Head injury (kids)

Primary survey and resuscitation:

• ABC: ensure that the child’s airway, cervical spine, breathing and circulation are secure.
• Rapidly assess the child’s mental state using the AVPU scale. 
• Use firm supraorbital pressure or jaw thrust as the painful stimulus.

A Alert

V Responds to voice

P Responds to pain  

• Purposefully
• Non-purposefully  

• Withdrawal/flexor response
• Extensor response

U Unresponsive

Assess pupil size, equality and reactivity 

Initial management flowchart:

Secondary survey:

Perform a formal Glasgow Coma Score (GCS)

Neck and cervical spine 

• Deformity
• Tenderness
• Muscle spasm

Head 

• Scalp bruising
• Lacerations
• Swelling
• Tenderness
• Raccoon eyes*
• Bruising behind the ear (Battles sign)

 Eyes 

• Pupil size
• Equality
• Reactivity
• Fundoscopy for retinal haemorrhage (may indicate non-accidental injury)

 Ears 

• Blood behind the ear drum*
• CSF leak*

 Nose

• Deformity
• Swelling
• Bleeding
• CSF leak*

Mouth 

• Dental trauma 
• Soft tissue injuries

Face

• Focal tenderness
• Crepitus

 Motor function 

•  Reflexes present
•  Lateralising signs

* suspect basal skull fracture if these signs present

Features on history:

1. Time and mechanism of injury
2. Circumstances of injury, e.g. accident, NAI, unexplained fall (consider seizure or arrhythmia)
3. Loss or impairment of consciousness and duration
4. Nausea and vomiting
5. Clinical course prior to consultation – stable, deteriorating, improving
6. Other injuries sustained
7. Past history of bleeding tendency

Investigations:  Neuroimaging (discuss with neurosurgeon):

Definite indications:

• Any sign of basal skull fracture on secondary survey (see above)
• Focal neurological deficit
• Suspicion of open or depressed skull fracture
• Unresponsive or only responding non-purposefully to pain
• GCS persistently < 8
• Respiratory irregularity/loss of protective laryngeal reflexes

Relative indications:

•  Loss of consciousness lasting more than 5 minutes (witnessed)
• Amnesia (antegrade or retrograde) lasting more than 5 minutes
• Persistent vomiting
• Clinical suspicion of non-accidental injury
• Post-traumatic seizures (except a brief ( <2 min) convulsion occurring at time of the impact)
• GCS persistently less than 14, or for a baby under 1 year GCS (paediatric) persistently less than 15, on assessment in the emergency department
• If under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head
• Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height).
• Known bleeding tendency

Use CHALICE or PECARN or CATCH Clinical Decision Rules

CHILDREN’S HEAD INJURY ALGORITHM FOR THE PREDICTION OF IMPORTANT CLINICAL EVENTS (CHALICE):  The rule has been shown to be sensitive at predicting patients who will either: – die from their intracranial injuries – need neurosurgical intervention or – have an intracranial injury on CT scan but require only observation and supportive treatment. – Inclusion criteria (ALL must be satisfied for the CHALICE rule to be applied) – Patients less than 16 years old with a history or signs of injury to head. – Loss of consciousness or amnesia not a requirement Rule: A CT head is required if any of the following criteria are present: History: – Witnessed loss of consciousness of >5 min duration. – History of amnesia (either antegrade or retrograde) of >5 min duration. – Abnormal drowsiness (defined as drowsiness in excess of that expected by the examining doctor). – ≥3 vomits after head injury (a vomit is defined as a single discrete episode of vomiting). – Suspicion of non‐accidental injury (NAI, defined as any suspicion of NAI by the examining doctor). – Seizure after head injury in a patient who has no history of epilepsy. Examination: – Glasgow Coma Score (GCS) <14, or GCS <15 if <1 year old. – Suspicion of penetrating or depressed skull injury, or tense fontanelle. – Signs of a basal skull fracture (defined as evidence of blood or cerebrospinal fluid from ear or nose, panda eyes, Battle’s sign, hemotympanum, facial crepitus, or serious facial injury). – Positive focal neurologic sign (defined as any focal neurologic sign, including motor, sensory, coordination, or reflex abnormality). – Presence of bruise, swelling or laceration >5 cm if <1 year old. Mechanism: – High‐speed road traffic accident either as pedestrian, cyclist or occupant (defined as accident with speed >40 mph). – Fall of >3 m in height. – High‐speed injury from a projectile or an object. If none of the above variables are present, the patient is at low risk of intracranial pathology.

