Dr. Mark R. Proctor - Pediatric Traumatic Brain Injury: Classification and Treatment Guidelines

traumatic brain injury. Uh, I was interested to learn that Doctor Proctor completed his undergraduate degree with a major in French, actually at Dartmouth prior to, uh, completing medical studies at Columbia University where he stayed for his general surgery intern year. Uh, subsequently completing an, uh, a fellowship, uh, excuse me, a residency in neurosurgery at Georgetown, uh, including a year of work in neurotrauma at Maryland's, uh, renowned shock trauma center. He returned to Georgetown for a chief residency year prior to joining Boston Children's as a fellow, where he's remained since. In 2016, after several years as a vice chairman of the Department of Neurosurgery, um, he was appointed to lead that department as a, as a neurosurgeon in chief. Um, and in 2017, was appointed full professor at Harvard Medical School. Doctor Proctor has an international reputation, uh, has pioneered minimally invasive approaches to the treatment of craniosynostosis, as well as novel and now widely accepted approaches to removal of dermoid skull-based tumors. Uh, including many other clinical accomplishments. Um, he has devoted a significant portion of his career to education, serving as, uh, associate program director for many years, uh, in the neurosurgery fellowship here. Ah, his, among his clinical accomplishments, his series on spinal instrumentation in children are the largest in the literature to date in this field and have defined the standard of care, ah, internationally. Ah, his approach to correction of hemivertebrae in children, uh, pioneered here, ah, has drawn children from across the world to have a novel single-stage operation, uh, uh, an approach that's considered too difficult at other centers, but which is, um, done routinely over here. Additionally, as the director of the Brain Injury Center, which is a novel multi specialty and multidisciplinary collaboration here, uh, an effort that has received philanthropic support from the National Hockey League among other sources, uh, Doctor Proctor coordinates a group that sees over 400 injured, injured children monthly, uh, a wealth of experience that I'm sure will inform his, uh, talk this morning. Doctor Proctor, welcome to the podium. Thank you. All I can think is that poor guy having to go through my CV and try and find something interesting in it. So, uh, thank you for inviting me for the talk. This was, this was a requested topic by you guys. So if you don't like the topic, you gotta be introspective about that. Uh, so we'll talk today about, uh, pediatric brain injury and, uh, I'm going to try and cover sort of the types of injury and then we're going to go over sort of the, the modern treatment guidelines, what would be considered sort of the evidence-based guidelines, although the evidence is, is not always incredibly strong on some of these things. So just a little bit of background, this is excluding concussions here, but you can see head injuries are still a very important cause of morbidity and a big source of the trauma we see here at Boston Children's. So it remains a leading cause of traumatic death and disability in children, and you know, about 5 million people live with the sequelae of brain injury. And again, that's, that's beyond concussion. One thing I just want to stress at the start is that we can have a serious impact on this. So Think First is a program that we run here at a Children's is a National Injury Prevention Foundation run in, uh, so we have it now in 46 out of the 50 states. Um, this was an article we put out last year looking at, it's now been around for 30 years. It's one of the only evidence proven, uh, programs where we actually go into schools and teach from 1st grade on. And technically, you can do it all the way from 1st to 12th grade, so repeating the message of uh sort of safe habits. So it's something, part of my career I've been very proud of. I was the chairman of the board of Think First for uh for 2 years and I've been on the board for 8 years there. So, um, it's run here through the trauma program and it's a very active program. So going through the different types of traumatic brain injury, we can see, and I'll, I'll just go be going through each of these individually, but I want to point out it's really sort of a spectrum of injuries. So when you look at things like concussion and diffuse exonal injury, it's really sort of the same injury, just different severities of that same injury. So starting with sort of lower forces and lower acceleration. And moving up to diffuse axonal injury, which is sort of the highest force injuries and subdural hematoma somewhere in between there. Most injuries we see to the brain, especially the ones that cause a lot of severe problems over time, are rotational. In other words, it's not simply that someone gets banged in the head, it's the way the, it's the way the brain moves inside the skull and the fact that the head is not positioned symmetrically on the spine, the weight is forward so that when you have any angular acceleration, the brain moves in a funny way compared to the skull, and that's really the basis of concussion. Uh, where there's relatively milder forces compared to some of the more severe ones, but it's why helmets don't really help, right? Because you're, it's not the blow to the head, it's the movement of the brain inside the skull. So I do want to, I'm pretty sure there's been a talk on concussion this year, but I just want to cover it just for a few slides to give a sense of what it is. And concussion is sort of the most mild of brain injuries, but it doesn't mean that the effects are mild. Some people can be fairly devastated by them, and I think this definition from the American Academy of Neurology is a, is a nice one. So any trauma induced alteration in mental status. May or may not be accompanied by loss of consciousness, and this is sort of the loss of consciousness piece is something that's really changed over the past decade or two. Not, it hasn't actually changed, but people's understanding of it has changed. So, even, even to this day, you'll hear people say, well, I didn't have a concussion. I didn't, I didn't pass out. And that's the reality is only about 10% of concussions have any associated loss of consciousness. So you just sort of have to get that, that out of your thinking. Uh, so, and, you know, any, any blow, even if it's not a blow to the head, but if the head had a lot of force, where you've got some sort of change like severe headaches, nausea, etc. can be, can be considered a concussion. So loss of consciousness is really a very small part of it. Just to give a little, a little sense because I, what I like about this case is the fact that when we see someone, let's say you see him in the emergency room, etc. it's really hard to diagnose the severity of concussion at the outset. So this was an actual patient, a seventeen-year-old, helmet to helmet contact. Uh, he was dazed, taken out of the game, but wasn't taken for medical attention until after the game when he just started really having intractable vomiting. And if you look at this scan, it's, it's arguably a pretty decent looking scan, relatively normal. What you will see is just a tiny bit of blood up in the front here, so sort of what you would call small bifrontal subdurals, but you probably would not call what I have at the bottom there generalized edema. But he, this guy was actually fairly sick. He was in the hospital for one week with intractable vomiting, not doing very well. And then there's his scan a month later when we saw him in follow-up. And again, what I want to point out is at the time of the injury, you couldn't