Emergency Department Guidelines for MANAGEMENT OF HEAD INJURY

Background
Approximately 1-2% of all Paediatric Emergency Department presentations are for head trauma. Fortunately, about 2/3 of these cases are of a trivial nature (ie. no concerning symptoms on history and no significant findings on physical examination) and the risk of intracranial injury is exceedingly small. In children with non-trivial head injuries (ie. those with significant history or symptoms or signs), intracranial injury is still uncommon (<5%). Trauma involving the head is the leading cause of death in children aged 1-15 years (~15% of deaths in this age group). The most common situation in which death occurs from head injury is after road traffic accident (particularly pedestrian children or cyclists). In younger children, falls are the most common cause of head injury. Boys sustain head injuries twice as often as girls and have four times the risk of sustaining a fatal head injury. The incidence of subdural haematoma (SDH) is higher in infants and adolescents. Extradural haematomas (EDH) are rare in children <4 years but then the incidence steadily increases with age. SDHs usually present with more clinical findings than EDHs where findings may initially be absent or mild. Early recognition and surgical treatment of certain intracranial injuries (ICI) improves outcome but predicting the presence of ICI by clinical history and examination alone is difficult, especially in younger children. CT scanning is a very sensitive means of detecting intracranial haemorrhage, but many younger children require sedation or general anaesthesia for this procedure. Several groups have published recommendations for neuro-imaging in paediatric head trauma based on results of large trials or literature review. Over the last decade, a number of decision rules have been developed to identify high risk adults with head injury who require a CT scan. More recently, the CHALICE study (a prospective diagnostic cohort study involving over 22,000 children with acute head injuries) has provided a highly sensitive clinical decision rule for identifying children with acute head injury who may be best evaluated with a CT head scan. This publication forms the basis of our departmental guidelines.

Developed: Aug 1998 Last updated: Dec 2004

Head Injury Guidelines

Page 1 of 4

Department of Emergency Medicine, Royal Childrens Hospital & Health Service District (Brisbane)

Indications for CT Head : The CHALICE decision rule

For children aged < 16 years presenting after trauma involving the head, a CT scan is recommended if any of the following criteria are present: History Witnessed loss of consciousness of > 5 minutes duration History of amnesia of > 5 minutes duration Presence of abnormal drowsiness 3 vomits following the head injury Suspicion of non-accidental injury (suspected child abuse) Any seizure after a head injury in a non-epileptic patient Examination Glasgow Coma Scale (GCS) <14, or GCS <15 if under 1 year old Suspicion of penetrating injury Suspicion of depressed skull fracture Tense fontanelle Signs of basal skull fracture Any focal neurological deficit/abnormality Presence of bruising/swelling or laceration >5cm in an infant Mechanism Head trauma in the setting of a high speed (>60km/hr) motor vehicle accident as either pedestrian, cyclist or occupant Head trauma in the setting of a fall from over 3m height Head trauma related to a high speed projectile If none of the above features are present, the child is at a low risk of having intracranial pathology.

The CHALICE rule has a sensitivity of 94.3% and a specificity of 89.1% for detecting intracranial pathology on CT scan. If we assume that the risk of intracranial pathology in our population of children presenting to the emergency department with head injury is similar to those in the CHALICE study population (1.2%), using the CHALICE criteria to order CT scans would result in us missing an intracranial abnormality in 1 out of every 5000 children we see with a head injury (NPV 100%; 95%CI 99.9% to 100%). The PPV (true positive rate) would be 8.6% (95%CI 7.7% to 9.7%) ie. approximately 1 in every 12 scans would be positive. Implementation of the CHALICE rule resulted in a CT scan rate of approximately 14%.

Developed: Aug 1998 Last updated: Dec 2004

Head Injury Guidelines

Page 2 of 4

Department of Emergency Medicine, Royal Childrens Hospital & Health Service District (Brisbane)

Other considerations
CT scanning is a safe, accurate and readily available investigation for older children who are able to lie still for the procedure. In younger children, particularly those under 5 years, general anaesthesia or procedural sedation may be required to achieve CT scanning. In addition, the risks of cranial irradiation need to be considered. Therefore, particularly in younger children, the risk of the investigation (CT) should be balanced against the risk of delayed diagnosis. Observation in the emergency department, for a period of at least 6 hours from the time of the injury, may be used as an alternative approach in children <5 years old whose indications are marginal (eg. vomiting, impact seizure, etc.) with CT reserved for those children who develop any of the above criteria during the period of observation.

Indications for Skull Radiograph

Many studies have illustrated that the presence of a skull fracture significantly increases the risk of intracranial injury. However, the absence of a skull fracture has a poor negative predictive value, as approximately 50% of intracranial injuries will not have an associated skull fracture. In addition, skull radiographs can be difficult to interpret and skull fractures may be easily missed by non-radiologists. Thus we do not support the continued use of plain skull radiographs for children with head trauma except for very occasional highly selected patients eg. suspected non-accidental injury.

