some early studiesSome early studies

Risks of acute traumatic intracranial Risks of acute traumatic intracranial haematoma in children and adults: haematoma in children and adults: implications for managing head injuries. implications for managing head injuries. BMJ, Teasdale, et al, 1990BMJ, Teasdale, et al, 1990

– If skull fx on Xray and no AMS- If skull fx on Xray and no AMS- 80 fold increase risk of intracranial hematoma80 fold increase risk of intracranial hematoma

Early studiesEarly studies

Predictive value of skull radiography for Predictive value of skull radiography for intracranial injury in children with blunt head intracranial injury in children with blunt head injury. Lloyd, et al. Lancet, 1997.injury. Lloyd, et al. Lancet, 1997.

– If skull fracture on Xray:If skull fracture on Xray:Sensitivity: 65% ICISensitivity: 65% ICI

NPV: 83%NPV: 83%

– If neurological abnormalities:If neurological abnormalities:Sensitivity: 91%Sensitivity: 91%

NPV: 97%NPV: 97%

Lloyd, et al, Lancet, 1997Lloyd, et al, Lancet, 1997

Conclusion: Conclusion: – Skull radiography is not a reliable Skull radiography is not a reliable

predictor of intracranial injurypredictor of intracranial injury – Clinical neurological abnormalities are a Clinical neurological abnormalities are a

reliable predictor of intracranial injuryreliable predictor of intracranial injury– If imaging is required, it should be with CT If imaging is required, it should be with CT

and not skull radiography.and not skull radiography.

Ohhhh….here we go!Ohhhh….here we go!

Dietrich, et al, Ann Emerg Med, Dietrich, et al, Ann Emerg Med, 19931993

Pediatric head injuries: can clinical factors Pediatric head injuries: can clinical factors reliably predict an abnormality on reliably predict an abnormality on computed tomography?computed tomography?– 12% with ICI 12% with ICI – LOC, amnesia, neuro deficits, GCS<15 LOC, amnesia, neuro deficits, GCS<15

increased risk for ICIincreased risk for ICI

– GCS 15: 5% with ICI GCS 15: 5% with ICI

Dietrich, et al, Ann Emerg Med, Dietrich, et al, Ann Emerg Med, 19931993

Pediatric head injuries: can clinical factors Pediatric head injuries: can clinical factors reliably predict an abnormality on reliably predict an abnormality on computed tomography?computed tomography?– 12% with ICI (90% isolated skull fx)12% with ICI (90% isolated skull fx)– LOC, amnesia, neuro deficits, GCS<15 LOC, amnesia, neuro deficits, GCS<15

increased risk for ICIincreased risk for ICI

– GCS 15: 5% with ICI GCS 15: 5% with ICI

That is worrisome!!! 1 out of 20!!!

Greenes and Schutzman, Greenes and Schutzman, Pediatrics, 1999Pediatrics, 1999

Clinical Indicators of ICI in Head-Injured Clinical Indicators of ICI in Head-Injured Infants (<2yrs)Infants (<2yrs)– 608 subjects608 subjects– 5% with ICI5% with ICI

13% if 0-2 months13% if 0-2 months

6% if 3-11 months6% if 3-11 months

2% if 1-2 yrs2% if 1-2 yrs

– 48% with ICI were asymptomatic 48% with ICI were asymptomatic

(but 93% had scalp hematoma)(but 93% had scalp hematoma)

Greenes and Schutzman, Greenes and Schutzman, Pediatrics, 1999Pediatrics, 1999

Conclusion:Conclusion:– Clinical signs of brain injury are insensitive Clinical signs of brain injury are insensitive

markers of ICI in infants. CT recommended.markers of ICI in infants. CT recommended.

