Paediatric Head Injury

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 A&E pa• Edinburgh sick kids: 12 “resus” HI pa

Head injury can be nasty

• 40-50% of trauma deaths are mainly attributable to HI

• 7% of “Mild” HI have later behavioural problems?

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

Anatomical

• Scalp: abrasions, haematomas, lacerations• Skull

– Vault (?depressed), Basal

• Brain– Focal Contusion coup, contrecoup

Haematoma subdural, intracerebral

extradural (90% adults c #, 70% kids)

– Diffuse ConcussionDAI

Secondary HI is preventable

• Hypoxia

• Hypovolaemia – (NB: open fontanelles, large scalp lacerations)

• Raised ICP – Blood, oedema, infection

• Hypoglycaemia, hypothermia, pyrexia, fits

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

So prevent it!

• Oxygen

• Treat shock

• Image appropriately

• Admit appropriately

• Refer appropriately

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

Relevant history

• MOI

• Clinical progression

• Presenting complaints– LOC, Amnesia, Vomiting, Fits, Visual deficits

• Warfarin

• Alcohol/drugs

• Social circs

APLS/ATLS Resus +

• ABC! – GCS < 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

Imaging – obs only?

• OrientedNo # 1/6000 Intra Cranial Haematoma

# 1/30 (ie, risk x 200)

• DisorientedNo # 1/120

# ¼ (ie, risk x 30)

• BUT these figures are for adults• 50% of children who die of HI have no # evident

Imaging – modality?

• SXR– Misses up to 50% of #– No “brain” information

• CT– Radiation = 40 x SXR (1 year’s background)– Sedation– Interpretation– Expense

• MRI? Ultrasound?

Imaging –SIGN guidelines ‘00CT vs SXR

• GCS <13 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 isn’t!

Imaging – Edinburgh ’01 Immediate CT vs Obs +/- CT

• GCS < 14• Focal signs• Fit (focal or long)• ? Depressed #

• ? Penetrating/basal #(possibly delayed)

• LOC > 5 min• Amnesia• Persisting symptoms

– HA, V, lethargy

• Haemophilia• Warfarin• Ehlers-Danlos

Imaging – Edinburgh ‘01

• SXR only for < 1 year, with visible HI

• LOC per se is not a reason to image(admit and observe only)

If children go off, it’s within 5 hours

Most vomiting immediately post-HI is “migrainous”, and in 24 hrs post-MI is viral

Admission - SIGN

• GCS<15 • Abnormal neurology; seizure at any time• Persisting HA/nausea/vomiting/>5’PTA• 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

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

NICE ’031 hr vs 8 hr CT

• GCS < 13 at any time• GCS < 15 at 2 hrs• Focal deficit or Fit• ? Dep./open/basal #• > 1 vomit (discretion!)• LOC/amnesia AND

– Coagulopathy– Dangerous MOI– > 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

So what should we do?!

• SXR probably not so useful in paeds if you’re 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 >10% chance of finding something

• NICE is “ideal”

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)

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

NICE – Reappraisal

• Becomes agitated or behaviour abnormal

• Sustained (>30’) fall in GCS (esp. motor)

• Any fall in GCS > 2

• Develop severe or increasing HA or persistent vomiting

• New or evolving neuro signs

Get CT!

NICE – Referral to neurosurgeon

“Significant” lesion on scan (surgical definition) OR:Regardless of imaging discuss if :• GCS < 9 after initial resus • Unexplained confusion >4 hours• Deterioration in GCS after admission (motor response)• Progressive focal signs • Seizure without full recovery • Definite or suspected penetrating injury• CSF leak

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…

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

Resources

• www.sign.ac.uk

• www.nice.org.uk

• www.trauma.org