Raised ICP and CT head Indications

Question 1

How does raised ICP present in children?

Answer 1

Irritable
Drowsy
Headache
Diplopia
Vomiting
Bulging fontanelle
Reduced GCS
Pupil changes 
Abnormal posturing (decorticate/decerebrate) 
Cushing’s triad (slow pulse, raised BP and breathing abnormality) = imminent conning
Papilloedema and hydrocephalus

Question 2

What usually causes raised ICP in children?

Answer 2

Meningoencephalitis 
Head injury 
Subdural/extradural bleeds (NIA?)
Hypoxia (near drowning) 
Ketoacidosis – cerebral oedema
Tumours

Question 3

How should raised ICP be managed in children?

Answer 3

ABCDE
Keep head in midline to help venous drainage
Treat hypos and seizures
DO NOT DO LP until CT obtained and child is intubated

Give mannitol or hypertonic saline
Dexamethasone
Fluid restriction and diuresis avoiding hypovolaemia

Question 4

When should an urgent referral be made in children you suspect of having CNS tumours?

Answer 4

Urgent referral if unexplained headache, focal symptoms or progressive weakness/numbness/unsteadiness. Majority of tumours are found in the posterior fossa.

Question 5

Which CNS cancers are common in children?

Answer 5

Medulloblastoma – midline cerebellar tumour causing speech difficulty, truncal ataxia and falls. More common in boys by 4:1.
Brainstem astrocytoma – most common brain tumour in children. Associated with neurofibromatosis 1 and prior radiation. Cranial nerve palsies and pyramidal tract signs.
Most others are gliomas and can be found in most places.

Question 6

How is motor response scored for children <4 in the Glasgow coma score?

Answer 6

Best motor response 
6 – Carries out a request 
5 – Localising response to pain 
4 – Withdraws to pain 
3 – Flexor response to pain 
2 – Extensor response to pain 
1 – No response to pain

Question 7

How is verbal response scored for children <4 in the Glasgow coma score?

Answer 7

Best verbal response 
5 – orientated 
4 – crying but consolable 
3 – inconsistently consolable 
2 – inconsolable crying 
1 – no response

Question 8

How is eye opening response scored for children <4 in the Glasgow coma score?

Answer 8

4 – spontaneous
3 – eye opening in response to speech
2 – eye opening in response to pain
1 – no eye opening

Question 9

What requires an immediate CT head in children with head injuries?

Answer 9

• Loss of consciousness lasting more than 5 minutes (witnessed)
• Amnesia (antegrade or retrograde) lasting more than 5 minutes
• Abnormal drowsiness
• Three or more discrete episodes of vomiting
• Clinical suspicion of non-accidental injury
• Post-traumatic seizure but no history of epilepsy
• GCS less than 14, or for a baby under 1-year GCS (paediatric) less than 15, on assessment in the emergency department
• Suspicion of open or depressed skull injury or tense fontanelle
• Any sign of basal skull fracture (haemotympanum, panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
• Focal neurological deficit
• If <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 of greater than 3m, high-speed injury from a projectile or an object)