really say that that was a bad looking scan. But for him, it was not a good looking scan because if you see a month later, you see, see these areas here where you have a lot more fluid, so the black being the subarachnoid space, and he, he happened to have a little congenital cyst in the back here and all of those spaces started to open up after a few weeks. So that's, so the right is his baseline scan. If you didn't have that scan, you wouldn't know on the left, the scan actually didn't look so good. Uh, but that's the point of concussion, you know, you don't know how, how good or bad they look at the time. You have to give them a little bit of time to see how they do. And uh throughout the talk, I just want to sort of focus a little bit about what's different in kids versus adults. So if you look at concussions from a biomechanical perspective, kids tend to be better off because the real problem with concussions is the size and the speed of the players these days in sports have have made concussions more prevalent. So if you see like what are some of the changes in football, where they, they changed where the kickoff was from, etc. and they change, like if you, if you down the ball in the end zone, now you're at the 25 instead of the 20, cause they're, they're trying to discourage uh plays where people are running full force over long periods of time. At each other. So that's, uh, those are the reasons for it. And kids just because they're slower and smaller, they don't necessarily create as much force. So from that perspective, they, they sort of are better off in concussion, but from every other perspective, they're sort of worse off. So that we'll talk a tiny bit about second impact syndrome, which is severe swelling to the brain after an injury. That's really a pediatric phenomenon. It's barely rarely, rarely described in adults. the immature brain seems much more susceptible to to long term injury. We used to think, well, kids survive their bad injuries better. That's probably just because they're in general healthier, but actually the brain does worse, and part of that is the bottom part, which is the environmental issues, is that although I I know all of you here today are learning a tremendous amount in this talk. If we think about what we do on a daily basis, we're not acquiring a whole lot of new skills on a daily basis, where, as those kids who, you know, school wasn't canceled today, they're acquiring all these new skills, and it's much more difficult to acquire new skills than to just do your daily routine. So, um, so from that perspective, if you got a high school student injured, that's a lot worse than if I were to go out and get a concussion where I might be able to go do my. You know, the operation I do 3 times a week without too much trouble, because it's not too much in the way of new skills. So you know, in most cases, as I said, you only know over time. It's important to note that nearly 90% of concussions are simple concussions that within a week they're back to normal, they're fine, there's no problems, but about 10% have prolonged symptoms, and those are the things that are harder to figure out at the onset. There's one study from Canada which has looked at Some of the factors that might predict longer concussions, and some of it was the age, uh, some of it was sex. So women were more likely to have prolonged symptoms than men, but it's still, it's, it's not, you know, all that accurate. So you still at the outset can't, can't really quite figure it out. Is there an anatomic or physiologic basis for that? And there really is. So this is, this is true of any brain injury, not just concussion, that in the first several days, there's a real uncoupling of the need for, for oxygen, uh, and glucose and the supply. So in the first few days, your, your necessity for glucose actually goes up, but your blood flow, which is here in red, goes down. So there's a sort of energy crisis early on, and that's why you have to be particularly cautious early on after a concussion or any, any brain injury. And then by about 3 to 7 days it's all starting to normalize again. So that's, that's felt to be the reason that there's that 3 to 7 day window. So what is the, what is the role of a physician now, you know, or if you follow football, you'll probably know that on the sideline of every game, there's an unaffiliated concussion expert, meaning they're not assigned with any team. They're assigned by the NFL. Uh, here in Boston, it's a guy, Brian Naheed, who's a a neurosurgeon at MGH. He's the Patriots' unaffiliated guy. There's, there has to be two of them. I'm not sure who the other one is. Um, so there's one on either sideline. Um. So in the, in the early phase, they want to identify is this an acute injury that's really something much worse than a concussion, not likely in a football game because you're wearing a helmet, etc. So, uh severe injuries aren't likely, but is there something like that for the subacute phase, the next few days? Well, if you suffered a concussion, should you go back to play? And the answer is you shouldn't when you're symptomatic because of the potential risk. And then over time, are you more susceptible to something like uh chronic traumatic encephalopathy. So second impact syndrome, it's just worth covering very, very briefly. It's a pediatric phenomenon. You don't really see it in uh in anyone beyond their late teens, early 20s, and it's essentially an uncontrollable brain swelling that occurs when you have a second blow to the head while you're still symptomatic from the first blow to the head. It's not really well understood, but it's extraordinarily um uh morbid. 50% morbidity and uh sorry, 50% mortality, 100% morbidity. This was uh what led to the concussion laws in every state. So, Zach Leisttead was a, a youth. He, he still is, uh, and, well, he's no longer a youth, but he's a, he was a 17 year old in Washington State who went back in symptomatic from a concussion, had severe brain herniation, is devastated neurologically, but that's what led to Washington, the state of Washington, uh, having the first concussion laws for, for students. The NFL then actually became an active champion of this, and now every state in the country has concussion laws. So we have it here in Massachusetts. There's generally about 4 components. One is that Every student and their family has to uh read information on a concussion and sort of sign something that I've, I've looked at this, I understand what concussion is. Uh, there's a requirement that if you suffered a concussion, you have to be pulled from play. Um, and one other component is that, uh, any, any group that use public lands for their, uh, for, for their play has to follow these. So you can't, you can't just exclude yourselves. The only group that could potentially exclude themselves. Uh, are, uh, private schools, and, but they tend not to. They follow it as well. So now every state in the country has this, and it's, it's an area where the NFL is actually sort of led, uh, led the charge on it, but I think part of that's a PR issue. Steve, you, do you still have a relative working at the NFL Players still, oh, protecting the players, good, on the right side of the law here. So then a concussion, we won't go over this in any detail, but Theoretically, if you've had a concussion, it's a minimum 7 day, um. Uh, return to play. So on day 7, you can get back to play. So the day 1 after the concussion would be no activity, complete rest, and then you sort of step it up, um, each day until by day 7 you can be back in play. So the minimum if a player suffered a concussion on a Sunday, theoretically they could not be back to play again in competition till the following Sunday. And, and