Indications for Neurosurgical referral

Neurosurgical consultation should be sought (early) in the following circumstances: Penetrating skull injury Base of skull fracture Depressed skull fracture Focal neurological signs Depressed level of consciousness at time of examination Decreasing level of consciousness Any child to be admitted to formal inpatient ward (usually McConnel) for observations because of a head injury

Criteria for discharge of patients after head injury

Any child in the CHALICE rule negative group (as long as they can be discharged into the care of a responsible adult who can continue to monitor their condition) Any child with a GCS of 14 or 15 with a normal CT head scan (this includes simple linear vault fractures with no haematoma) The absence of any symptoms that cannot be handled at home (i.e. confusion, persistent vomiting, headache requiring more than simple analgesia) Although the risk of deterioration after discharge (using these discharge criteria) is minimal, it is not zero. Parents/carers should be instructed regarding the need for continued observation at home and the warning signs that should prompt immediate return to the emergency department. These are detailed in our Head Injury Advice sheet which should be given to each family prior to discharge.
Developed: Aug 1998 Last updated: Dec 2004 Head Injury Guidelines Page 3 of 4

Department of Emergency Medicine, Royal Childrens Hospital & Health Service District (Brisbane)

Management of raised intracranial pressure in DEM

In the setting of head trauma, raised intracranial pressure (ICP) may be the result of either a generalised swelling or focal haemorrhage/swelling. Generalised increase in ICP in the supratentorial compartment initially causes transtentorial (uncal) herniation and later, if unabated, progresses to transforaminal (central) herniation ie. coning. Unilateral increase in ICP (due to local haemorrhage) can cause ipsilateral uncal herniation. In these cases, the 3rd cranial nerve may be compressed against the tentorium causing ipsilateral pupillary dilatation. In children with head trauma, raised ICP should be suspected in the presence of: Depressed or deteriorating level of consciousness Abnormal oculocephalic reflexes dolls eye movement or dysconjugate upward gaze Abnormal posture decorticate or decerebrate (may be elicited with painful stimulus) Abnormal pupillary responses, unilateral or bilateral dilatation Abnormal breathing patterns (may vary - hyperventilation, Cheyne-Stokes, apnoea) Cushings triad (late sign) bradycardia + hypertension + breathing pattern abnormality Papilloedema (late sign) may not be present in acutely raised ICP In children, the most common cause of raised intracranial pressure is cerebral oedema. Other causes in the setting of head trauma include expanding extradural, subdural or intracerebral haematomas. Management is aimed at preventing further rises in ICP and/or removing its cause (surgical evacuation of haematomas). Emergency management of raised ICP includes: Raise head of bed 20o Intubate and ventilate aim for pCO2 of 28-32 mmHg Mannitol 0.5-1.0 g/kg (2.5-5.0 ml/kg) if evidence of impending coning (eg Cushings triad) Ensure adequate systemic blood pressure - remember Cerebral Perfusion Pressure (CPP) = Mean Arterial Pressure (MAP) Intracranial Pressure (ICP) Urgent referral to Neurosurgeons for potential surgery

Further Reading
1. 2. Dunning J, Daly JP, Lomas JP, Lecky F, Batchelor J, Morton RJ, Mackway-Jones K. The CHALICE rule for minor head injury in children. ICEM 2004. Dunning J. Daly JP. Malhotra R. Stratford-Smith P. Lomas JP. Lecky F. Batchelor J. Mackway-Jones K. [Children's Head injury Algorithm for the Identification of significant Clinical Events Study (CHALICE Study).] The implications of NICE guidelines on the management of children presenting with head injury. Archives of Disease in Childhood. 2004; 89(8):763-7. American Aademy of Pediatrics. The management of minor closed head injury in children. Pediatrics 1999;104:1407-15. Savitsky EA, Votey SR. Current controversies in the management of minor pediatric head injuries. Am J Emerg Med 2000; 18:96-101. Quayle KS. Minor head injury in the pediatric patient. Ped Clin N Amer 1999; 46:1189-99. Kraus JF et al. Brain injuries among infants, children, adolescents and young adults. Am J Dis Child 1990; 144: 684. Fisher JD. Symptomatic blunt head injury in children - A prospective, single investigator study. Clin Ped 1997; 36: 461-465. Advanced Paediatric Life Support The Practical Approach. 3rd edition 2001. BMJ Books Head Injury Guidelines Page 4 of 4

3. 4. 5. 6. 7. 8.

Developed: Aug 1998 Last updated: Dec 2004