1. Paediatric Head Injury

2. 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

3. Head injury can be nasty 40-50% of trauma deaths are mainly attributable to HI 7% of “Mild” HI have later behavioural problems?

4. Classifications –Mild GCS 14-15 (80%) –Moderate GCS 9-13(10%) –SevereGCS 3-8(10%) Anatomy: scalp, skull, brain –Focal vs Diffuse MOI: Blunt vs penetrating Path: Primary vs Secondary Brain Injury

5. Anatomical Scalp: abrasions, haematomas, lacerations Skull –Vault (?depressed), Basal Brain –Focal Contusioncoup, contrecoup Haematomasubdural, intracerebral extradural (90% adults c #, 70% kids) –DiffuseConcussion DAI

6. Secondary HI is preventable Hypoxia Hypovolaemia –(NB: open fontanelles, large scalp lacerations) Raised ICP –Blood, oedema, infection Hypoglycaemia, hypothermia, pyrexia, fits

7. 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

8. So prevent it! Oxygen Treat shock Image appropriately Admit appropriately Refer appropriately

9. APLS/ATLS Assessment AVPU/GCS/PERLAMPLE/MIST Lacs, haems, palpate for depressed # Fontanelles Ear/nose CSF/blood, Panda/Battle signs CNS – focal signs, fundi Other injuries (especially c-spine), ?NAI

10. Relevant history MOI Clinical progression Presenting complaints –LOC, Amnesia, Vomiting, Fits, Visual deficits Warfarin Alcohol/drugs Social circs

11. 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

12. Imaging – obs only? Oriented No # 1/6000 Intra Cranial Haematoma #1/30(ie, risk x 200) Disoriented No #1/120 #¼(ie, risk x 30) BUT these figures are for adults 50% of children who die of HI have no # evident

13. 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?

14. Imaging –SIGN guidelines ‘00 CT 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!

15. 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

16. 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

17. 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

18. 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

19. NICE ’03 1 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

20. 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”

21. 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)

22. 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

23. 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!

24. 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

25. 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…

26. 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

27. Resources www.sign.ac.uk www.nice.org.uk www.trauma.org