Head Injury

Question 1

Reasons for worry?

Answer 1

• open wound/ lump on the scalp - severity of the blow to the head - LOC - change in behaviour since the event

Question 2

why is head injury so common in children? (approx 300,000 attending hospital in the UK per year)

Answer 2

Children’s heads are large and heavy in proportion to the body, so they tend to fall head first. The majority of these are children with head injuries are fine.

Question 3

What is more common cause of brain injury following a blow to the head in children > brain haemorrhage or diffuse swelling

Answer 3

diffuse swelling of the brain tissue over the next 24 hours. (CT scan urgent to tell the difference)

Question 4

important safety netting points when discharging a patient with a minor head injury?

Answer 4

can never be 100% sure there isn’t haemorrhage/ oedema developing - parents bring them to a facility with a CT scanner if they become drowsy or out of character, have a persistently bad headache, or are persistently vomiting

Question 5

If the child’s head hits the windscreen in a car accident, what characteristic pattern of glass shatter occurs?

Answer 5

“bullseye” appearance of the windscreen. Tis means a significant head injury was sustained

Question 6

What sort of height is a significant fall for a child?

Answer 6

from their own height or higher. This may not be very high from an adult’s perspective e.g. fall from a table, chair or even a bed may cause significant injury.

Question 7

Points to consider in the history of a child with head injury?

Answer 7

DURING

• MOI: knocked out?
• Eye witness account: cry straight away? eye open and looking around meaningfully? floppy?
• what can the child remember (remember falling? who saw it happen? who called for help? were they able to get up straight away?)

AFTER

• LOC? how long for? (>1 minute = CT head)
• Seizure? (= CT head). Generalised or focal, lasted how long?
• behaviour? (their normal self?). Persistent drowsiness = CT head. Below V on AVPU = urgent intervention. Irritable = may indicate cerebral oedema, contusions and haemorrhage.
• Headache? (unusual for <6 to have a HA, brain haemorrhage nearly always causes a HA). Do they mean pain where the bump is or all over HA?
• vomiting? 3 or more vomits = CT head - consider NAI, esp in children not yet walking. Hx vague/ inconsistent? Injuries around eye and ear?

Question 8

Reasons for CT head?

Answer 8

Persistent drowsiness, irritability, headache and persistent vomiting

If the mechanism of injury is low risk and the child is orientated, you can wait a few hours to see if the symptoms settle.

Question 9

red flags for behaviour following a head injury?

Answer 9

• persisting quiet/ irritable which is out of character - drowsiness that doesn’t improve within an hour or 2 - irritability that doesn’t settle with reassurance and paracetamol/ ibuprofen

Question 10

neurological assessment following a head injury?

Answer 10

• mainstay is observing the child’s behaviour: drowsines, irritability
• Focal neurological signs e.g. pupil abnormalities or limb weakness are late signs, often after behaviour and level of consciousness changes
• Level of consciousness in children. AVPU or GCS (eyes, verbal, motor)
• check for symmetry - if haemorrhage > localised pressure effect > selective weakness of the arms and legs on one side, or a difference in the size of the pupils.

Question 11

A child who is at __ or lower on the AVPU scale voice needs a CT scan.

Answer 11

V

Question 12

Patients who are P or U on the AVPU scale require what intervention?

Answer 12

unlikely to be protecting their own airway with the normal reflexes, and could vomit and aspirate, so they also require intubation by an anaesthetist, and will need Intensive Care.

Question 13

P on the AVPU scale corresponds roughly with __ on the Glasgow Coma Scale.

Answer 13

8

Question 14

signs of a skull fracture?

(NB: Skull fractures will heal, but it is underlying damage that concerns us - most will need CT)

Answer 14

• soft or large swellings
• mechanism of injury: infant landing from above its head height onto a hard surface. Being hit by an object like a golf club, or landing against something sharp like the corner of a table, can cause a depressed skull fracture.
• boggy haematoma

NB: a bump like an egg, especially if on the forehead, is common, and is hardly ever a sign of fracture

Question 15

imp to be aware of NAI when dealing with facial injuries

what would raise suspicion?

Answer 15

• facial bruising and bleeding in non-walking infants
• vague/ inconsistent history
• injuries don’t match the mechanism stated