Paediatric Acute care Guidelines PMH Emergency Department

Background

  • In all head injuries consider the possibility of cervical spine injury

General

  • Head injury is the leading cause of death in children > 1 year of age
  • Head injury is the 3rd most common cause of death in children
  • Ratio of head injury, boys to girls is 2:1
  • Ratio of fatal head injury, boys to girls is 4:1

Risk factors

High Energy Mechanism:

  • Fall from > 1 metre
  • Motor vehicle accident (MVA)
  • Assault
  • Projectile (e.g. golf, cricket ball)
  • Lack of history

Increased Risk of Bleeding: 

  • Thrombocytopenia or other haematological disorders
  • Medication (e.g. quinine, penicillin, digoxin, anti-epileptics, salicylates, heparin, warfarin)

Signs of Raised Intracranial Pressure (ICP) Include:

  • Cushing’s reflex (hypertension with bradycardia)
    • Note: relative bradycardia alone can herald raised ICP before patient becomes hypertensive
  • Unilateral or bilateral pupillary dilatation
  • Deteriorating GCS (changing by more than 2 points)
  • Developing focal neurological signs
  • Extensor posturing

Assessment

Mild Head Injury Moderate Head Injury Severe Head Injury
  • 95% of head injuries are mild
  • GCS 14-15
  • AVPU = A
  • No LOC 
  • Normal neurological examination     
  • GCS 9-13
  • AVPU = V
  • 3 or more vomits
  • Brief seizure after head injury
  • Amnesia of event
  • LOC < 5 mins
  • Large scalp laceration, bruise or abrasion (> 5cm in < 1 year old)
  • Drowsy
  • Features of basal skull fracture
    • Blood behind tympanic membrane
    • CSF leak from ear/nose
    • Raccoon eyes
    • Battles sign
  • Open or depressed skull fracture
  • High energy mechanisms
  • GCS < 9
  • AVPU = P or U
  • Seizures
  • Focal neurological deficit
  • Raised ICP
  • Penetrating head injury

 

Examination

Head: 

  • Penetrating injury
  • Depressed skull fracture
  • Large bruising or swelling
  • Panda eyes
  • Battles sign (bruising behind the ear)
  • CSF from nose or ear
  • Fundi
    • Papilloedema not seen acutely
    • Retinal haemorrhage in NAI
  • Pupillary reaction – equal, reactive, size

CNS:

  • Full neurological examination

Investigations

Indications For a Skull X-Ray:

  • Focal impact to head
  • Boggy swelling to head (potential depressed skull fracture)

Indications For Head CT:

  • Focal neurological deficit
  • Depressed skull fracture
  • Deterioration in GCS of more than 2 points
  • Penetrating skull injury
  • Possible basal skull fracture
  • Post traumatic seizure with no history of epilepsy
  • Suspicion of open or depressed skull injury or tense fontanelle
  • Clinical suspicion of non accidental injury
  • Age < 1 year: presence of bruising, swelling or laceration > 5 cm on the head

Two or more of the following:

  • LOC > 5 minutes
  • Abnormal drowsiness
  • More than 3 vomits (discrete episodes)
  • Amnesia (antegrade or retrograde) lasting > 5 minutes
  • Dangerous mechanism of injury:
    • High speed MVA – either as pedestrian, cyclist or vehicle occupant
    • Fall from > 3 metres
    • High speed injury from a projectile or an object
  • Bleeding tendency

Indications For C-spine CT:

  • GCS < 13 on initial examination
  • Intubated
  • Focal neurological signs
  • Paresthesis on upper limb or lower limb
  • Strong clinical suspicion despite normal X-Rays
  • Plain X-Ray difficult to take or inadequate
  • Plain X-Rays abnormal
  • Definitive diagnosis of cervical spine injury needed (e.g. before surgery)

Other X-Rays and CT As Clinically Indicated:

Bloods:

  • FBC
  • Coagulation profile
  • U&E
  • BGL
  • Venous blood gas
  • LFT + Lipase (if abdominal trauma)
  • Group and hold or cross match

Management

Initial management

Mild Head Injury

Moderate Head Injury

  • CT if indicated (see above)
  • Admit to ED Observation Ward (4E)
  • Neurological observations half hourly until GCS = 15, then hourly thereafter
  • Consider Head CT if:  
    • Persistent headache
    • Persistent vomiting
    • Drowsy
    • New neurological signs
    • Deteriorating GCS
  • If the child remains well discharge home with the Head Injury and Return To Sport Fact Sheet

Severe Head Injury:

The aim is to prevent further secondary injury to the brain after the initial serious primary head injury.
Treatment for:

  • Hypoxia:
    • Intubate (continue C-spine precautions)
    • Keep ETCO2 35-40
    • SpO2 100%
    • Keep head in midline at 30o
    • Insert nasogastric tube (orogastric tube if concerned about a base of skull fracture)
    • Consider cooling
  • Hypotension:
    • 0.9% saline bolus of 20mL/kg (as required)
    • Consider inotrope infusion
  • Raised Intracranial Pressure:
    • Hypertonic 3% saline:  3mL/kg as a slow IV push
    • Mannitol 20% solution:  0.5 – 1g/kg (2.5 – 5 mL/kg) IV over 20 minutes
    • Hyperventilation to decrease ETCO2: 35-40
  • Seizures:
    • Load with Phenytoin 20mg/kg over 30 minutes

Admission criteria

Children Who Will Need Admission:

  • Severe head injuries
  • Moderate head injuries with:
    • Abnormal CT – admit under Neurosurgical Team
    • Children who have not had a CT and need a period of observation – admit to the ED Observation Ward

       

Nursing

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