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Head Injury Guideline

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    Assessment

    Background to condition:

    Head injuries are common in children of all ages. Causes include falls, sporting accidents, road traffic accidents and non-accidental injuries.

    A key aim of head injury management is to prevent or minimise secondary brain injury which occurs as a result of hypoxia, poor cerebral perfusion, cerebral bleeding, hypoglycaemia, seizures and fever

    How to assess:

    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:

    Head_injury_guideline.png

    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:

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

    Investigations:

    Neuroimaging (discuss with senior doctor or 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

    Consider other investigations:

    Multiple trauma present, see Major trauma guideline

    Cervical spine imaging

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

    ECG (query arrhythmia as cause of fall)

    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 – jump to Management

     

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

    Moderate

     

    • 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

    Severe

     

    • 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 bradycardia, hypertension and widened pulse pressure (Cushing's triad)
        • 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

    Minor head injury:

    • 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:

    • 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.
    • Adequate analgesia
    • Consider anti-emetics, but consider a longer period of observation if anti-emetics are given.

    Severe Head Injury:

    The initial aim of management of a child with a serious head injury is prevention of secondary brain damage. The key aims are to maintain oxygenation, ventilation and circulation, and to avoid rises in intracranial pressure (ICP).

    Urgent CT of head and c-spine. Ensure early neurosurgical and ICU intervention.

    Cervical spine immobilisation should be maintained even if cervical spine imaging is normal.

    Intubation and ventilation:

    • Child unresponsive or not responding purposefully to pain
    • GCS persistently <8
    • Loss of protective laryngeal reflexes
    •  Respiratory irregularity

    In consultation with the neurosurgeon consider measures to decrease intracranial pressure:

    • Nurse 20-30 degrees head up (after correction of shock) and head in midline position to help venous drainage.
    • Ventilate to a pCO2 35mmHg 4-4.5 kPa (consider arterial catheter).
    • Ensure adequate blood pressure with crystalloid infusion or inotropes (e.g. noradrenaline) if necessary.
    • Consider mannitol (0.5-1 g/kg over 20-30 min i.v.) or hypertonic saline (NaCl 3% 3 ml/kg over 10-20 min i.v.).
    • Consider phenytoin loading dose (20 mg/kg over 20 min i.v.).

    Control seizures: see Afebrile seizures

    Correct hypoglycaemia

    Analgesia: sufficient analgesia should be administered by careful titration. Head injured children are often more sensitive to opioids.

    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

    Head Injury handout - Return to sport

    • can be given to older children with concussion symptoms to advise about graded return to sport.

    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.

    For advice and inter-hospital (including ICU level) transfers ring the Sick Child Hotline: (03) 9345 7007

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