Research Saves Injured Kids by Dr. Alison Gardner

I always wanted to be a pediatrician. First as a pediatrician and now as a researcher, it’s my job to care and lobby for kids. 

Sometimes our kids are injured no matter how many precautions we take and it’s our job to find the best ways to treat these seriously injured children. The golden hour is where you can intervene and improve outcomes from issues like airway troubles, and blood loss, and that sort of thing. That's where, in the emergency room, I come into play. 

Dr. John Petty and I were talking and he brought up the fact that he sees many kids come to the emergency department after trauma with low blood pressure but they have not lost blood. In fact, oftentimes their primary and only injury is a bad head injury. 

In medical school we are taught through the American College of Surgeon’s Advanced Trauma Life Support (ATLS) manual how to respond during that golden hour. It defines the standards of care for trauma patients. It says that if we see evidence of low blood pressure, or shock, that hemorrhage is what we're supposed to think. They're losing blood somewhere. If it's not blood loss out of their body, they're probably bleeding inside their abdomen or internally somehow. There is a sentence in the manual that says isolated or intracranial injuries don't cause shock.

Dr. Petty and I discussed and decided this might be different for kids than adults, and we decided to investigate because it might change our care. Instead of giving them fluids and blood we might do something different to help their blood pressure. In fact, if you've injured your brain, more fluids could cause the brain to swell more and that would be detrimental.

We started a very small study of patients that were treated at our Level I trauma center. We reviewed the details of 31 kids with low blood pressure to see the final cause of their injuries when they were discharge. We found that in kids under 5 years old that came in with low blood pressure and evidence of shock, 50 percent of the time they had an isolated head injury. They didn't have injuries that cause internal blood loss.

The question then becomes, what is the problem? That's guides our treatment. We found it was age dependent. In kids 5 to 11 years old, we found that about 25 percent of those kids had a head injury. This phenomenon disappeared in our teenagers.

After discussion with colleagues at other institutions, we decided to expand our study to review cases from the National Trauma Database. We don't know all the answers to our questions yet, but more research is needed. We need to find better ways to help save more injured kids during the crucial golden hour of treatment. Head injury is a real problem in kids, and it's something that's not entirely preventable.

Our infectious disease colleagues began studying the causes of mortality in pediatric patients decades ago and were able to develop vaccines and improve antibiotics in the mid-1900s. We don't see kids dying a lot from infectious disease anymore. Now we see the same thing with cancer. Childhood leukemia is not a death sentence anymore, and that’s due to hard work in the mid-1980s and 1990s. Their work is impactful.

Now childhood trauma is killing more kids than all other causes combined. I’m involved in the care of these injured kids every day. Since we can’t completely prevent injuries, it's our time to take on this challenge and help save the lives of injured kids.

- Dr. AlisonGardner, Assistant Professor of Pediatrics and Emergency Medicine at Wake Forest Baptist Medical Center

Head Impacts in Kids by Jillian Urban

How many of you have kids who play soccer, football, hockey, basketball? Have any of you had a concussion or know someone who has had a concussion, particularly a young athlete? Many of your may know that concussions are an important topic at the moment. Head injuries commonly occur in football, but they also occur in many other sports including soccer, lacrosse, cheerleading, and basketball. 

The Center for Injury Biomechanics at Wake Forest University has been working with the Childress Institute for Pediatric Trauma for the past two years, and that partnership is now entering its third year. In that time, the Institute has provided us with $350,000 to support medical image data collection as part of a pilot study to collect head impact, neurocognitive, and imaging data from 147 youth and high school athletes. We have collected tens of thousands of head impacts and medical images on a larger scale than has ever been attempted. This work has allowed us to apply for and receive a grant from the National Institutes of Health worth $3.5 million to continue this study in youth players for the next five years. The focus of our study is on football but there are many opportunities to study head injuries in other sports, helmeted and non-helmeted, as well as in boys and girls.

Other researchers have studied professional and college football for the past 10 years. There are only 2,000 NFL players and 100,000 college football players, one NFL player for every 50 collegiate players. However, these statistics are just the tip of the iceberg. There are approximately 1.3 million high school football athletes (ages 14-18) and 3.5 million youth athletes (ages 6-13). That is 1,750 youth football players for every NFL player. We have a tremendous number of youth athletes in this youngest age group, and it is the age group about which we know the least.  Young children’s brains are growing and developing so one of the questions we are asking is - what happens to the brain of a young athlete who has 100, 500, or even 1,000 impacts over the course of a football season? What can we do to avoid or mitigate these impacts?

We commonly think of exposure when we are talking about sun exposure.  We can apply this concept to head impacts where the concussion is a single bad event, similar to a sun burn, and a season or lifetime of impacts is analogous to a lifetime in the sun. Much of the focus of researchers for the past 10 years has been on the concussion – something that might happen once or twice over the course of a career.  However, the question at hand is what has a greater effect on the brain: a few concussions or a season or a playing career of subconcussive repetitive head impacts?

