Acute head injury in children is common and potentially serious. The evaluation of the head injured child depends on the history, physical examination, and at times imaging (non-contrast CT scan [For imaging guidelines for the head injured child, see the blog post Head Injury Imaging Guidelines From NICE and from the National Institute for Health and Care Excellence, 2014. ‘Head injury’, NICE clinical guideline 176. London: National Clinical Guideline Centre]).
You will have observed the child’s behaviour while you were taking a history.
This boy (in the accompanying video) has a cut on his forehead but is interacting normally while the doctor is talking to the mother.
Children who come to see a doctor may be quiet when they arrive, but usually brighten up after they settle in.
When a child has had a head injury, it can be easy to assume that quietness, or irritability, is due to being upset. However, if you talk to the child in the right way for a while, and get them to interact with you, you can begin to tell if they are just upset and frightened, or if they are truly drowsy or irritable.
Drowsiness is fairly common but usually improves within an hour or two. If it doesn’t, the child does need a CT scan. Irritability is less common and if the child does not settle down with reassurance and some paracetamol or ibuprofen, it means they should have a CT scan. This child appeared irritable, but could be calmed down.
The Neurologic Exam of the Head Injured Child.
What follows is from Key Points in Examination–Neurological Examination from Spotting The Sick Child):
[In the child with a head injury] The mainstay of your neurological assessment is, in fact, the child’s behaviour. We have discussed drowsiness and irritability in the general examination section.
Specific examination for focal neurological signs such as pupil abnormalities or limb weakness are late signs, which occur after the behavioural change or decrease in the level of consciousness.
So let’s first see how to assess level of consciousness in children.
There are 2 ways of doing this. The simplest is called the AVPU scale. This takes seconds to do, and is a commonly used phrase these days.
A stands for alert. This is recorded on the right hand side of this child’s assessment form.
You can assess this even in small babies you can assess this. See how this baby fixes and follows with its eyes. This shows she is reacting to what’s going on.
V means that the child only responds to voice – in other words if someone rouses them by talking to them.
P stands for a response only if a painful stimulus is inflicted – this can be by pressing hard on the fingertips, or rubbing the sternum, or pressing on the eyebrows. Insertion of a cannula is another test.
U stands for unresponsive – in other words, no crying or movement at all.
A child who is at V or lower on the AVPU scale voice needs a CT scan.
Patients who are P or U on the AVPU scale are unlikely to be protecting their own airway with the normal reflexes, and could vomit and aspirate, so they also require intubation by an anaesthetist, and will need Intensive Care.
The Injury Itself
It is important to check the child’s scalp all over, carefully.
Here you are looking for signs of a skull fracture. A bump like an egg, especially if on the forehead, is common, and is hardly ever a sign of fracture.
However, soft or large swellings may imply an underlying fracture. Skull fractures themselves will heal, but it is underlying damage that concerns us, and most children with a fracture will need a CT scan.
Think about the mechanism of injury. A clash of heads in football or banging your head against a cupboard door is unlikely to cause a fracture. An infant landing from above its head height onto a hard surface is quite likely to have a skull fracture. Being hit by an object such as a golf club, or landing against something sharp like the corner of a table, can cause a depressed skull fracture.
Here you see a depressed skull fracture. This will need to be referred to a neurosurgeon.
In babies and infants the parent will have found, or you will find, a swelling – usually on the side of the head, which is very squashy and soft. This is called a boggy haematoma and can be surprisingly big – it may be a few centimetres wide.
There is nearly always a fracture underneath one of these. As in the section above, check the history carefully to make sure the injury was a true accident.
The injury may be to the face. The facial bones are quite soft in children and only fracture with severe mechanisms of injury such as a direct blow with a heavy object or collision with something at high force, such as an unrestrained car passenger or hitting an object while quad biking.
This means that you can reassure parents if there is a bump on the forehead, bleeding from the nose, or wounds on the face, and just ensure that you give them verbal and written instructions at discharge, explaining what symptoms to look out for and where they should go to for help if this happens.
The only caveat when dealing with facial injuries are that facial bruising and bleeding can be signs of non-accidental injury, especially in non-walking infants. Make absolutely sure you believe the history and that it is given to you in detail, that it sounds genuine, and the injuries match the mechanism stated, as in this case.