Management of the paediatric patient with acute head trauma

Question 1

What is the incidence of head trauma leading to brain injury in children in Canada?

Answer 1

130-200 cases per 100 000

Question 2

What is TBI?

Answer 2

This term is used to describe the symptoms and signs that result from trauma to the brain itself, which may or may not be associated with findings of injury on imaging studies.

Question 3

Why are children at higher risk of developing an intracranial lesion due to head trauma?

Answer 3

1. Larger head-to-body size ratio
2. Thinner cranial bone
3. Less myelinated neural tissue

Question 4

What are the most common causes of head trauma in children and youth presenting to Canadian ED?

Answer 4

1. Falls
2. Sports-related injuries
3. Being hit on the head, by an object or by colliding with an obstacle
4. Injuries involving the use of a bicycle
5. Injuries involving motor vehicles, especially as a pedestrian.

Question 5

What are the most common causes of intracranial injury?

Answer 5

1. falls from a height above three feet (91 cm, or twice the length/height of the individual)
2. involvement in a motor vehicle accident (either as a passenger or a pedestrian)
3. impact from a high-velocity projectile

Question 6

What are some signs of head trauma?

Answer 6

1. Headache
2. Amnesia
3. Impaired level of consciousness, disorientation or confusion
4. Vomiting
5. Loss of consciousness
6. Blurred vision
7. Seizures
8. Lethargy
9. Irritability

Question 7

What signs are particularly associated with intracranial injury?

Answer 7

1. Prolonged loss of consciousness or impaired level of consciousness
2. Disorientation or confusion; amnesia
3. Worsening headache
4. Repeated or persistent vomiting

Question 8

What is the classification of the severity of head trauma?

Answer 8

1. GCS 14 to 15: Minor head trauma
2. GCS 9 to 13: Moderate head trauma
3. GCS ≤8: Severe head trauma

Question 9

What is the GCS?

Answer 9

Eye Opening:
4 Spontaneous
3 To verbal stimuli
2 To pain
1 None

Best Verbal Response:
5 Oriented
4 Confused
3 Inappropriate words
2 Incomprehensible sounds
1 None

Best Motor Response
6 Follows commands
5 Localized pain
4 Withdraws to pain
3 Flexion to pain
2 Extension to pain
1 None

Question 10

What is the pediatric GCS?

Answer 10

Eye Opening:
4 Spontaneous
3 To verbal stimuli
2 To pain
1 None

Best Verbal Response:
5 Coos, babbles
4 Irritable, cries
3 Cries to pain
2 Moans to pain
1 None

Best Motor Response
6 Normal spontaneous movement
5 Withdraws to touch
4 Withdraws to pain
3 Abnormal Flexion
2 Abnormal Extension
1 None

Question 11

What is the first management priority?

Answer 11

Stabilize vital signs

Question 12

What should be avoided to prevent secondary injury to the brain?

Answer 12

1. Hypoxia
2. Hypotension
3. Hyperthermia
4. Raised ICP

Question 13

What should be considered?

Answer 13

Possibility of abusive head trauma

Question 14

What elements should be included in a pertinent history?

Answer 14

1. The mechanism of head trauma, whether witnessed or not;
2. The state in which the patient was found, including loss of consciousness or seizures;
3. Presenting symptoms, especially impaired level of consciousness, disorientation or confusion, amnesia, worsening headache or repeated vomiting; and
4. Medical history of head injury, neurological disorders, medication use and bleeding diathesis.

Question 15

What is the initial assessment and stabilization of the airway?

Answer 15

Consider possible injury to the cervical spine

Maintain head and neck in a neutral position

Immobilization: Sandbags, intravenous solution bags, towel rolls (younger patients)

Age-appropriate rigid cervical collar or manual in-line immobilization (older patients)

Orotracheal intubation if cannot maintain airway adequately with positioning and after suctioning

Question 16

What is the initial assessment and stabilization for breathing?

Answer 16

Intubation if unable to maintain adequate oxygenation and ventilation, despite provision of supplemental oxygen

Use rapid-sequence induction technique

Maintain cervical spine precautions

Question 17

What is the initial assessment and stabilization for circulation?

Answer 17

Hemodynamic instability unlikely to be caused by intracranial injury alone (exception: Significant intracranial or scalp bleeding in a young infant).

If present:

a) Investigate extracranial lesions causing hemorrhagic or hypovolemic shock
b) Insert two large-bore intravenous catheters; fluid bolus of 20 mL/kg of normal saline
c) Repeat until vital signs improve.

Question 18

What is the initial assessment and stabilization for disability?

Answer 18

Perform rapid assessment, including:

a) Glasgow Coma Scale score adapted to age
b) pupil size and reactivity to light
c) tone, reflex and movement of all four limbs
d) fontanelle (infants)
e) signs of basal skull fracture: Periorbital ecchymosis (‘raccoon eyes’), ecchymosis over the mastoid bone (Battle’s sign), obvious leakage of CSF from the nose or ears, hemotympanum. If one or more of these signs is present, no tube should be placed by the nasal route

Question 19

What is the management of a patient >2yo with history of acute impact to head and GCS 14-15 who is asymptomatic, normal general and neurological exam, low risk cause of trauma, and GCS 15?