Are you seeing where we are going yet…Are you seeing where we are going yet…

1 in 8 infants <2months of age with ICI1 in 8 infants <2months of age with ICI

AAP: Technical Report: Minor AAP: Technical Report: Minor Head Injury in Children, 1999Head Injury in Children, 1999Risk of ICIRisk of ICI– 0-7% if GCS 150-7% if GCS 15– 4-10% if GCS 15 with hx of LOC or amnesia4-10% if GCS 15 with hx of LOC or amnesia

– Conslusion:Conslusion:True prevalence not clearly knownTrue prevalence not clearly known

If GCS 15 and no issues, risk <1% ICIIf GCS 15 and no issues, risk <1% ICI

If GCS 15 but hx of LOC, amnesia, vomiting, or If GCS 15 but hx of LOC, amnesia, vomiting, or seizure, risk 1-5%seizure, risk 1-5%

AAP: Technical Report: Minor AAP: Technical Report: Minor Head Injury in Children, 1999Head Injury in Children, 1999Conclusion:Conclusion:– Literature- not sufficient evidence for clinical Literature- not sufficient evidence for clinical

decision ruledecision rule– NonethelessNonetheless

a small percentage of children with minimal to a small percentage of children with minimal to minor head injury will have significant ICIminor head injury will have significant ICI

““CT scan is the most sensitive, specific and CT scan is the most sensitive, specific and clinically safe modality of identifying ICIclinically safe modality of identifying ICI””

4 month old presents after falling off the couch, from dad’s sleeping arms, onto a hard wood floor…

Patient at high risk for ICI, right? Looks well… but may be asymptomatic!

Play it safe!!!!

This is also why CT rates This is also why CT rates skyrocketed?skyrocketed?

TimelineTimelineAAP Technical Report- 1999AAP Technical Report- 1999AM J Roetgen, Feb 2001 AM J Roetgen, Feb 2001 (BAM!!!!!!)(BAM!!!!!!)– Estimated risks of radiation-induced fatal Estimated risks of radiation-induced fatal

cancer from pediatric CT. Brenner, et al. cancer from pediatric CT. Brenner, et al. – Helical CT of the Body: Are Settings Helical CT of the Body: Are Settings

Adjusted for Pediatric Patients? Paterson, Adjusted for Pediatric Patients? Paterson, et al.et al.

– Perspective. Minimizing Radiation Dose for Perspective. Minimizing Radiation Dose for Pediatric Body Applications of Single-Pediatric Body Applications of Single-Detector Helical CT: Strategies at a Large Detector Helical CT: Strategies at a Large Children's Hospital. Donnelly, et al.Children's Hospital. Donnelly, et al.

People recognized the riskPeople recognized the risk and things are out of controland things are out of control

Head CTsHead CTs

The CT numbers were The CT numbers were dramatically increasing but were dramatically increasing but were we reducing morbidity and we reducing morbidity and mortality? mortality?

Or were we just finding Or were we just finding radiological abnormalities radiological abnormalities in clinically well kids?in clinically well kids?

All at the expense of irradiating them

Schutzman, et al, Pediatrics, Schutzman, et al, Pediatrics, May, 2001May, 2001

Evaluation and management of children Evaluation and management of children younger than 2 years old with apparent younger than 2 years old with apparent minor head trauma: Proposed guidelines.minor head trauma: Proposed guidelines.

– ““We sought to develop guidelines…to identify We sought to develop guidelines…to identify children with complications of head trauma children with complications of head trauma and reduce imaging proceduresand reduce imaging procedures..””

