In minor head injury (definition?!), statistically significant correlation between intracranial haemorrhage and:
- skull fracture
- focal neurology
- history of loss of consciousness
- GCS abnormality (difficult to gauge in preverbal children…)
Headache and vomiting were not found to be predictive and there was great variability in the predictive ability of seizures. (meta-analysis, ArchDisChild 2004;89)
SIGN 110 suggests immediate CT for:
- GCS less than 14
- high speed mechanism
- witnessed loss of consciousness for more than 5 minutes
- Suspicion of open or depressed skull fracture
- Any sign of basal skull fracture
- Tense fontanelle
- Focal neurological deficit
Otherwise, early (ie within 8 hours) CT should be considered if:
- bruise/swelling/laceration >5cm on head
- post-traumatic seizure without epilepsy (and not reflex anoxic)
- amnesia (antero- or retrograde) >5 minutes
- suspicion of NAI
- Significant fall
- 3+ discrete episodes of vomiting
- abnormal drowsiness
- GCS other than 15 in under 1yr old, assessed by experienced provider
If suspicion of NAI, extra rule applies – CT should be done “as soon as child is stable” (and ideally within 24 hrs) if under 1 yr, or neuro signs (incl haemorrhagic retinopathy).
Any loss of consciousness should be assessed, but interestingly retrograde amnesia has to be for >30 minutes to warrant assessment, whereas NICE would do immediate CT! Otherwise 2+ vomits, severe and persistent headache, coagulopathy, difficulties with assessment or social situation, or any other indication for CT.
Admit if any indications for CT, although it also says discharge can be considered if social situation suitable!
NICE head injury (2017) guidelines
similar criteria, but suggests immediate CT for more. Change in practice from admit and watch (Royal College of Surgeons guidelines) to diagnose and decide. Leads to far fewer skull XRs, a lot more CTs and maybe half as many admissions. Some centres have seen cost savings due to earlier discharge.
CT within 1 hour for:
- age over 1 year, GCS<14 on initial assessment;
- age under 1 yr; GCS<15 on initial assessment.
- GCS<15 at 2 hours after injury.
- age under 1yr plus bruise, swelling or 5cm laceration.
- Suspicion of NAI.
- Loss of consciousness >5min (witnessed).
- Post-traumatic seizure without epilepsy.
- Abnormal drowsiness.
- Suspected open or depressed skull fracture, or tense fontanelle.
- Any sign of basal skull fracture – haemotympanum, panda eyes, CSF leak from ears/nose, Battle’s sign.
- Focal deficit.
Plus CT within 1 hour if MORE than 1 of the following:
- Witnessed loss of consciousness more than 5 minutes
- Abnormal drowsiness
- 3+ discrete episodes of vomiting
- Dangerous mechanism eg high speed road traffic accident, fall >3m, high speed projectile
- Amnesia (retro or antegrade) >5 min
If only 1 of the above, then observe minimum 4 hours – go to CT if during that time:
- GCS <15
- Further vomiting
- Episode of abnormal drowsiness
In children under 10yr, CT for spine should be avoided (risk to thyroid) unless severe head injury (eg GCS<=8), strong suspicion despite plain films, or inadequate plain films. Over 10yr, CT is investigation of choice if:
- GCS<13 (so 1 point less than for head).
- intubated.
- inadequate plain films.
- Continued suspicion.
- Needing multi-region scan anyway!
Neuroscience centres are expected to be able to perform initial management of multiple injuries in children. Local guidelines for transfer should be drawn up – there are benefits for being in a neurosurgical centre even if surgery is not required.
Kids with a fracture are not as prone to intracranial lesions as adults, at the same time they are more likely to have intracranial lesion without a fracture!
Note increased risk of malignancy with CT. So observe for 4 hours if persistent vomiting, review by senior clinician to decide further observation rather than CT. Involve parents in decision [BMJ 2019;365:l1875]
Management
No good RCTs! Avoid secondary brain injury – 1 episode hypotension post head injury triples mortality. Cerebral blood flow is low in first 24hr, peaks at 48hr. Depends on temperature, seizures, pain/anxiety.
Glasgow Coma Score (GCS) 9-12 is moderate, <=8 is severe (equivalent to P or U in AVPU score) and is indication for ventilation to protect airway as reflexes potentially unreliable.
Diffuse axonal injury progresses over 24+ hrs, difficult to see on scan.
Consider external drain/ventriculostomy for intracranial haemorrhage. ?Remove contused brain ?Decompressive craniectomy
Neuroprotective strategy:
- Head up 30deg, straight
- Maintain pCO2 at 35-40mmHg
- Cool if febrile (awaiting data on role of hypothermia). Paralyse to avoid shivering. Paralysis will make seizures difficult to recognise: role for prophylactic anti-epileptics?
- Analgesia
- (steroids not helpful)
- CVP&arterial BP monitoring, ensure adequate perfusion pressure
- ICP monitoring if neuro signs, GCS <9, post decompression. Bolt gives data but does not allow CSF drainage. ICP takes 7-10 days to settle
For RICP, 3% NaCl 3-5ml/kg bolus – Keep osmo <310mmol/l.
For induction, thiopentone is traditionally used. Ketamine theoretically increases ICP but no real evidence. Adding fentanyl smooths cardiovascular response to procedure.
CT@72h is prognostic.
Shaken Baby: lethargy, vomiting, apnoeas, seizures (40-80%), opisthotonus, irritability. See NAI.