Answer 19

Determine if other medical or social indication for admission and if not then consider discharge with written instructions

Question 20

What is the management of a patient >2yo with history of acute impact to head and GCS 14-15 and any of the following:
1. Abnormal mental status
2. Abnormal neurological status
OR 3. Suspect skull fracture?

Answer 20

Perform CT scan and admit to hospital. If positive consider contact neurosurgery

Question 21

What is the management of a patient >2yo with history of acute impact to head and GCS 14-15 and any of the following:

a) Hx of LOC
b) Amnesia
c) Confusion
d) Lethargy or irritability
e) Repeated or persistent emesis
f) Severe or persistent headache
g) Immediate post-traumatic seizure
h) Physician discretion

Answer 21

Observe in ED for 4-6h and consider CT scan. If symptoms improve and GCS 15 consider discharge, otherwise admit

Question 22

What are indications for skull X-rays?

Answer 22

1. Skull X-rays need not be performed routinely in all patients
2. <2yo with large, boggy hematoma
3. > 2yo Obvious penetrating lesion
4. > 2yo suspected depressed skull fracture
5. Concern for abusive head trauma

Question 23

What are the indications for CT?

Answer 23

1. All patients presenting with moderate to severe head trauma

Absolute:

1. Focal neurological deficit on P/E
2. Clinically suspected open or depressed skill fracture, or a widened or diastatic skull fracture observed on X-ray

Relative:

1. Abnormal mental status (GCS <14 at any time or GCS <15 at 2h after injury)
2. Clinical deterioration over 4-6h of observing symptomatic patient in ED, including worsening headache or repeated emesis
3. Signs suggestive of a basal skull fracture
4. Large, boggy scalp hematoma in child ≥2 years of age; in younger children, consider performing a skull x-ray first
5. Mechanism of trauma raising suspicion for serious injury (eg, falling from a height, a motor vehicle collision in which speed was a factor, or impact with a projectile, such as a gunshot or a metal fragment)
6. Persistent irritability in a child <2 years of age
7. Seizures at the time of the event or later
8. Known coagulation disorder

Question 24

What is the CATCH rule?

Answer 24

CT Head is required for children with a minor head injury plus any one of the following findings:

High risk (need for neurological intervention):

1. GCS <15h @2h after injury
2. Suspected open or depressed skull fracture
3. History of worsening headache
4. Irritability on examination

Medium risk (brain injury on CT scan):

1. Any sign of basal skull fracture (eg, hemotympanum, ‘raccoon’ eyes, otorrhea or rhinorrhea of cerebrospinal fluid, Battle’s sign)
2. Large, boggy hematoma of the scalp
3. Dangerous mechanism of injury (eg, motor vehicle collision, fall from a height ≥3 feet (≥91 cm) or down five stairs, falling from a bicycle without a helmet)

Minor head injury is defined as an injury sustained within the past 24h associated with witnessed LOC, definite amnesia, witnessed disorientation, persistent emesis, or persistent irritability in child <2yo

Question 25

What are the recommendations re: management of minor head trauma (GCS 14-15)?

Answer 25

1. Asymptomatic patients may be discharged home to the care of reliable parents or guardians.
2. If after initial evaluation there is headache or repeated vomiting, or there is a history of loss of consciousness at the time of trauma, a period of clinical observation, with reassessment, is indicated.
3. In the child younger than two years of age, and particularly in children younger than 12 months of age, greater caution is advised.

Question 26

What are the recommendations re: management of moderate head trauma (GCS 9-13)?

Answer 26

All patients with moderate head trauma should undergo imaging by CT.

Question 27

What are the recommendations re: management of severe head trauma (GCS <8)?

Answer 27

1. Once the patient with a severe head injury has been stabilized, including intubation, a cranial CT scan should be performed.
2. Management should include:
   a) Continuous monitoring of vital signs and, if possible, end-tidal CO2

b) Mechanical ventilation to maintain normal oxygenation and ventilation
c) Maintenance of a normal core temperature
d) Providing sedation and analgesia, particularly during procedures and transport
e) Fluid administration as required to maintain normovolemia and avoid hypotension.
3. Patients with severe head trauma require referral to a trauma centre with neurosurgical and paediatric critical care services.

Question 28

What are the recommendations re: post-traumatic seizures?

Answer 28

1. Patients with impact seizures or an isolated post-traumatic seizure shortly after the event, but whose neurological examination and imaging are normal, are at low risk of further complications and may be discharged.
2. Administering phenytoin to prophylax for post-traumatic seizures in pediatric head trauma patients is not proven effective

Question 29

What is the prognosis for acute head trauma?

Answer 29

The majority of patients with minor head injury do not exhibit intracranial pathology and their symptoms will resolve quickly.

Question 30

What are indicators of poor prognosis?

Answer 30

1. Clinical severity at initial presentation, esp. GCS <5
2. Presence of raised ICP
3. Presence and severity of injuries at other body sites
4. Pre-injury ADHD
5. SES

Question 31

What is recommended re: prevention?

Answer 31

Clinicians treating infants, children and youth should include injury prevention when counselling families.