Schutzman, 2001: Schutzman, 2001: Management StrategyManagement Strategy

Stratify patients into 4 groupsStratify patients into 4 groups– High riskHigh risk– Some risk because of concerning symptomsSome risk because of concerning symptoms– Some risk without symptomsSome risk without symptoms– Low riskLow risk

Schutzman, 2001Schutzman, 2001

High riskHigh risk– CT indicated!CT indicated!– Qualifications:Qualifications:

AMS, focal neuro deficit, signs of depressed or AMS, focal neuro deficit, signs of depressed or basilar SF, evidence of SF, irritability, bulging basilar SF, evidence of SF, irritability, bulging fontanelfontanel

LOC >1min and vomiting >5 times or lasting longer LOC >1min and vomiting >5 times or lasting longer than 6 hours (but not evidence based)than 6 hours (but not evidence based)

(maintain a low threshold for children <3 months)(maintain a low threshold for children <3 months)

Schutzman, 2001Schutzman, 2001

Intermediate RiskIntermediate Risk– Group 1Group 1

CT/ observationCT/ observation– 3-4 episodes of 3-4 episodes of

emesisemesis– Transient LOCTransient LOC– Hx of lethargy or Hx of lethargy or

irritabilityirritability– Behavior not Behavior not

baselinebaseline– Nonacute SF Nonacute SF

(>24hrs)(>24hrs)

Intermediate RiskIntermediate Risk– Group 2 Group 2 (Unknown or (Unknown or

concerning mechanism)concerning mechanism)

CT/ Skull XrayCT/ Skull Xray

– Higher force mechanismHigher force mechanism– Fall onto hard surfaceFall onto hard surface– Scalp hematomaScalp hematoma– Suspect intentional injurySuspect intentional injury

SchutzmanSchutzman

Low Risk Low Risk – Observation/ DischargeObservation/ Discharge

Minimal mechanism and clinically wellMinimal mechanism and clinically well

More studies trying to figure this More studies trying to figure this issue out – the search for the issue out – the search for the

low risk patientslow risk patients

Palchak, et al, Annals of Emerg Palchak, et al, Annals of Emerg Med, 2003Med, 2003

A Decision Rule for Identifying Children A Decision Rule for Identifying Children at Low Risk for Brain Injuries After at Low Risk for Brain Injuries After Blunt Head TraumaBlunt Head Trauma

University of California, DavisUniversity of California, Davis

2043 subjects2043 subjects

Palchak, 2003Palchak, 2003

Outcome variables:Outcome variables:(1) TBI on CT(1) TBI on CT

(2) TBI requiring acute intervention NS procedure, antiepileptics >7d, persistent neuro deficits until d/c, >2 days for inpatient tx for symptoms related to head injury


TBI requiring acute interventionTBI requiring acute intervention– We sought to define an outcome that was

meaningful to clinical decision making, independent of the sensitivity of neuroimaging technology, and independent of physician accuracy in recognition of subtle traumatic brain injuries on CT.

Translation: It is not the CT we care about… it is the patient!!!!!


Predictor variablePredictor variable– AmnesiaAmnesia– LOCLOC– HAHA– SzSz– VomitingVomiting– Clinical SFClinical SF– Focal NDFocal ND– Scalp hematoma <2 yrScalp hematoma <2 yr– AMSAMS

Relative Risk of ICI on CTRelative Risk of ICI on CT

2.12.1

2.62.6

1.51.5

2.42.4

2.32.3

5.55.5

5.35.3

2.62.6

6.86.8


Predictor variablePredictor variable– AmnesiaAmnesia– LOCLOC– HAHA– SzSz– VomitingVomiting– Clinical SFClinical SF– Focal NDFocal ND– Scalp hematoma <2 yrScalp hematoma <2 yr– AMSAMS

RR of acute interventionRR of acute intervention

4.74.7

7.67.6

4.54.5

5.35.3

3.53.5

11.311.3

10.610.6

1.21.2

21.721.7


Decision tree Decision tree

for predicting for predicting

TBI with acute TBI with acute

interventionintervention

Palchak, et al, 2004Palchak, et al, 2004

Does an Isolated History of LOC or Does an Isolated History of LOC or Amnesia Predict Brain Injuries in Amnesia Predict Brain Injuries in Children After Blunt Head Trauma?Children After Blunt Head Trauma?