if you become symptomatic in one of those steps, you have to go back to the beginning. And then just sort of last thing on concussion, chronic traumatic encephalopathy. You know, this, I will say it is not as clear cut as it's sort of made out to be in the media. It definitely seems to exist as a disease where there's these changes what are called topathies in the brain. It seems to be uh subconcussive blows can do this, so you don't have to have documented concussions to suffer from it. But if you, you know, if you look at the study, studies out of BU, they say basically everybody gets this, whereas there's pretty good data that actually probably it's a minority of players who get it. They just the people who donate their brains to the study are the ones that were symptomatic from it. So we, we don't really know where this is going to be in 5 or 10 years. We definitely think it's a real disease process, but we don't completely understand its incidence and prevalence. OK, so then moving on to uh things that are a little bit more significant than concussion and uh We'll just cover for soft tissue injuries. So lacerations. An important thing to note, especially in the pediatric population, is this can be a very significant source of hemorrhage and a source of anemia in kids. So if you have a young child with a big scalp laceration, you definitely want to be looking at their blood count. we'll go over these, these types of ecchymosis. Retinal hemorrhages very important if you're looking at someone with suspected child abuse to look for retinal hemorrhages and entrance wounds. We don't see a lot of gunshot wounds to the head, but we have one in-house right now, a self-inflicted gunshot wound to the head. So you always want to check and see if there's some somewhere something entered. We've seen some other really Bizarre ones. We had one child with a garden hoe injury. We had one baby literally fall off a bed and fall on a plug that wasn't plugged in and came in with the plug coming out of their head. So you can have entrances of really weird things into the head with one pencil that, you know, came in with a pencil coming right out of the eye. So, obviously, probably very few of you would miss the pencil coming out of the eye is my guess. So subgalal hematoma, this is just so you can see, you know, between the skull here and the scalp, you can get a lot of blood, and this is an older child because the skull is thick, but in a baby that could be a significant source of blood. I do want to make it clear though, cause that, that sort of gets translated to think that any bleeding in the head can cause Significant drops in your hematocrit. It's not really true. If you have a massive bleed in your brain, you're actually gonna, you're gonna die from it before your hematocrit goes down. But in the subgalal space, this, this is true. Sometimes these can calcify. So this is sort of just an interesting phenomenon where babies are so good at forming bone, they form a new shell of bone around the hematoma, and eventually that absorbs. The skull just, just grows into it. So eventually this, this bone goes away and the skull meets this bone. So you don't actually have to treat those surgically, even though they can look quite disturbing on a young baby. Raccoon's eyes. So this is just, this is evidence of a frontal fracture, uh, frontal base of the skull fracture. Here, uh, battle sign, uh, that this is a fracture of the, um, temporal bones. Uh, here, battle that you would think it's sort of a cool sound was actually a doctor battle. It was not, uh, not like a war battle, um, but that's uh also a sign of a skull fracture. And you can get several different types of skull fractures. Open just means there's a scalp laceration over it. Closed means there's no laceration. So linear, think of linear as sort of like cracking an egg, right? So you can get cracks around an egg well away from where you broke it on the edge of the edge of the bowl, and the skull is like that too. So you can, you can suffer a trauma in one area and the fracture can extend to the other side. It may not even be. Fractured on the side where where you struck it because a baby's head is so distensible that you can't always predict the source of the blow from, from where the fractures are as opposed to a depressed fracture, which is always suffered right under where the where the blow was. So here's what we call linear fractures, and in a baby, you always have to distinguish what are the normal lines in the skull. So these are normal lines. Like these are the coronal sutures, but that's a fracture, that's a fracture, that's a fracture, uh, that's a fracture. So when you see multiple fractures like that, you always have to worry about child abuse. That doesn't tend to happen from just a non, uh, non-trivial trauma. So this is someone whose head was hitting, hitting a surface a number of times. Here's a depressed skull fracture. Pretty obvious. This one is called a ping pong fracture. I always thought it was because it looked like you got hit by like a really hard ping pong ball, but it's, it's actually, if you ever push on a ping pong ball, you can see the way it depresses in there. That's why it's called a ping pong fracture. And then just add in a little bit of, you know, some of the things we've done here. So uh this is a study out of the emergency room. Lia Nigrovich, who's, who's awesome. She's a great researcher, led this study, and it was something that was sort of always to me. It seemed crazy. We were admitting all these skull fractures. They were all staying a period of hours and, and going home and we're trying to figure out, well, can we, can we reduce that? So we took up an initiative in 2012. It was, you know, we got the results and it was published here in 2016, where this is the algorithm. So you know, you don't necessarily have to be able to see everything, but if you had a head CT and there was a non-displaced skull fracture and there were no social concerns. Uh, and there were certain discharge criteria. Did they, were they normal mentally? Were they non-focal on the neurologic exam? Could they, could they eat? Uh, and, um, If they were less than 2 months, we were more likely to admit them. So if, if all of these things held, then they were discharged, and if there was any concerns, they got admitted to the, to the medical service. So how did this, how did this sort of impact things? So if you look over time, and this is, this is from the publication, we had a baseline admission rate for isolated skull fractures of 71%. So 71% of the kids that came in, they may have been absolutely fine. We got admitted just because it was our practice to do so. Then we started the algorithm. We started to see a little lowering of the trend, and then the emergency room, I mean, they are great in QI in our emergency room, right? So what did they start to do? Well, if there was a certain emergency room doctor that admitted a patient afterwards, even though they could have been discharged, they were given a survey and saying, you know, what were the rationales for this, and Dr. Becher, the head of the emergency room, might go talk to them and say, Tell me why you were admitting this patient. Was there a concern? just to be sure everyone was on board with this algorithm. And you could see what happened then over just essentially two years is our admission rate went from 71% down to 47%. So pretty marked, you know, 25%, nearly a reduction in the kids we were admitting, and this was actually done through one of these PPQI grants where we were encouraged to sort of find easy measures to save money, and this was a, this was a massive savings in, in money by not admitting the kids. And here you can see just in another