Head injury

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full PCH Emergency Department disclaimer.

Aim

To guide staff with the assessment and management of head injury in children.

Background

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

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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 intracranial pressure (ICP) before patient becomes hypertensive
• Unilateral or bilateral pupillary dilatation
• Deteriorating Glasgow Coma Scale (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
• Paresthesia on upper limb or lower limb
• Strong clinical suspicion despite normal X-ray
• 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
• UEC
• Blood glucose level (BGL)
• Venous blood gas
• LFT + Lipase (if abdominal trauma)
• Group and hold or cross match

Management

Mild head injury

• Observe for 2-4 hours in ED if there is clinical concern
• Most can be discharged home with the Head Injury - Health Fact sheet

Moderate head injury

• CT if indicated (see above)
• Admit to ED Short Stay Unit
• 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 - Health 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 30 degrees
• 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 Short Stay Unit
    • Utilise PCH Short Stay Unit: Medical Documentation - Head Injury Clinical Pathway (> 2 years old). 

Endorsed by:	Director, Emergency Department	Date:	Mar 2018
		Review date:	Mar 2021

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