PECARN clinical decision rule aims to determine which children are at very low risk of important brain injury and who therefore do not require a CT scan of the head.  The PECARN clinical decision rule consists of 2 age specific rules:  — one for children less than 2 years of age — one for children 2 years and older  Inclusion criteria (ALL must be satisfied if PECARN algorithm to be applied):  — Age < 18 years old — GCS 14 or 15 — Presented to ED within 24 hours of head trauma Exclusion criteria (if ANY are present the algorithm cannot be applied): — Trivial injury mechanisms: ground level falls, walking or running into stationary objects, no signs or symptoms of head trauma other than scalp abrasions and lacerations. — Penetrating trauma — Known brain tumours — Pre-existing neurological disorders — Neuroimaging at an outside hospital before transfer — Patients with ventricular shunts — Bleeding disorders

CATCH Clinical Decision Rules

Consider other investigations : Cervical spine imaging

1. 5-10% of severe TBI have an associated unstable cervical fracture
2. can be cleared clinically and/or radiologically
3. in the patient with TBI clinical clearance is not an option
4. until cleared patients must be immobilized (hard collar, in-line stabilisation, log rolling)
5. Imaging options
   1. Xray C Spine:
      1. lateral c-spine only misses 15% of injuries
      2. lateral c-spine, AP and PEG misses 10% of injuries (25-50% of studies being inadequate)
      3. lateral c-spine, AP, PEG, swimmers (oblique views) still misses 10% and may displace injuries!
   2. CT :
      1. alone misses ligamentous injury without bone fracture, risk 1/1000
   3. 3 view xrays + CT (high resolution, 1.5-2mm slices with sagittal reconstructions)
      1. misses <1% on injuries

6. APPROACH to C spine
   1. Full spinal immobilization care until cleared
   2. Detailed history + examination
      1. mechanism of injury
      2. speed
      3. other injuries
   3. CT c-spine (high resolution, 1mm slices with sagittal reconstructions)
   4. Formal radiologist + Orthopaedic/Neurosurgical expert opinion
   5. Any doubt:
      • High risk injury or neurological deficit -> MRI
      • CT abnormal -> MRI
      • Normal -> clear cervical spine
   6. NEXUS Criteria or Canadian C spine Rules

Consider other investigations :

Venous blood gas

blood sugar level (especially in small children and in adolescents who have been drinking alcohol)

ECG (query arrhythmia as cause of fall)

Check for multitrauma and other investigations such as bloods, FAST, Xrays, CTs

Glasgow Coma Scale (GCS) – level of consciousness

≥ 4 years		< 4 years
Response	Score	Response	Score
Eye opening		Eye opening
Spontaneously	4	Spontaneously	4
To verbal stimuli	3	To verbal stimuli	3
To painful stimuli	2	To painful stimuli	2
No response to pain	1	No response to pain	1
Best verbal response		Best verbal response
Orientated and converses	5	Appropriate words or social smile, fixes, follows	5
Confused and converses	4	Cries but consolable; less than usual words	4
Inappropriate words	3	Persistently irritable	3
Incomprehensible sounds	2	Moans to pain	2
No response to pain	1	No response to pain	1
Best motor response		Best motor response
Obeys verbal commands	6	Spontaneous or obeys verbal commands	6
Localises to stimuli	5	Localises to stimuli	5
Withdraws to stimuli	4	Withdraws to stimuli	4
Abnormal flexion to pain (decorticate)	3	Abnormal flexion to pain (decorticate)	3
Abnormal extension to pain (decerebrate)	2	Abnormal extension to pain (decerebrate)	2
No response to pain	1	No response to pain	1

 

How to assess severity of head injury:

Minor head injury

• No loss of consciousness
• Up to one episode of vomiting
• Stable, alert conscious state
• May have scalp bruising or laceration
• Normal examination otherwise

Management

• The patient may be discharged from the Emergency Department to the care of their parents ( see Discharge Requirements).
• If there is any doubt as to whether there has been loss of consciousness or not, assume there has been and treat as for moderate head injury.
• Adequate analgesia

Moderate head injury

• Brief loss of consciousness at time of injury
• Currently alert or responds to voice
• May be drowsy
• Two or more episodes of vomiting
• Persistent headache
• Up to one single brief ( <2min) convulsion occurring immediately after the impact
• May have a large scalp bruise, haematoma or laceration
• Normal examination otherwise

 Management

• If, on the history from the parents and ambulance, the child is not neurologically deteriorating they may be observed in the Emergency Department for a period of up to 4 hours after trauma with 30 minutely neurological observations (conscious state, PR, RR, BP, pupils and limb power).
• The child may be discharged home if there is improvement to normal conscious state, no further vomiting and child able to tolerate oral fluids.
• A persistent headache, large haematoma or possible penetrating wound may need further investigation, discuss with consultant.
• Consider anti-emetics, but consider a longer period of observation if anti-emetics are given.