form, this is sort of our baseline admission rate. The guideline came out here and then the survey came out and you can see that's when we really started dropping the admissions rate. And through the PIS database, what we saw is that this did not, this was not a phenomenon happening around the country, right? So this is the admission rates at all PIS hospitals. We're included in this. Um. But their admission rates are still up around 80%, so we, we admit far fewer kids and hopefully after that article came out in pediatrics we're going to see similar drops nationally. OK, subarachnoid hemorrhage. So this is any blood sort of around the surface of the brain. So the brain is, is lined with all sorts of vessels that course between the brain and the dura, and they're very susceptible to bruising or tearing with relatively mild traumas, and So subarachnoid hemorrhage is the most common thing you'll see on a scan after, after an injury. Uh, this is, uh, I put this here just as a more uh obvious example. This is from an aneurysm, but here you can see all of this area, all of the areas that normally would be black that are oops now filled with blood are subarachnoid hemorrhage. So all of those, all of those regions. So from an aneurysm, you're gonna get a much more severe one because it's a major artery that's ruptured, um. But seeing little wisps of blood like that that is very common. All right, epidural hematoma. This is one you, you know, you might hear about. We actually have a protocol here. If we know an epidural is coming in from the outside, we actually bypass the emergency room. We got the ORs waiting. We go straight to the emergency room. So why, why is it such a huge Emergency. So epidural and hematomas are a collection of blood between the skull and the dura. So it's usually caused from a fracture of the skull and the vast majority of them. It's torn a blood vessel and that blood vessel is actively bleeding and uh starting to put pressure on the brain. So this is the one where you might have that lucid period, right? You hit your head, you get a little skull fracture, you're fine. But then the blood is starting to accumulate sort of silently at first and then it becomes quite, quite obvious, and this is, uh, you know, like Natasha Richardson who died a couple of years back from a skiing accident. This is the sort of thing where you hit your head, by all accounts, you seem fine, and then within an hour or so, you, you herniate and die. And this is one where if you can get to it early, these are the most gratifying cases we probably do in neurosurgery. So here's an epidural hematoma. When you see these different colors of blood, so the white blood being um the blood that's already clotting, this is actually hyper acute blood. It hasn't even clotted yet, uh, which means that there's just active bleeding going on here. And uh if you can get that, and here's the fracture that's caused that. So if you can get that child to surgery very quickly, that's an amazingly gratifying procedure where they're home, you know, within a day or two. And you've really saved a life. So this is that same child. These are relatively easy operations, but it's just the access to it. And we generally will encourage, and we had this happen just two weeks ago, if let's say there was a child who was in Elliott Hospital with a big epidural, we said please take it out and just we'll come pick up the patient, and our transport team goes up, sort of waits for the patient as soon as they come out of the operating room, brings them down here for post-op care. But that child did, did great, whereas if you try to get them down here with a big epidural, and that's 1 hour or 2 hours of transport time, etc. they may not have survived. Uh, here's just, this is another example of an epidural. Here. You can see the, the fracture that's caused it, and here you can see from that fracture site, they're bleeding anteriorly, and it's, it's what you, they're convex because they, uh, they're limited by where the dura attaches to the, to the skull. And that just uh post-op. brain contusions, these are just focal bruising between the brain or in the brain. It's sort of like a bruising anywhere in the body. The most common sites are frontal and temporal because if you think what we were talking about that it's the brain banging into the skull, it's most likely to bang up on the frontal bone and just behind the eyes at the temporal bone. So these are the areas we commonly see contusions. A coup would be that it happened right under the, the site, so that's sort of the direct trauma. Contra coup is what, let's say you fall back and the back of your head hits the hits the brain, but your, your skull is stopping before your brain does. So the front of your brain hits up into the front of your skull. So you can fall back, hit the back of your head, and get bifrontal contusions, and those could be quite severe. I've seen people die of those from falling back, hitting the back of their head, uh, but it was the frontal contusions that got them. And here's just sort of examples here, and this is just sort of a nice example of how it happens right on the bone edges here. So that's the sphenoid bone. You can see a contusion here and in that general region. This is an unusual contusion. You, you shouldn't normally see one back in that area, and this is just what it looks like pathologically. Subdural hematoma. So, you know, you would think on the surface, epidural hematoma can actually get quite large, um. Why does that do so well? And yet the average subdural hematoma doesn't do very well. And the, and the reason is because the bleeding in a subdural hematoma, as opposed to generally being from, say, a torn artery, is almost always from really badly bruised brain. So it's a different etiology. So the mechanism was much more severe for it to happen, and there's a much higher mortality and the and the children do on average much worse with acute subdurals versus epidurals. This is sort of an interesting, uh, subdural, and the, and the presentation on this child was just a big head. It wasn't that they just had a bad trauma or something terrible was going on. And you might be able to make out that that blood looks a little different from that blood, which looks a little different from that blood, a little different from that blood. So what is this? This is generally thought to be that there was multiple episodes of bleeding. So this is a child abuse case. It's where on a repetitive basis, the baby was, was shook, and that's what caused multiple ages of blood. And if you look at the scan on the right, the only intervention was putting that child in foster care. So taking him out away from the family, and this is a scan two months later. So if you, as long as the, you know, the source of the trauma is taken away, these things can get better on their own. But this is an acute subdural hematoma, and you can see here the brain looks very different, right? It's hard to make out any normal distinctions in the brain here. You've got, you do have subdural blood. It's going inner hemispheric, which is always a little bit more worrisome in its pattern for a child abuse type picture, but also the, the, the brain just looks, it's very homogeneous. You don't see gray, white very well. This is probably a child who's also suffered. An anoxic injury, which is common in, in, uh, child abuse cases because not only is the head banged around, but they often have a respiratory arrest and you can imagine that if someone just committed child abuse, they're not as likely to call medical attention right away. So these, these cases are all non-accidenal trauma or child abuse, and you can see here, I mean this, if you're not used to looking at