PEDIATRICS, June 2004PEDIATRICS, June 2004

University of California, DavisUniversity of California, Davis


Same dataset– 42% with hx of LOC and/or amnesia– Risk of TBI increased if LOC

(3.7% v 9.7%)

– Risk of TBI if with LOC or amnesia and absence of other findings was _____?


Same dataset– 42% with hx of LOC and/or amnesia– Risk of TBI increased if LOC

(3.7% v 9.7%)

– Risk of TBI if with LOC or amnesia and

absence of other findings was ZEROZERO (0 of 164).


Conclusion:Conclusion:– Recommendation to eliminate isolated LOC Recommendation to eliminate isolated LOC

and/or amnesia as indications for CT in and/or amnesia as indications for CT in pediatric trauma patientspediatric trauma patients

Maguire, et al, 2009Maguire, et al, 2009

Should a Head-Injured Child Receive a Head CT Scan? A Systematic Review of Clinical Prediction Rules

Pediatrics, July 2009

Maguire, 2009Maguire, 2009

“Given the potential harm of cranial CT, including the possible need for sedation…and lifetime estimated risk of cancer mortality of 1 per 1400 head CT scans, predicting which children can be safely managed without CT scanning is vitally important.”

Maguire, 2009Maguire, 2009

Conclusion:– Eight clinical prediction-rule derivation studies

were identified. They varied considerably in population, methodological quality and performance.

– Need for a larger study.

Osmond, et al, CMAJ, 2010Osmond, et al, CMAJ, 2010

CATCH: A clinical decision rule for the use CATCH: A clinical decision rule for the use of CT in children with MHTof CT in children with MHT– Pediatric Emergency Research Canada Pediatric Emergency Research Canada

(PERC)(PERC)– 3866 patients enrolled3866 patients enrolled– 4.1% with ICI4.1% with ICI– 0.6% requiring NS intervention0.6% requiring NS intervention

PERC, 2010PERC, 2010

High risk factors (need for NS intervention)High risk factors (need for NS intervention)(100% sensitivty, 70% reduction of CT)(100% sensitivty, 70% reduction of CT)– GCS <15 within 2 hoursGCS <15 within 2 hours– Suspicion of open fractureSuspicion of open fracture– Worsening HA Worsening HA – IrritabilityIrritability

Medium risk factors (ICI on CT)Medium risk factors (ICI on CT)(98% sensitivity, 50% reduction of CT)(98% sensitivity, 50% reduction of CT)– Large boggy scalp hematomaLarge boggy scalp hematoma– Sign of basal skull fxSign of basal skull fx– Dangerous mechanismDangerous mechanism

AND THEN…AND THEN…

……there is the BIG mommathere is the BIG momma

Kupperman, et al, Lancet, 2009Kupperman, et al, Lancet, 2009

Identification of children at very low risk of Identification of children at very low risk of clinically-important brain injuries after head clinically-important brain injuries after head trauma: a prospective cohort studytrauma: a prospective cohort study

– PECARN- Pediatric Emergency Care Applied PECARN- Pediatric Emergency Care Applied Research Network- Research Network-

25 PEDs25 PEDs

– 42,412 children enrolled42,412 children enrolled

PECARN, 2009PECARN, 2009

Derived and validated a prediction ruleDerived and validated a prediction rule

ICI- 5.2% ICI- 5.2% Clinical important TBI- 0.9 %Clinical important TBI- 0.9 %– Death, NS intervention, intubation >24 hours, Death, NS intervention, intubation >24 hours,

hospitalized for >2 nights because of non-surgical hospitalized for >2 nights because of non-surgical management of TBImanagement of TBI

Neurosurgical intervention- 0.1% Neurosurgical intervention- 0.1%

>2 yrs

Potential 86% reduction in CT

<2 yrs

Potential 86.1% reduction in CT

RE-visit: 4 month old presents after falling off the couch, from dad’s sleeping arms, onto a hard wood floor. On exam well, but with a small

parietal hematoma.

