Paediatric Head Injury

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Paediatric Head Injury
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Head injury is common

• USA 0.2-0.4, UK 1 million HI presentations pa
• E/W 8 sev, 18 mod, 280 mild HI per 100,000 pa
• UHW 6624 HI patients in 2004
• About 50 are paeds
• Scotland 4 of under 5s attend AE pa
• Edinburgh sick kids 12 resus HI pa

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Head injury can be nasty

• 40-50 of trauma deaths are mainly attributable
  to HI
• 7 of Mild HI have later behavioural problems?

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Classifications

• Mild GCS 14-15 (80)
• Moderate GCS 9-13 (10)
• Severe GCS 3-8 (10)
• Anatomy scalp, skull, brain
• Focal vs Diffuse
• MOI Blunt vs penetrating
• Path Primary vs Secondary Brain Injury

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Anatomical

• Scalp abrasions, haematomas, lacerations
• Skull
• Vault (?depressed), Basal
• Brain
• Focal Contusion coup, contrecoup
• Haematoma subdural, intracerebral
• extradural (90 adults c , 70 kids)
• Diffuse Concussion
• DAI

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Secondary HI is preventable

• Hypoxia
• Hypovolaemia
• (NB open fontanelles, large scalp lacerations)
• Raised ICP
• Blood, oedema, infection
• Hypoglycaemia, hypothermia, pyrexia, fits

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Pathophysiology

• ICP
• Normally about 10 mmHg
• Higher, worse outcome
• CBF
• Normally about 50 ml/100g/min
• EEG disappears at about 20
• CPP MAP ICP
• Munro-Kellie

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So prevent it!

• Oxygen
• Treat shock
• Image appropriately
• Admit appropriately
• Refer appropriately

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APLS/ATLS Assessment

• AVPU/GCS/PERL AMPLE/MIST
• Lacs, haems, palpate for depressed
• Fontanelles
• Ear/nose CSF/blood, Panda/Battle signs
• CNS focal signs, fundi
• Other injuries (especially c-spine), ?NAI

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Relevant history

• MOI
• Clinical progression
• Presenting complaints
• LOC, Amnesia, Vomiting, Fits, Visual deficits
• Warfarin
• Alcohol/drugs
• Social circs

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APLS/ATLS Resus

• ABC!
• GCS lt 9 needs RSI and normocapnia
• Sudden deterioration
• 20 Mannitol 5ml/kg
• Aim at MAP 90 mmHg
• IV morphine in ventilated patient (?)
• Treat seizures as per APLS

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Imaging obs only?

• Oriented
• No 1/6000 Intra Cranial Haematoma
• 1/30 (ie, risk x 200)
• Disoriented
• No 1/120
• ¼ (ie, risk x 30)
• BUT these figures are for adults
• 50 of children who die of HI have no evident

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Imaging modality?

• SXR
• Misses up to 50 of
• No brain information
• CT
• Radiation 40 x SXR (1 years background)
• Sedation
• Interpretation
• Expense
• MRI? Ultrasound?

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Imaging SIGN guidelines 00CT vs SXR

• GCS lt13 or E2
• GCS 13-14 but not improved at 4 hrs
• GCS falling
• New or progressive focal signs
• Xray or clinical evidence of any
• GCS 15 but fitted, severe HA, N/V, irritable,
  tense fontanelle

• GCS 13-14
• GCS 15 but non-trivial MOI, LOC, amnesia,
  vomited, full thickness scalp lac, inadequate
  history
• Or if CT should be done but isnt!

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Imaging Edinburgh 01 Immediate CT vs Obs /-
CT

• GCS lt 14
• Focal signs
• Fit (focal or long)
• ? Depressed
• ? Penetrating/basal
• (possibly delayed)

• LOC gt 5 min
• Amnesia
• Persisting symptoms
• HA, V, lethargy
• Haemophilia
• Warfarin
• Ehlers-Danlos

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Imaging Edinburgh 01

• SXR only for lt 1 year, with visible HI
• LOC per se is not a reason to image
• (admit and observe only)
• If children go off, its within 5 hours
• Most vomiting immediately post-HI is
  migrainous, and in 24 hrs post-MI is viral

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Admission - SIGN

• GCSlt15
• Abnormal neurology seizure at any time
• Persisting HA/nausea/vomiting/gt5PTA
• Xray or clinical or penetrating injury
• Irritable/abnormal behaviour
• Difficulty making full assessment
• Medical or social reasons, inc WARFARIN
• For children any LOC, any suspicion NAI

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Triage, Assessment, Investigation and Early
Management of HI in Infants, Children and Adults

• More CTs, fewer admissions? Cost neutral??!!
• Algorithms
• Referral from Telephone health advisers
• Referral from Community medical services
• Selection of patients with HI for CT Head
• Selection of patients with HI for C Spine xray

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NICE 031 hr vs 8 hr CT

• GCS lt 13 at any time
• GCS lt 15 at 2 hrs
• Focal deficit or Fit
• ? Dep./open/basal
• gt 1 vomit (discretion!)
• LOC/amnesia AND
• Coagulopathy
• Dangerous MOI
• gt 30 min antegrade

• Anyone else with any LOC/amnesia
• (to get CT within 8 hours of injury!)
• SXR if CT unavailable
• (Patients to ask why!)
• SXR as part of skeletal survey in ?NAI

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So what should we do?!

• SXR probably not so useful in paeds if youre
  going to admit the child anyway
• SXR still has role in ?NAI
• SXR in adults still has use, even with NICE
• SIGN was pragmatic only do CT if gt10 chance
  of finding something
• NICE is ideal

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NICE - Admission

• Clinically significant abnormality on CT
• GCS still not 15 after CT
• Meets criteria for scan, but CT unavailable
• Continuing worrying signs of concern to the
  clinician (eg, vomiting, severe HA)
• Other sources of concern (eg, drugs,other
  injuries, ?NAI, meningism, ?csf leak)

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NICE Obs

• GCS, pupils, limbs, RR, HR, BP, T, SpO2
• Minimum frequency for those with GCS 15
• Half hourly for 2 hours
• Then hourly for another 4 hours
• Then 2 hourly thereafter
• If GCS deteriorates then revert to half hourly
  obs
• Only units with staff experienced in paeds HI obs

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NICE Reappraisal

• Becomes agitated or behaviour abnormal
• Sustained (gt30) fall in GCS (esp. motor)
• Any fall in GCS gt 2
• Develop severe or increasing HA or persistent
  vomiting
• New or evolving neuro signs
• Get CT!

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NICE Referral to neurosurgeon

• Significant lesion on scan (surgical
  definition) OR
• Regardless of imaging discuss if
• GCS lt 9 after initial resus
• Unexplained confusion gt4 hours
• Deterioration in GCS after admission (motor
  response)
• Progressive focal signs
• Seizure without full recovery
• Definite or suspected penetrating injury
• CSF leak

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NICE - Discharge

• GCS 15, no continuing worries
• Verbal and written advice
• Parental supervision
• GP follow up within 1 week for all those scanned
  or admitted, with letters to GP, community paed,
  school MO, HV

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NICE hand-outs

• HI imaging flowchart (NICE, SIGN)
• C-spine imaging flowchart (NICE)
• (NB no need for peg views and only exceptional
  need for CT in under 10s)
• Paeds GCS
• Discharge leaflets
• HI proforma

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Resources

• www.sign.ac.uk
• www.nice.org.uk
• www.trauma.org