scans, it may not be as obvious, but you're just starting to lose the distinction in the brain, the gray-white differentiation in the brain here. So you see little bits of hemorrhage, not, not a whole lot, but a brain that's looking somewhat unhealthy. And this is an immediate MRI in that same patient, right? So this is the CT scan, maybe not incredibly impressive, but there's signs. When you look at the MRI, these are diffusion weighted images, any area that's white here. Is stroke. Um, so you could see this, that, that same brain that you saw on the CT scan was diffusely stroked out bilaterally, and this is within literally within a couple of hours of getting here. So in those cases, you know, that's when we talk about sort of, you know, futility and we'll we'll look at that a little bit at the end. There are some cases just there's just really not a whole lot we could do about them because the injury has been suffered already. And this is that same patient now, one day later, so we put in a drain, but you could sort of appreciate how, how bad things are looking now. Now you can really start to see the strokes on the CT scan. The ventricles have collapsed because the brain is swelling. Uh, so a much, much worse looking picture. And this is 2 months later, and you can see how the brain has essentially dissolved, uh, you know, it's, it's, it's really sort of devastating, devastating injury, um. It's kind of like I think this is a patient who's you've just currently been involved with for a baclofen pump. This was the original sets of injuries on that same, that same patient. And then diffuse axonal injury, uh, these are, these are injuries like I said, from a, from a mechanistic perspective, these are some of the more severe injuries. There was a lot of force created or present to create these injuries, and it's an injury where there's so much acceleration and deceleration. That internally the brain was disrupted. So in diffuse external injury, we have the cell bodies. They connect to axons. These axons are now disrupted because they've been sheared by the uh the forces and what you might see on. On an MRI, this is sort of classic right here. You see the corpus callosum, which is the main white matter tract going from one side of the brain to the other, is just sort of ripped in half. These are other like little axonal injuries. This happens to be a contusion down here just showing the classic sites of contusions, but diffuse axonal injury, you can have a, you can sometimes have a scan that actually looks pretty good, a CT that can look almost normal, and yet the child's in very bad shape. And we had one of those. Relatively recently, the child who had the bad uh spinal cord injury, uh, that many of you might know, I know Chris, Chris was involved in the care, uh, also had diffuse axonal injury from, from being hit by a car. So now I'm gonna move on a little bit to the, the guidelines, um. So the guidelines for the management of TBI, uh, just to give a little, a little history. So these were first started by the Brain Trauma Foundation, and in 2016, they published their fourth set of guidelines for adults. Um, and what, what was the rationale for guidelines was meant to sort of standardize care that it was felt that the management of severe injury was sort of a potpourri, and if you're in one center, you'd be completely Treated completely differently than in another center, so this was an attempt to standardize all of that and at least give guidelines for how to standardize it to see what's working, what's not working, and, you know, as Dave Mooney likes to say, well, if you, if you have a pretty standard way of managing it, now you want to test compound, you know, X, Y, or Z or manipulation, you know, A, B, or C, it's a lot easier to introduce a change and see if it's, if it's meaningful. So, uh, as I said, the, the adult version is on its 4th guideline, and now they've actually just made it into a living document. In other words, there's not going to be a 5th guideline. There's just going to be evolutions of the guidelines. It's all online. It's not printed, um. The pediatric ones are on the second version. So there was one in 2003, a second one in 2012, and now the Congress of Neurological Surgeons is working on a new, a new version of the guideline, but it's not going to have any significant changes. I sort of am familiar with the process and recommendations. Uh, you know, the standard, you know, kids are not little adults. It was found, and we'll, we'll go through this a little bit, that the guidelines for adults just were really not so pertinent for, for kids and all mechanisms, especially around some of the numbers around where should you control, uh, cerebral perfusion pressure, etc. So there was clearly a demand for having a separate pediatric guideline. And just as we go through these, just to give you a sense, you know, class one would be a good quality randomized controlled trial. You could see that almost never exists in brain injury. In fact, it doesn't exist in the pediatric guidelines at all, and there's very poor, you know, in the adults there's like one class one study. So, so we have very poor Class one study. Class 2 studies were considered, you know, sort of moderate or poor randomized control, good quality cohort studies, good quality case control studies, and Class 3 was sort of everything else, including case series, right? So, so the degree of evidence gets pretty low as you march down and unfortunately, most of what we're going to be looking at is class 3 evidence. So ICP monitoring, and then I think this one is, is fairly interesting. So you think, well, you know, of course, we should put intracranial pressure monitors in these kids. That's a well established way of treating them. But in fact, it's only class 3 evidence that it's, that it's even helpful, uh, that it should be considered. Uh, it is commonly accepted that about 1/3 of folks with a severe brain injury will have elevated ICCP. So there's a rationale for doing it, but there's no good studies that show it actually improves outcome. And this is an interesting study that just came out in JAMA, uh, just a few months ago, and they, they use the national databases to look at kids treated with ICP monitors and without ICP monitors. And obviously, when you look at national databases, you don't get very granular on your data. But what, what they found was that in fact the kids that had a monitor versus not, there was no evidence of a functional survival benefit with ICP monitoring. So I, I don't think that's going to take us away from the practice of using them, but I just want to make it clear, it's not like we're using them because there's like amazing data saying this really helps and makes a difference in the outcome of these kids. Um, CPP, so cerebral perfusion pressure, right? So this is sort of the, the, the gold standard, right? So if you know what someone's mean arterial pressure is and you know what their ICP is, you just subtract one from the other. You take, you know, if the mean pressure is 90 and their ICP is 20, well, then their cerebral perfusion is 70. Um, and we, we know in adults that the, the guidelines are 60 to 70, right? So you want to keep it at least 60 to 70. Are there separate guidelines for kids? And, and this was really, as you can see again, class 3 evidence, it's really sort of wishy-washy, uh, and they basically said for, for infants, uh, it should be about um 40, and as you get, uh, to, to, to sort of toddlers and above, it should be sort of, uh, 40 to 50, and then adolescents, uh, was 50 to 60 and then moving to the adults where it's 60 to 70, but these are I can tell you that these are not based on, like, you know, incredible studies and