Not so simpleNot so simple

ProsPros

– Excellent radiological Excellent radiological modalities modalities

– Serious pathology with Serious pathology with known and effective known and effective interventionintervention

– Fast and easyFast and easy– Pressure from familyPressure from family

– Answers a questionAnswers a question– Medical Legal FearsMedical Legal Fears

ConsCons

– Risk of radiation exposureRisk of radiation exposure– Increase medical costsIncrease medical costs– Increase LOSIncrease LOS– Possible risk of sedation Possible risk of sedation – What are we teaching the What are we teaching the

public?public?– What is our responsibility What is our responsibility

to the field of medicine?to the field of medicine?

Not so simpleNot so simple

ProsPros ConsCons– Parental concernsParental concerns

– Medical LegalMedical Legal

Almost the end…Almost the end…

How to dispo the CT- kids?How to dispo the CT- kids?

Schutzman, et al, Pediatrics, Schutzman, et al, Pediatrics, 20012001

If CT normal, clinically wellIf CT normal, clinically well– 0 had late deterioration0 had late deterioration

If Skull fracture, but no ICI on CTIf Skull fracture, but no ICI on CT– 0 had late deterioration.0 had late deterioration.

Concussion Concussion

Return to play Return to play recommendationsrecommendations

AAP Policy: Clinical Report—Sport-Related Concussion in Children and Adolescents

2010

ConcussionsConcussions

Constellation of symptomsConstellation of symptoms– PhysicalPhysical

Fatigue, HAFatigue, HA

– CognitiveCognitiveMemory and concentration dysfunctionMemory and concentration dysfunction

– EmotionalEmotionalIrritability, anxietyIrritability, anxiety

– Sleep disturbanceSleep disturbance

Typically resolved in 7-10 daysTypically resolved in 7-10 days

ManagementManagement

Assessment with PE and Neuropsych Assessment with PE and Neuropsych testingtesting

Cognitive and Physical RestCognitive and Physical Rest

Progressive Exercise ProgramProgressive Exercise Program– No immediate return immediate return– A gradual and graded returnA gradual and graded return

Rest-> light aerobic activity-> sport-specific Rest-> light aerobic activity-> sport-specific exercise-> full contact practice-> return to playexercise-> full contact practice-> return to play

Second Impact SyndromeSecond Impact Syndrome

DebateDebate

Sustaining a head injury prior to resolution Sustaining a head injury prior to resolution of a previous concussionof a previous concussion

Cerebral congestion -> diffuse cerebral Cerebral congestion -> diffuse cerebral swellingswelling

All case reports <20 yrs oldAll case reports <20 yrs old

Postconcussion SyndromePostconcussion Syndrome

WHO- no clear definitionWHO- no clear definition

DSMIV- >3mo, >3 symptomsDSMIV- >3mo, >3 symptoms

Down the pipelineDown the pipeline

Other Diagnostic ModalitiesOther Diagnostic Modalities

RadiologicalRadiological

Rapid MRIRapid MRI

Low dosing CT scanLow dosing CT scan

Biomarkers for Head InjuryBiomarkers for Head Injury

Neuron-specific endolaseNeuron-specific endolase

Glial fibrillary acidic proteinGlial fibrillary acidic protein

D-dimerD-dimer

S100BS100B

Myelin-basic proteinMyelin-basic protein

Cleaved tauCleaved tau

In SummaryIn Summary

Minor Head Injury is extremely commonMinor Head Injury is extremely commonICI on CT is seen about 5% of timeICI on CT is seen about 5% of timeClinically important ICI <1%Clinically important ICI <1%Requiring NS approx. 0.1%Requiring NS approx. 0.1%CT use has skyrocketedCT use has skyrocketedMedical radiation exposure not benignMedical radiation exposure not benignClinical Prediction Rule ExistsClinical Prediction Rule ExistsMore things to come…More things to come…

Thank you…Any Questions?Thank you…Any Questions?