Severe head injury

• Decreased conscious state – responsive to pain only or unresponsive
• Localising neurological signs (unequal pupils, lateralising motor weakness)
• Signs of increased intracranial pressure:
  • Uncal herniation: Ipsilateral dilated non-reactive pupil due to compression of the oculomotor nerve
  • Central herniation: Brainstem compression causing
    • Cushing’s triad :: bradycardia, hypertension and widened pulse pressure
  • Irregular respirations (Cheynes-Stokes)
  • Decorticate: arms flexed, hands clenched into fists, legs extended, feet turned inward
  • Decerebrate: head arched back, arms extended by the sides, legs extended, feet turned inward
• Penetrating head injury
• CSF leak from nose or ears

Management

1. The initial aim of management of a child with a serious head injury is prevention of secondary brain damage. 
2. The key aims are to maintain oxygenation, ventilation and circulation, and to avoid rises in intracranial pressure (ICP).
3. Urgent CT of head and c-spine. Ensure early neurosurgical and ICU intervention.
4. Cervical spine immobilisation should be maintained even if cervical spine imaging is normal
   1. Put soft collar, remove hard collar
5. Intubate: if
   1. Child unresponsive or not responding purposefully to pain
   2. GCS persistently <8
   3. Loss of protective laryngeal reflexes
   4. Respiratory irregularity
   5. RSI with Ketamine – Okay, no evidence of increased ICP, been debunked
6. Decrease ICP

 { CPP = MAP – ICP :: normal ICP 7-15mmHg, sustained increases > 20mmHg is associated with ischaemic brain injury} 

1. elevation of head of bed 30 degrees
2. medications to cause osmotic pull
   1. Mannitol: bolus of 0.25-1g/kg
      1. Mechnism of mannitol: decrease in blood viscosity, as well as osmotic pull to decrease brain swelling given that it does not cross the BBB (provided it is intact)
   2. Hypertonic saline 3%NS
      1. used when patient hypotensive because it has no osmotic diuretic effect
      2. bolus of 2-6cc/kg, then infusion of 0.1-1cc/kg/hr
3. hyperventilation
   1. Ventilate to a pCO2 35mmHg 4-4.5 kPa 
4. optimise venous return from brain:
   1. head up positioning, no venous obstruction (remove hard collar), low PEEP

7. Ensure adequate blood pressure
   1. inotropes, vasopressors
   2. maintain cerebral perfusion pressure to > 60mmHg
8. decrease cerebral metabolic rate:
   — sedation, analgesia
   — paralysis
   — avoid hyperthermia
   — treat seizures
   1. Consider phenytoin loading dose (20 mg/kg over 20 min i.v.).
9. Correct Hypoglycemia
10. Repeat CT scan to exclude a new mass lesion
11. Consider hypothermia (decrease cerebral metabolism, possible neuroprotection)
    1. Adverse outcome in paediatric TBI RCT from CCCTG
    2. McIntyre MA suggesting titrated to ICP and prolonged duration maybe beneficial

Consider surgical techniques (to reduce volume in the ‘box’, or to ‘open the box’):
— EVD (if already present, ensure patent and draining)
— haematoma evacuation
— decompressive craniectomy (controversial)

Discharge requirements:

Head injury – general advice information sheet – should be given to all parents.

Ensure the parents have clear instructions regarding the management of their child at home especially to return to hospital immediately if their child:

• becomes unconscious or difficult to rouse
• becomes confused
• has a fit
• develops a persistent headache
• vomits more than once
• develops any bleeding or watery discharge from the ears to nose
• First 6 hours is the “red zone”, then 24hrs is the “yellow zone”
• Waking up patient q2hrs is probably not necessary (and if the clinician believes the patient to be high-risk, he/she should be kept in the department longer)
• Partially waking up the patient once during the night to assure reasonable behaviour might be reasonable, especially if in the “red zone” time

Head Injury handout – Return to sport

• can be given to older children with concussion symptoms to advise about graded return to sport.
• stay off activities until 1 week after resolution of post- concussive symptoms (headache, amnesia, dizziness), and then to use a step-wise approach:
  • mild exertion to increase HR, sport-related activity with no contact, progressive return to full practice
  • then return to game situations – if symptoms develop at any of these stages, go back to the previous stage and consult the primary care giver of the patient

When to consider consultation with local paediatric or paediatric neurosurgical team:

• Moderate head injury with
  • Ongoing drowsiness or vomiting
  • Unexplained confusion lasting for more than 4 hours

When to consider transfer to a tertiary centre:

• All severe head injuries
• Deteriorating conscious level (especially motor response changes)
• Focal neurological signs
• Seizure without full recovery
• Definite or suspected penetrating injury
• Cerebrospinal fluid leak
• Child requiring care beyond the comfort level of the hospital