Pediatric Office Emergencies – Head Injury

For more on this topic, please see Reference (5) for a 2010 podcast on pediatric head injury from Emergency Medicine Cases and Reference (6) BEEM Cases 1 – Pediatric Minor Head Injury.

If an infant or child in your office has any of the following indications below for a non-contrast CT (to rule out skull fracture and intracranial bleed) Reference (1) then you should promptly call EMS and transfer to the Emergency Department while keeping the patient under continuous observation pending transfer of care:

1. Altered mental status (agitation, somnolence, repetitive questioning).
2. Loss of consciousness (more than a few seconds and associated with high risk mechanism).
3. Seizure
4. Persistent vomiting
5. GCS 14 or less
6. focal neurologic findings
7. signs of acute skull fracture or basilar skull fracture (“raccoon eyes – –. Orbital ecchymoses,) (battle sign) – – bruising in the mastoid area, blood tinged or clear drainage from the nostrils or years, he Moten panel him).
8. Infant with boggy scalps swelling in the parietal, temporal, or occipital areas or the bulging fontanelle.
9. Severe mechanisms (Patient may be first observed for 4 to 6 hours in the absence of any of the following findings):
   1. In whom falls from greater than 3 feet (under two years of age) or from greater than 5 feet (above two years of age)
   2. had struck by high-impact object
   3. automobile – – pedestrian crash
   4. fall from bicycle without helmet
   5. automobile crash with patient injection, rollover, or death of another passenger

An outstanding  guideline is Clinical Practice Guidelines: Head Injury from the Royal Children’s Hospital Melbourne Clinical Practice Guidelines. It is very quick to review and functions as an excellent checklist. In addition, there are links to two outstanding patient care handouts: Head injury – general advice and Head injury – return to sport.

Here are some excerpts from the Clinical Practice Guidelines: Head Injury:

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).

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.

Resources:

(1) The Complete Resource on Pediatric Office Emergency Preparedness. 2013. Springer. This excellent book is brief and to the point. The authors are from Texas Children’s Hospital and Texas Children’s Pediatrics. Blunt Head Trauma,  pp 19 – 21.

(2) Clinical Practice Guidelines: Head Injury from the Royal Children’s Hospital Melbourne Clinical Practice Guidelines. It is very quick to review and functions as an excellent checklist.

(3) Head injury – general advice from the Royal Children’s Hospital Melbourne Kids Health Info Fact Sheets.

(4) Head injury – return to sport from the Royal Children’s Hospital Melbourne Kids Health Info Fact Sheets.

(5) Episode 3: Pediatric Head Injury podcast from Emergency Medicine Cases.

(6) BEEM* Cases 1 – Pediatric Minor Head Injury from BEEM Cases. *Best Evidence in Emergency Medicine.