data. This is sort of, uh, in general, just more gestalt than, than anything else. Advanced neuromonitoring like we talked about intracranial pressure monitoring. Well, what about putting monitors in the brain that measure temperature or oxygen, etc. Well, again, sort of class 3 data, and there was only certain times it was really recommended that you, you use this that we'll, we'll go over. But should we, there's things like, you know, the reps will come and try and sell what's called LICOX, which is a monitor that measures like 4 or 5 different parameters in the brain, and does that help? And It's, you know, the reality is, I mean, it gives you lots of good numbers and things you can treat, but sometimes you're just sort of chasing your tail and maybe it doesn't make a difference in the, in the long run. Uh, neuroimaging, uh, again, class 3 data. You, you think we, we know you should get a CAT scan when they come in and another one within 6 hours, etc. etc. There's no evidence for that, right? We're this is sort of a clinical, clinical practice. Uh, so we tend to do, I mean, you, I sort of said what our practice is here. Obviously, you get an imaging study at the onset, another one, depending on the severity of the first one, you know, between 68, 12 hours, uh. The guidelines actually say you should have initial study and another one in 24 hours. Uh, I want to just point out another study we did. That came out in pediatrics a couple of years ago on uh trying to reduce the number of CT scans, especially in our mild injuries uh in the um in the emergency room. So, uh. What did we do? We created an algorithm and very similar to the skull fracture one. Again, like I said, it's it's sort of easy. Our emergency room is very, very well oriented for creating these studies and algorithms and checking the results. So if you had a child with a blunt head injury and then these things were just sort of the basics of the triage, etc. the MD gets the history, and here's sort of the meat of it that if they were uh The less than 2 years, greater than 2 years, really all that changed was what were the predictors, but if they were, uh, almost regardless of age, if they had an altered mental status or a skull fracture that you could detect, they should get a, they should get a head CT here. But if they, if they didn't have that and they were um They were younger kids, so you'd get if there is there a hematoma, loss of consciousness, severe mechanism, etc. and if they were older than 2, loss of consciousness, vomiting, severe injury or severe headache. And so it's just a way of going through an algorithm and deciding who needed a CT. And if they had no predictors, no CT, 1 to 2 predictors, just observation in the emergency room for a longer period of time, and 3 predictors, they got a CT scan. So how did this impact the number of imaging studies we got? So our baseline rate of imaging here in the emergency room for, for kids with minor injuries was 21%. So that's already quite low if you look at the national standards. Uh, but we said, you know, we're still more than half of our studies are negative studies. Can we stop doing some of them? So, when we introduced that guideline, we got down from 21% to 15%. And then when we started, you know, teaching the individual doctors that were still ordering the scans and saying, hey, do you know about this algorithm, etc. it went down to 9%. So we cut our rate from 21% to 9%. So now you have less than a 1 in 10 chance if you come to our emergency room with a minor head injury of getting a scan. If you go to a community hospital, it's more, it's a lot closer to 100%. Because it's just sort of the, the, the routine. And here you can see these are, these are only pediatric hospitals. So our baseline rate here on the bottom was much lower than the, the other phys hospitals. Uh, everyone was sort of reducing their number of imaging studies, uh, but we cut it in half from 20% down to 9%. So the, you know, again, that was a study we got, uh, through the PPQI, uh, grant initiatives. All right. Hyper osmolar therapy. Here there's actually, this is like one of the areas there's actually a little bit better data. It's class 2 data. And surprisingly, this, this is actually useful, Chris, you should get off your phone and listen to this one. Don't use mannitol in kids, right? So, uh, so hypertonic saline is actually what has been shown to be effective in, uh, in kids. Uh, and actually mannitol, no study met inclusion. So the, the general recommendations that were not to use mannitol for control of increased intracranial pressure in kids, uh, but to use hypergonic saline as necessary. Temperature control. This has been an area of a lot of discussion and debate over the past many years. A couple of really well funded, well designed adult studies were closed early because actually the people being cooled in the studies had a significantly higher mortality than the ones not being cooled. Um, so it's, so they've actually closed. There's no further adult studies going on in hypothermia for brain injury. There's some things going on for spine injury. So they looked at it in kids and actually the class 2 evidence is to avoid hypothermia if you're only going to do it for 24 hours. So it's not to cool the kids, it's the class 2 evidence is not to cool the kids. And then the class sort of 3 evidence is, well, if you are going to cool them, you have to do it for at least 48 hours. If you reverse it at 24 hours, that's actually, that's actually worse. These guidelines came out in 2012. Since then, the cool kids trial, which was the pediatric trial for For this was actually closed because of utility. In fact, the kids being cooled were doing worse. So, uh, so the next version of the guidelines is going to be even more negative on the use of hypothermia. Um. For those that know Rob Tasker in our ICU, he actually came out with an article just a few months ago looking at cooling, and he's trying to use a lot of statistical methods to say, well, there may be some benefit to cooling. So if you use Bayesian statistics, and I'm not, I'm not really a statistics guy, but maybe Dave Zurkowski can help us with this one, if you use Bayesian statistics, maybe there is some benefit to cooling, but it's, you know, you really sort of have to start to push the data to find any benefit to the cooling. CSF drainage. Again, this is, this is sort of class 2 data. So uh you can drain CSF via an EVD. This will actually help decrease the intracranial pressure and gives you the intracranial pressure. And one thing that is definitely different in kids is the use of a lumbar drain. So not indicated in adults, but in kids, if you have a functioning external ventricular drain, so a drain coming out of the head, draining off fluid. And you're still not getting as much effect as you want, you can add a lumbar drain to get off even more fluid from below. But you never want to put a lumbar drain in without a drain in the brain because you can herniate downward. So if you have a lot of pressure in the brain compartment and you take off any buffer from below, you can herniate. So you have to have both drains if you're going to use the lumbar drain. Barbiturates, so sort of class class 3. This is sort of the traditional like pentobarb coma. The biggest concern about doing that is if you're going to use it, you have to be sure it could drop your blood pressure. So if you use it and you drop the blood pressure, that's actually worse than not using it. Decompressive craniotomy. So this is also Class 3 evidence. In fact, it's class 3 evidence in kids. It's not considered an option in adults any longer because there's been some big studies showing poor results with decompressive cra craniotomy. Just the