Head injury

  • See also

    Major paediatric trauma – Primary survey
    Major paediatric trauma - Secondary survey
    Cervical Spine Assessment

    Key Points

    • Most head injuries are minor.
    • A head injury may still be significant despite there being no loss of consciousness.
    • Consider inflicted injury, especially in infants (See Non accidental injury).
    • Concurrent cervical spine assessment is required.
    • Children under 2 years old with anything more than a trivial injury should have a more conservative approach to assessment and have a longer period of observation.

    Assessment

    Primary survey and resuscitation:
    Rapidly assess the child's mental state using the AVPU scale.
    A Alert
    V Responds to voice
    P Responds to pain    

    • Purposefully
    • Non-purposefully: Withdrawal/flexor response or extensor response

    U Unresponsive
    Assess pupil size, equality and reactivity 

    History

    • Time and mechanism of injury
    • Circumstances of injury, e.g. accident, NAI, unexplained fall (consider syncope).
    • 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
    • Presence of amnesia
    • Post injury seizure
    • Presence of headache

    Secondary survey

    • Look specifically for palpable skull fractures, signs of a fractured base of skull (haemotympanum, racoon eyes, Battle’s sign and for CSF leak).
    • Document a formal Glasgow Coma Score (GCS) and neurological examination.
    • Assess for other injuries.

    Glasgow Coma Score

    ≥ 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

    Management

    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.
    • Any GCS < 8.
    • GCS persistently <13.
    • Suspected Non Accidental Injury.
    • Any seizure that occurs more than 2 minutes after impact.

    The need and timing of neuroimaging for children requires weighing the clinical benefit with the risk of radiation exposure and the need for sedation. For children other than the above, this decision should be made by a senior clinician – if in doubt, call the paediatric retrieval service to discuss with a paediatric emergency physician.

    Consider other investigations

    If other injuries present, as clinically indicated.
    Consider investigation for causes of falls e.g. alcohol, other ingestions, arrhythmias, hypoglycaemia (see Syncope).

    Treatment

    Trivial head injury

    • If on the basis of history and examination there are no clinical concerns, if the child has a normal conscious state, and is acting normally, they may be discharged from the Emergency Department to the care of their parents.
    • Ensure adequate analgesia.
    • Ensure discharge advice given to parents.

    Mild Head Injury/ concussion

    • Children with GCS 13-15 and other signs of mild head injury (headache, drowsiness, vomiting, loss of consciousness > 5 seconds, not acting normally as per parents or significant mechanism of injury) may be observed in the Emergency Department for a period of up to 6 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 return to normal conscious state and can tolerate oral fluids.
    • A persistent headache, irritability, confusion or drowsiness may need further investigation, discuss with a senior doctor.
    • A concussion is a minor head injury which temporarily alters brain function. Post concussive symptoms are common, and advice should be given regarding rest and gradual return to activity. See parent information.
    • Ensure adequate analgesia.
    • Consider anti-emetics.

    Moderate Head Injury

    • GCS 9-12.
    • Consult a senior doctor or neurosurgeon for advice.

    Severe Head Injury:

    Signs of severe head injury include GCS <8, presence of focal neurological signs, signs of increased intracranial pressure or signs of basal skull fracture.  

    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 consideration of imaging of c-spine. Ensure early neurosurgical consultation

    Cervical spine immobilisation should be maintained until formal assessment occurs. See Cervical Spine Assessment.

    Intubation and ventilation:

    • Consider intubation if:
      • Child unresponsive or not responding purposefully to pain
      • GCS persistently <8
      • Loss of protective laryngeal reflexes
      • Respiratory irregularity or suspected hypoventilation
    • Avoid hypotension and hypoxia during intubation, and provide in-line C-spine immobilisation.  
    • Avoid hypoxia.
    • Intubation should be done by a clinician with airway management skills (anaesthetist, emergency physician), if possible.

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

    • Maintain head position: Nurse 30 degrees head up (after correction of shock) and head in midline position to help venous drainage.
    • Ventilate to a PaCO2, approximately 35-40 mmHg (consider arterial catheter).
    • Consider mannitol (0.25-0.5g/kg over 20-30 min I.V.) or hypertonic saline (sodium chloride 3% 3 ml/kg over 10-20 min I.V.).

    Control seizures

    • Seek neurosurgical advice early.
    • Consider treatment with benzodiazepines to immediately control seizures. Observe closely for subsequent hypotension or hypoventilation and manage appropriately.
    • Consider a phenytoin or levetiracetam loading dose.
    • See afebrile seizures.

    Other measures:

    • Ensure adequate blood pressure with crystalloid infusion or inotropes (e.g. noradrenaline) if necessary.
    • Correct hypoglycaemia.
    • Maintain normothermia.

    Analgesia and sedation:

    • Analgesia and sedation with morphine and midazolam should be administered by careful titration. Children with head injury are often more sensitive to opioids.
    • Consider muscle paralysis (e.g. pancuronium or vecuronium).

    Consider consultation with local paediatric or paediatric neurosurgical team when:

    • Failure to return to normal within 4 hours
    • Suspected NAI
    • Uncertainty surrounding when to perform neuroimaging

    Consider transfer to a tertiary centre when:

    • 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 emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Consider discharge when

    The child is acting normally as per the parents and can tolerate fluids.
    Ensure the parents have clear instructions regarding the management of their child at home especially to call 000 or return to hospital immediately if their child:

    • becomes unconscious or difficult to rouse
    • becomes confused
    • has a fit
    • develops a persistent headache
    • develops any bleeding or watery discharge from the ears or nose

    Advise parents that children with anything other than a trivial head injury may take up to 4 weeks to recover, and graded return to activity is recommended.

    Parent information sheets

    Head injury - general advice  
    Head Injury - Return to school and sport 
    Raising Children Network Concussion

    Last Updated October 2018