We are studying this using two methods. Before, post-concussion, and after the football season we collect medical imaging and neurocognitive data. The kids participating in the study come in for an appointment at the hospital where we perform a computer-based test that measures how fast they think and how well they remember things. We collect medical imaging data including a magnetoencephalography scan, or MEG, which listens to their brain - specifically the magnetic activity of the brain and an MRI, which takes different types of pictures of the brain but with no radiation. These together allow us to measure the functional activity of the brain, along with the structure of the brain.

In between the pre- and post-season scan, they practice and play football. We instrument the helmets of youth and high school football players with a sensor system that fits in the existing helmet. The sensor system sits on the crown of the head of the athlete and wirelessly transmits each head impact to a sideline laptop during all practices and games. We are measuring the location of impact on their helmet and the acceleration, representing the severity of the hit in terms of Gs. We use this data to better understand head impact exposure on the field in order to better inform safety on the field, helmet safety, and to better understand age-specific injury risk and injury mechanisms. Our imaging collaborators measure changes in the brain from the MRI and MEG and are looking to see if they correlate to the number and magnitude of impacts they have received.

We have found that many of our athletes are receiving a greater percentage of their head impact exposure during practices compared to games, which is something our players and coaches have direct control of through modifying practice drills and limiting the number of contact practices. Additionally, by studying two different groups with different league rules on contact practice with our partners at Virginia Tech, we have found that one league significantly reduced the head impact exposure of the athletes without affecting how hard they hit during games. 

The study has many opportunities to go beyond youth and high school football. There is a lot we do not know about female athletes and even non-helmeted sports such as soccer where we see a high incidence of concussion. The results of this study will help us to better understand how to reduce head impact exposure and ultimately keep our kids safe. 

- Jillian Urban, Wake Forest University Center for Injury Biomechanics

Concussions in Kids

Many of you have heard a lot of talk in the news lately about concussions and head injuries from kids playing sports. I’m personally invested in this issue because my wife Lisa and I lost our younger son, Matthew, after he sustained a traumatic brain injury during a high school football game in 2008. I’m professionally motivated by the issue as the executive director of the Childress Institute for Pediatric Trauma.

As your kids go back to school and sports this month, we wanted to give you facts about concussions to help kids continue to play it safe:

• Young children and teens are more likely to get a concussion and can take longer to recover than adults 
• Recognizing and responding properly to concussions when they first occur can help prevent further injury or even death 
• Athletes who have had a concussion, at any point in their lives, have a greater chance of getting another concussion 
• Traumatic brain injuries (TBI) or concussions are a contributing factor to 31 percent of all injury-related deaths in the U.S.

Although the NCAA and NFL have pledged millions of dollars to study college and youth sports safety, up until now the effects of sports on kids have been vastly understudied. Did you know that 70 percent of the U.S. football-playing population is younger than 14? The Childress Institute is in its third year of funding a long-running study of 9- to 12-year-olds to track the cumulative impact on the brain of head contact across multiple seasons. The good news is, people are paying attention and we can start to make a difference as we learn more.

• Symptoms may appear mild, but the injury can lead to significant life-long impairment
• Each year, U.S. emergency departments treat an estimated 175,000 sports-related TBIs for boys and girls 
• During the last decade, emergency department visits for sports-related TBIs, among children and adolescents increased by 60 percent 
• 62 percent of sports-related injuries occur during practice not games

Based on the research we do have, we can help prevent and reduce injuries:

• Limit contact during sports practices (when appropriate for the sport) 
• Change rules and/or ban or limit the use of certain drills or techniques to help reduce the chances of injury 
• Check sports equipment often to make sure the equipment fits the athletes well, is in good condition, stored properly, and is repaired and replaced based on instructions from the equipment companies 

Action can help improve outcomes for kids:

• Educate coaches, parents, athletic trainers and athletes – inform and educate coaches, athletes, and their parents and guardians about concussion through training and/or a concussion information sheet

• Remove athlete from play – an athlete who is believed to have a concussion should be removed from play right away – “When in doubt, sit it out”

• Obtain permission to return to play – an athlete can only return to play or practice after at least 24 hours AND with permission from a health care professional trained in concussion care

My best advice as a parent of children who played multiple sports is not to be afraid to go to practice and ask questions. You are your child’s best advocate, so the more you know the better off everyone is.

To learn more about recognizing concussions in your young athlete, visit the CDC’s concussion website. You can learn more about my family’s personal story with sports-related traumatic brain injuries by visiting MattGfellerFoundation.org. We hope you will all help kids play it safe this fall.

- Bob Gfeller, Executive Director of the Childress Institute for Pediatric Trauma