government, I added some slides just to sort of show what we mean by that. So what do, what do we mean by decompressive craniectomy? It's a little bit like, say, it's a fasciotomy for an orthopedic injury. So if you, uh, you could do it in two ways. Let's say someone has a big subdural, you take out the subdural and you leave the bone off. So you give the brain the ability to swell out. Or if you have someone, let's say without a big mass lesion, but the intracranial pressure keeps rising for a few days after the, after the trauma, you can then go take off pieces of skull to let the brain swell out. So here's a, here's a unilateral uh lesion. So here you can see that subdural hematoma. Um, and you can get a sense the brain's very tight. They're shifted over here. So this is a case where you can, uh, here's another one, you can take off that bone, take out that clot, and, you know, you can see you leave the bone, you leave the bone off here. That's another view of the skull, and you let the brain swell out. This is a child where there's no mass lesion. You wouldn't be taking this out because you have to go in and take out a hematoma. But on the other hand, you can see how, how severe the shift is here, how the ventricles are being effaced on one side. So the rationale for doing this, this is actually not a trauma patient, this is a stroke patient. The rationale for doing it in this patient, who you can see their middle cerebral artery was, was cut off. This was a cardiac patient here, is that they've suffered a massive stroke here on the left. But you, I'm sorry, on the right, but you want to save the left side of the brain. So if you take off that skull and you let the brain now herniate outside the skull rather than pushing it to the other side, you can save the contralateral side of the brain. So you're not trying to save the right side. The injury has already been suffered. You're trying to save the other side. And here's the result. This was, you know. I was going to say it's a good result. I don't know that a lot of people would say that's a great result, but if you look here, you see the right side of the brain was completely devastated, and yet the left side was completely protected and looks, looks pristine at the end of things. Had we not done that. The left side of the brain also would have been devastated. So, so your goal here is, you know, you're sort of cutting your losses, so to speak. Hyperventilation, uh, class 3 evidence to avoid it. So you don't want to overly hyperventilate because as you hyperventilate, less blood is going to the brain. It's sort of, you know, that classic relationship of carbon dioxide to blood flow. So this is the, this is the one time where you might use advanced neuromonitoring like those oxygen sensors in the brain. If you feel you have to hyperventilate, but you want to be sure the brain's still getting enough oxygen, that's when you might use something to monitor the oxygen in the brain. Steroids. This is one of the best evidence we have that you should not use steroids in brain injury. This is true in adults and kids. So no role for steroids in brain injury and a decreasing role for steroids in spinal cord injury. A sedation and paralysis. This was interesting is basically they said it's really up to the treating physician. I mean, that's where they came out on this because there's no good evidence. The only thing they really recommended strongly is not to use propofol in kids because of the FDA warnings. Uh, glucose and nutrition. Again, they basically said all they came out and said was it's really up to the treating physician. Most of us feel that you, you do want to start nutrition fairly early within 3 to 5 days and someone who's had a bad head injury. Um. But it's not, there's not great evidence to support that either. Seizure prophylaxis, this is actually based on old data. They're still using phenytoin in the guidelines, but that you should, uh, you should can consider the use of phenytoin for one week just to reduce seizures in that week. They does not decrease the chance you're going to have a seizure 10 years later. That risk is still there. And then this is just sort of the overall comparison of looking at what's different in kids versus adults. So, if you look at ICP monitoring, there's better evidence to use it in adults than kids. Uh, the numbers that they use for, for ICP a little higher in adults than kids. CPP, we talked about, uh, pediatric guidelines, uh, are less favorable for advanced neuromonitoring. Hypertonic saline versus mannitol, that's, that's a relatively big difference. So the studies in adults which show Mannitol is more effective and in kids it's hypertonic saline. Uh both adults and pediatrics are sort of negative on hypothermia, although in adults it's much stronger. They say you should definitely not use hypothermia. CSF drainage, the one thing different in kids is that you can add a lumbar drain, no real difference in the use of barbiturates. Um, decompressive craniectomy not recommended in adults and may be considered in kids, so that's one of the other differences there. Hyperventilation, avoided in both kids and adults. Uh, no steroids, don't use propofol in kids, and then nutrition and seizure prophylaxis is, uh, um, as you see, so really sort of up to the clinician. And then there's some cases that are just, you know, beyond, beyond treatment in general. This is actually a case from several years ago. I don't know, Dave may not remember, but I remember he and I seeing this patient together in the trauma bay. This is a patient who fell out of a 3rd story window, severe, severe injuries, sort of gave himself his own decompressive craniectomy. Uh, but the brain was just sort of wiped out immediately, fixed and dilated. There's certain times we just know the outcomes are going to be so bad that your best bet is not, not intervening. So if you have a child who's a glassed out 3, fixed pupils, there's really no meaningful survival in any literature, uh, and, you know, you have to be a little bit realistic about, about where the outcomes are going to go. Uh. That's, this is another one, really severe bilateral brain swelling already infarcted at the time. Just a couple of things on future direction and then wrap it up that uh As we look at the guidelines, you know, how do we do any better? I mean, this is pretty pathetic, right? I mean, if we look at everything's class 2 or 3 data. So there's a trial going on now called ADAPT, which is Approaches and Decisions for acute pediatric TBI, uh, and it's trying to accumulate 1000 patients across multiple institutions. Using things that we're already doing, so there's no intervention in the ADAPT trial, but it's an attempt to really rigorously study these patients. If it gets to 1000 patients, which is well on its way, it'll be 5 times bigger than any other study, and hopefully we can get a little bit closer to some of the answers in how we manage these kids. There's 2 adult. Things going on that are similar, which is track TBI and centered TBI. One's the American study. One's a European study. And then Pegasus is a study out of Seattle where they're looking at pediatric guidelines, adherence and outcomes. They, this is just to see if you can get 80% adherence to, to a guideline management, which isn't even that easy to do. Does it affect the outcome. So, there are people who are trying to make this a little bit more scientific and rigorous, but it's, it's not really very easy. And so this is just really very general conclusions, you know, brain injury, a very major cause of death and disability. I would really advocate for prevention. I will say prevention has had major impacts, you know, if you've looked until this past year, morbidity