Articles and Updates from Phoenix Children's
“I have been knocked out a few times, but I have no idea how many concussions I have ever had!”
Trauma, and particularly traumatic brain injury (TBI), are the leading causes of death and disability in children, more so than all other pediatric diseases combined. TBIs result in more children with disabilities than any other problem we face in pediatric medicine. Each year in the United States, a half million children will suffer a head injury. For those who suffer a significant TBI, there is a very high likelihood they will have a permanent disability or other types of morbidity including seizures in epilepsy in what we term, “posttraumatic epilepsy.” We also know that even a “concussion,” otherwise known as a mild TBI, can result in upwards of 15% having a permanent neurocognitive disability requiring further rehabilitation and care of and for extended periods of time due to changes in thinking, depression, anxiety, memory deficits, headaches, sleep disturbance and many other different signs and symptoms of post–concussive syndrome. We also know that once someone has had a head injury, especially one that has been symptomatic, it’s more likely they will suffer another symptomatic head injury even with a lesser or mild mechanism of injury. You become more “susceptible” to further head injuries and concussions.
Mechanisms of Injury
Conceptually, the primary injury occurs based on the primary mechanism (i.e.) motor vehicle collision, fall, etc. The primary injury is the actual tissue damage that occurs to the brain after that primary mechanism. The secondary mechanisms are the cascade of pathophysiological effects that occur as a result of that primary injury. This includes swelling and inflammation, hemorrhagic expansion, excitotoxicity, etc. The secondary mechanisms lead to worsened damage to the brain and occurs from the time of the primary injury throughout the acute stage which we term “secondary injury.” If we add further insults to injury such as insufficient oxygenation, hypotension resulting in a decrease in cerebral blood flow, insufficient nutrients, etc., it worsens the secondary mechanisms and leads to worsened secondary injury and damage.
Multiple Approaches to TBI Care
Clearly, the best outcomes following a TBI are obtained through 3 approaches to care. The first is prevention of that injury from the primary mechanism or at least, mitigate or lessen the primary injury as much as possible. That is the reason for speed limits, bicycle and motorcycle helmets, seatbelts, car seats and other safety measures that prevent children from dying and/or lessen the potential morbidity from the primary mechanism (i.e.) while riding in a car or using a bike helmet to prevent a more severe primary injury when the head hits the ground. The second is aggressive acute care management of the injured child. Our goals are to lessen or decrease the potential second insults (i.e.) maintain good oxygenation and blood pressure, and lessen the secondary mechanisms (i.e.) temperature regulation, identify and prevent vasospasm, etc. Lastly, once the child has recovered through the acute and subacute stages, it’s important to obtain neuro rehabilitation in order to maximize the child’s connectivity and plasticity and optimize their recovery from their injury. These basic concepts aren’t necessarily groundbreaking, and we consider these different principles whether the child’s brain was injured due to trauma or to other types of injury including pediatric stroke, status epilepticus, infection/meningitis or encephalitis, etc. All of these are “brain injuries” and the best outcomes come from prevention or mitigation of the primary mechanism, acute and aggressive early care to create an environment for the brain to heal and maximizing the child’s plasticity and recovery through neuro rehabilitation and therapy.
For all these different elements of care required for a child at risk for a brain injury, families should seek a comprehensive center with specialists and expertise in injury prevention, trauma and neurotrauma, neurocritical care and neuro rehabilitation, like Barrow Neurological Institute at Phoenix Children’s. We have come a long way but there is still so much we do not know or understand when it comes to brain injury and its treatment. It’s that very reason that it is so important to have communication between all these different specialties, to identify our gaps in knowledge, move things forward through clinical and translational research, and disseminate that information at all levels through education and scientific exchange. As you will see through the multiple contributions to this blog on brain injury and brain injury awareness this month, it requires multiple perspectives to further our knowledge in this area and improve the outcomes for all patients we care for each day.