Thank you!

ReferencesBerger RP. The use of serum biomarkers to predict outcome after traumatic brain injury in adults and children. J Head Trauma Rehabil 2006;21:315-333.Brenner, Elliston C, Hall E and Berdon W. Estimated Risk of radiation-induced fatal cancer from pediatric CT. Am J Roentgenol 2001; 176:286-296. CDC, MMWR, Nonfatal Traumatic Brain Injuries from Sports and Recreation Activities --- United States, 2001—2005. July 27, 2007:56 (29); 733-737. Dietrich AM, Bowman MJ, Ginn-Pease ME, Kosnick E, King DR. Pediatric head injuries: can clinical factors reliably predict an abnormality on computer tomography? Ann Emerg Med 1993;22:1535-1540.Donnelly LF, Emery KH, Brody AS, Laor T, et al. Minimizing Radiation Dose for Pediatric Minimizing Radiation Dose for Pediatric Body Applications of Single-Detector Helical CT: Strategies at a Large Children's Hospital. Body Applications of Single-Detector Helical CT: Strategies at a Large Children's Hospital. AM J Roengtenol 2001; 176:303-306.AM J Roengtenol 2001; 176:303-306.Frush DP, Donnelly LF, Rosen NS. Computer Tomography and Radiation Risks: What the Pediatric Health Care Providers Should Now. Pediatrics 2003; 112:951-957.Greenes DS, Schutzman SA. Clinical Indicators of Intracranial Injury in Head-Injured Infants. Pediatrics 1999;104:861-867.Halstead ME, Walter KD and the Council on Sports Medicine and Fitness. Clinical Report- Sports Related Concussion in Children and Adolescents. Pediatrics 2010; 126:597-615.Homer CJ and Kleinman L. Technical Report: Minor Head Injury in Children. Pediatrics 1999;104:e78

ReferencesKupperman N, Holmes JF, Dayan PS, et al; for the Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009; 374: 1160-1170.Llyod DA, Carty H, Patterson, M, Butcher CK, Roe D.Llyod DA, Carty H, Patterson, M, Butcher CK, Roe D. Predictive value of skull Predictive value of skull radiography for intracranial injury in children with blunt head injury. Lancet radiography for intracranial injury in children with blunt head injury. Lancet 1997;349:821-824.1997;349:821-824.Maguire JL, Boutis K, Uleryk EM, Laupacis A and Parkin PC. Should a head-injured child receive a head CT scan? A systematic review of clinical prediction rules. Pediatrics 2009;124:e145-154,Osmond MH, Klassen TP, Wells GA, et al; for the Pediatric Emergency Research Canada (PERC) Head Injury Study Group. CATCH: a clinical decision rule for the use of computer tomography in children with minor head injury. CMAJ 2010; 184: 341-348.Palchak MJ, Holmes JF, Vance, CW, et al. Does an isolated history of loss of consciousness or amnesia predict brain injuries in children after blunt head trauma? Pedaitrics 2004; 113,e507-513.Paterson A, Frush DP and Donnelly LF. Helical CT of the body: are settings adjusted for the pediatric patient. Am J Roentgenol 2001;176: 297-301.

ReferencesSchutzman SA, Barnes P, Dujaime, AC, et al. Evaluation and management of children younger than two years old with apparently minor head injury: Proposed guidelines. Pediatrics 2001;107:983-993.

Teasdale GM, Murray G, Anderson E, et al. Risks of acute traumatic intracranial hematomas in children and adults:implications for head injuries. BR Med J 1990;300:363-367.

Williams WH, Potter S and Ryland H. Mild traumatic brain injury and postconcussion syndrome: a neuropsychological perspective. J Neurol Neurosurg Psychiatry 2010;81:1116-1122.

minor head trauma: what a headache! joshua rocker, md director of education, pem dept cohen...

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