and fatality from car accidents has gone down markedly over the past 5 to 10 years. What's the, what's responsible for that? Most of it is technology. It's seatbelts. It's antilock brakes were not as effective as we thought, but traction control is very effective. Stability control in cars has markedly reduced the rates of injury. So there's a lot of technology things we can do. We like to think that the laws make a difference like helmet laws and stuff, but You can see, you know, each year we sort of go back and forth on whether or not there should be helmet laws. There in this state for kids, there's a bicycle helmet law and a helmet law for motorcycles, but as soon as you, you know, if you, I have a place in New Hampshire, you get to that border and you see on either side of the border, people are taking off their helmets if they're going north or putting them on if they're going south. So people are not very adherent to these things. Uh, and the optimal management continues to evolve. Thanks. Very comprehensive uh summary on. Brain injury and what we all need to know about as, as general surgeons. I'd like to thank uh you and your colleagues for all of the assistance that you provide for us taking care of our mutual patients in the trauma bay and, and thereafter who come in with trauma. It's, it's clear in, in the figures that both you and David show where brain injury is the primary cause of death in those patients is how big a role trauma plays for us. So I, I gather from your conclusion, we're always asking people their thoughts on football and concussions. I, I presume from yours that you would say that we would, you would not support dissuading kids from participating in Football and and hockey where they're likely to get these concussions. So, you know, I was fortunate. I have two sons who are both college athletes. One was a tennis player and the other is a rower. So I think, you know, what I would, what I would say is I think participation in sports is really important. And if you look, you know, this was focused on brain injury, right, but if you look at one of our, what are our real societal problems, it's not people dying of a head injury in the long term, it's, it's inactivity. Obesity Uh, the DSM, uh, whatever we're on now, you know, '87, whatever, just defined video game addiction as a new, as a new problem, right? So, we're trying to balance a lot of things in there and what I would, I would say personally, and I was a, I was a college athlete as well, is you are better off doing a sport than not doing a sport in general, you know, when I was on the missions committee at the medical school, sports were looked at very seriously. I mean, obviously you had to have good grades, but Uh, if you were an athlete, it was always a bit of a leg up because you're, you're used to working in teams, you're, you know, you're more likely to be a good team player and know how to work with others. And the cardiovascular benefits are significant. So, my general advice to a family, well, should I let my child play football? I was like, well, if that's what they're passionate about and they're going to go out and do it, there's a lot of good lessons you can learn from, from playing football, and I think you're better off playing. Football than not playing anything. Would I, if given like if here are the five sports my child is interested in, would I put football on the top of the list, you know, probably, probably never, but there was an interesting study we did here. And we went to NESCAC schools, which are NESCAC or like the New England Small College Athletic Conference. It's like Colby where Dave's daughter went. Uh, I have 22 kids in NSCAC schools, Hamilton and Wesleyan, and we looked at, it was a, it was a survey, 3 decades out, uh, and we looked at the football players versus the non-football players. And the only differences in the survey we could find was on average, the football players were making more money than the non-football players. I mean, that was the only, the only difference in the, in the survey. So we think that probably the case for CTE and stuff is a little overstated, that it's probably at the very top echelon of the players. I mean, almost not every player, but 90% plus in the players in the uh in the BU study were professional football players. But if you're playing at the high school and lower college levels, is your risk of a chronic brain injury really high? Probably not. So, so I would say I would strongly encourage sports, and if you're only passionate about ones where you might hit your head, it's still probably better off than not playing a sport. Additional questions for Doctor Proctor. Don't ask me about Bayesian statistics, Bayesian statistics. We're. Any statistics, but in terms of your thinking, in terms of the potential for impacting improvement in the management of pediatric TBI with that ADAPT trial, any expectations in terms of some parameters that might actually lead to some improvement? I, I, I do think it's, I mean, because it's going to be a relatively more rigorously studied group, I think we'll probably get more firm guidelines on. ICP monitoring because, you know, that study that came out this year saying there's no benefit was based just on PIS databases and they looked at kids who had an ICP monitor and those that didn't without really accounting for severity and mechanism, etc. I think we'll get better data there, probably better data on CPP, um. I'm not sure a ton of things will change in there or whether an external ventricular drain is better than just the monitor will probably come out of there. So I do think it's going to be beneficial. I don't think we're necessarily going to get everything's all of a sudden going to rise to Class one data. I mean, of course that's not a randomized controlled study, but you know, I think trying to look at this in a more rigorous way, as you know, there's a big trend right now to look at national databases, you know, kids' database or the PIS for the pediatric hospitals, and I think you can glean certain things from there, but you're not going to get very granular in those where this, these, these are 1000 kids where they really are monitoring very closely all of the interventions and mechanisms, etc. Any final questions for doctor, Doctor? Doctor Jackson. So Mark, it's almost 50 years to the day that uh Bill Masterton died of a head injury playing hockey, and it was a fairly innocuous injury. He is the only NHL player to have died while playing the sport, and he fell backwards, uh, just while standing still, uh, presumably from that coup contracoup type mechanism you described, which raises the question, should people who are just skating. Wear helmets, and especially kids who are learning at this skate. You know, our, our general guideline on helmets is any sport that has wheels or is on the ice should, should have helmets. So, you know, skateboards, roller skates, bicycles. Being, being on the, I could tell you, I, when my kids were learning to skate, they were definitely, definitely in helmets, but it's, uh, you know, if you're likely to fall, which many of us are on the ice, um, it, it makes sense. I mean, as you know now, uh, all NHL players have to have helmets. Any hockey player at any level has to have a helmet, so it's It's sort of become and now a face mask, right? For a while they had helmets without face masks and you know, they all had a pretty smile with no teeth, um. So it's become much more clear on the, you know, on the organized levels, and yes, I would, I would certainly say if you're going to be on ice, you should have a helmet. Well, Mark, thank you so much for being with us today. Sure. I. OK. Yeah. I. And Oh yeah. Yeah, that's. Yeah. Yeah. I.