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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
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