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Clear guidance on the assessment and management of children that have sustained a head injury.
This guidelines is to be used in children that have suffered a head injury.
Emergency Department medical and nursing staff.
Head injuries are common in children of all ages. Causes include falls, play/sporting accidents, road traffic accidents and non‐accidental injury. The SIGN Guideline 110 on head injury uses a broad definition to include “patients with a history of a blow to the head or the presence of a scalp wound or those with evidence of altered consciousness after a relevant injury.” The level of consciousness as assessed by the Glasgow Coma Scale (GCS) is used to determine the severity of a head injury.
It is important to gain as much information as possible regarding the nature of the incident which should include:
Examples of High Energy Head Injuries
High speed/rollover motor vehicle collision
Child struck by motor vehicle
Child ejected from motor vehicle
Accident involving motorised recreational vehicles
Bicycle collision
Fall from height greater than 1 metre or more than 5 stairs
Impact from golf club, cricket or baseball bat
Perform a primary survey and ensure the child’s airway, cervical spine, breathing and circulation are secure.
The AVPU scale is used for the rapid assessment of neurological status during the primary survey.
AVPU Scale |
||
---|---|---|
A |
Alert |
|
V |
Responds to Voice |
|
P |
Responds to Pain |
|
U |
Unresponsive |
Also assess pupil size, equality and reactivity and look for other focal neurological signs.
A formal GCS forms part of the secondary survey, which should also specifically include:
Paediatric Glasgow Coma Scale Modification for young children/infants underlined |
|
|
---|---|---|
Feature |
Scale Responses |
Score |
Eye Opening |
Spontaneous To voice To pain None |
4 3 2 1 |
Verbal Response |
Orientated/ Smiles, fixes, follows, words to usual ability Confused / Cries but consolable Inappropriate words/ Persistently irritable, moaning Incomprehensible words/ Agitated and inconsolable None / None |
5 4 3 2 1 |
Motor Response |
Obeys commands / Normal Movement Localise to pain Withdraw to pain Flexion to pain Extension to pain None |
6 5 4 3 2 1 |
Total |
|
3 ‐ 15 |
Any patient with significant co-morbidities (including CSF drainage devices – ‘shunts’) should be discussed with the ED consultant prior to discharge from the emergency department
Minor Head Injury
Always consider the need for appropriate analgesia.
In the absence of any comorbidity and with satisfactory home circumstances, these children may be discharged from the ED with their parent/responsible carer.
Written head injury advice should be given to and discussed with parents/carers before a child is discharged. This should include clear instructions regarding symptoms that, if observed in their child, should prompt an immediate return to the ED.
If there are any doubts about the mechanism of injury or possible loss of consciousness, treat as for mild head injury.
Mild Head Injury
Always consider the need for appropriate analgesia.
These children should be observed in the ED for a period of time, with 30 minutely neurological observations (HR, RR, BP, GCS, pupils and limb power).
If there is an improvement back to normal conscious state with no further vomiting (they should be able to tolerate oral fluids in the department), no other comorbidity and satisfactory home circumstances, these children may be discharged from the ED with their parent/responsible carer. Written head injury advice should be given to and discussed with parents/carers before a child is discharged. This should include clear instructions regarding symptoms that, if observed in their child, should prompt an immediate return to the ED.
Senior advice should always be sought (Emergency Medicine ST3 / ED Consultant) regarding the need for further investigation and/or admission for any child who remains drowsy / continues to vomit / has a persistent headache or where there has been any deterioration during their time in the ED.
Moderate Head Injury
Always consider the need for appropriate analgesia.
These children require 30 minutely neurological observations (HR, RR, BP, GCS, pupils and limb power) whilst in the ED.
Children with a GCS ≤ 13 should have an immediate CT scan.
Children with one or more of the other criteria should be considered for CT scanning within 8 hours.
Any request for a CT scan should always be discussed with an ED Consultant.
The above criteria are also all indications for admission to hospital and therefore senior advice should always be sought (Emergency Medicine ST3 / ED Consultant) regarding admission and further investigation.
Severe Head Injury
Perform a primary survey and ensure the child’s airway, cervical spine, breathing and circulation are secure.
Prevent secondary brain injury by maintaining adequate ventilation and oxygenation.
Control any seizures
In conjunction with ED Consultant/PICU/Neurosurgery consider measures to decrease intracranial pressure:
Arrange immediate CT scan
Unless requiring neurosurgical intervention, any child with a head injury requiring admission to hospital will be admitted under the care of the Paediatric Surgical team.
A surgical bed should be organised and the senior paediatric surgical trainee on call informed of the admission.
All medical/nursing paperwork should be completed including a drug kardex and an IV fluid prescription chart if indicated.
Neurological observations will be continued on the surgical ward as follows:
1 hourly neurological observations for the first 4 hours
2 hourly neurological observations for the next 8 hours
4 hourly observations thereafter
Children should not have a skull X‐ray unless there is a specific clinical indication, such as when part of a skeletal survey for investigation of non‐accidental injury.
Imaging the Cervical Spine
In children < 10 years initial assessment of the cervical spine should be by lateral and AP plain X‐rays.
Cervical spine CT scanning should be used for those patients with a severe head injury, or where there are symptoms or signs of spinal cord injury or where plain X‐rays are abnormal or inadequate.
Indications for Head CT Scan
* Any head CT scan request must be discussed with an ED Consultant
Last reviewed: 23 August 2017
Next review: 13 November 2019
Author(s): Steve Foster
Approved By: Clinical Effectiveness
Reviewer Name(s): Paediatric Clinical Effectiveness & Risk Committee