Head injuries in children. Dr Jason Hort Paediatrician Paediatric Emergency Physician, June 2017 Children s Hospital Westmead

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2 Head injuries in children Dr Jason Hort Paediatrician Paediatric Emergency Physician, June 2017 Children s Hospital Westmead

3 Objectives Approach to minor head injury Child protection issues Concussion

4 Perspective Tertiary children s hospital Neurosurgical service 24 hr paediatric medical and nursing service Referral patterns biased to severity Generally good access to ct scan

5 Wentworth Falls ( most of the time)

6 Sometimes it pours

7 Anyone involved in the management of major head injury?

15 Assessment A with c spine B C D- AVPU then modified GCS and pupils Don t ever forget glucose E- Secondary survey

17 Modified GCS Modified Glasgow Coma Scale Use for young children and infants who have limited receptive and expressive language abilities Has amendments for the assessment of verbal response

18 Eye opening Spontaneous To voice To pain None Verbal response Appropriate words or social smile, fixes and follows Cries, but is consolable Persistently irritable Restless, agitated None Movement/motor response Spontaneous movement (<1yr) Obeys command (>1yr) Localises to pain Flexion- withdrawal to pain Flexion-abnormal Extension None Score

19 GCS Has prognostic value in trauma patients GCS 3-5 = severe HI, significant likelihood of permanent impairment GCS 6-8 = moderately severe HI, needs ICU, may have permanent impairment GCS >8 = more likely to have good outcome

20 Assessment of HI severity Mild moderate severe Use of modified gcs For mild head injury, gcs >13 Development of different guidelines address first hours after injury up to 24 hours Age, mechanism, symptoms and signs are all part of these guidelines

21 Risk stratification from the guidelines

22 Three Cases

24 History Mechanism examination

25 3yo Rear seat passenger, restrained, Truck hits car Mod GCS 6 E=1, V=1 M=4 Pupil left large and unreactive Helicopter retrieval Intubated on scene, 500ml crystalloid,

27 Guidelines Ministry of health Head injury guidelines or rules Based on chalice study Also Catch and Pecarn studies Recent Predict study paediatric research in emergency depts. International collaborative Comparing these in children in aust+nz

28 Chalice Study Group UK Chalice Children s head injury algorithm for the prediction of important clinical events A prospective multicentre diagnostic cohort study to provide a rule for selection of high-risk children with head injuries for CT scanning The first head injury decision rule for children Misses 5% of significant injury

29 The CATCH rule The Canadian Assessment of Tomography for Childhood Head injury Prospective cohort study patients 15% scan rate

30 PECARN Pediatric emergency care applied research network More who not to scan, Up to 50% of head injured children would get a scan

31 Australian review- lancet april children 23% admitted Clinically significant head injury Ct rate of 10.5% 83 <1% neurosurgery 15 died

32 Statistics Head injuries 1-2% of visits to ED Classification according to GCS Mild HI GCS = 97% Moderate GCS 9-13 =0.5% Severe GCS 8 or less = 0.6%

33 CT scan Ct scan radiation risk 1/1000 brain tumours from ct scan Under 4 yo may need sedation May be more helpful to say For observation, may need a scan

34 CT scan Earn your ct scan Document reasons and criteria they meet for ct scan Observation as an alternative 4hrs post injury 6 hrs post injury overnight

35 10 yo playing golf Hit in the left head by a golf club Initial loc 1-2 mins A little confused, Went home Subsequently a little more sleepy Presents to small country hospital

36 Abc intact pr 90,bp 110/60 Gcs 14, perl, e=3,v=5, m=5 Swelling to left side of head 10 pm at night, No scanner, What to do?

39 11 month old 11 mth old, visiting grandfather at private hospital, fell out of pram, after standing up, On tiles, Took a deep breath and cried, Consolable, Remained irritable, Kept vomiting

40 Presents 18 hours later With Mother and grandmother Mother with plaster cast on leg Irritable, Temp 36.5, pr 140,well perfused RR 24, sats 97% room air Pupils 2+ equal

41 Crying, Moving all limbs, Briefly consolable, fixes and follows, Fontanelle full, Boggy swelling right occipitalparietal region No other injury,

42 When not crying quiet, responds to pain Modified gcs E2, V4, M4 =10 Quiet enough to CT scan without sedation

44 Middle meningeal artery

45 Large right extradural with mass effect Right parietal skull fracture Urgent theatre I am not a bad mother

46 Good response Discharged after one week Rehab team involved Child Protection team involved, DOCs previously involved, No siblings, lives with GM An accidental injury

47 Child protection Screening Delay in presentation Story not consistent/compatible Other injuries Previous history

48 Discharge

49 Discharge

52 Concussion A concussion is an injury to the brain caused by sudden strong movement of the brain against the skull. A child does not need to be knocked out (lose consciousness) to have concussion. it is important to be on the lookout for warning signs which could appear immediately after a bump to the head or body, or over the following hours and days.

61 Concussion Know the signs and symptoms of concussion; and if you suspect a concussion, remove the child from play immediately. Physical activity is essential to the healthy development of children and young people and should be encouraged. It is important however, to be aware of the risk of sports concussion so that children may be given the best care when needed. A concussion is an injury to the brain caused by sudden strong movement of the brain against the skull. This is caused by a collision with another person or object. A child does not need to be knocked out (lose consciousness) to have concussion. Most concussion injuries do not involve any loss of consciousness, so it is important to be on the lookout for warning signs which could appear immediately after a bump to the head or body, or over the following hours and days.

68 Herniation Extensor posturing or hemiparesis Hypertension, bradycardia, irregular respirations Pupillary signs sluggish reaction, unilateral or bilateral dilation

70 Why children Large head to body ratio, high centre of gravity skull thinner and plastic transmits rather than attenuates impact skull fractures more common

71 Adults who suffered severe brain injuries as preschoolers only ¼ work full time and independently

72 GCS of 3-4 at 24 hours is BAD Severe TBI persistent multiple deficits Mild or moderate- recover verbal and non verbal skills and achieve IQ scores in the normal range. Young children with severe TBI flattest recovery

73 Who gets a CT scan?

74 Head Injury descriptors Extra axial = outside the brain Intra axial = inside the brain Extra axial- skull, extradural (epidural), subdural subarachnoid and intraventricular Intra axial - contusion, laceration, haemorrhage and DAI (= diffuse axonal injury) from rotational and shearing forces,

75 TBI leading cause of morbidity and mortality in paediatric trauma Most common cause is falls, Then MVA s

76 Chalice Study Group UK Inclusion criteria - any pt < 16 yrs with a history or signs of injury to the head. LOC and amnesia was not a requirement children presenting to the ED of 10 hospitals in 2 ½ yrs

77 Chalice Study Group UK Results 774 children had a CT head 281 (1.2%) patients showed an abnormality on CT 137 (0.6%) patients required neurosurgical intervention 15 patients died

78 CT Yes: History Witnessed LOC of > 5 min duration History of amnesia (antegrade or retrograde) of > 5 min Abnormal drowsiness 3 vomits after head injury Suspicion of NAI Seizure after head injury in a pt with no history of epilepsy

79 Examination GCS < 14, or GCS < 15 if < 1 year old Suspicion of penetrating or depressed skull injury or tense fontanelle Signs of basal skull # Positive focal neurology Presence of bruise, swelling or laceration > 5 cm if < 1 year old

80 Mechanism High speed RTA either as pedestrian, cyclist or occupant ( > 40 m /h) Fall of > 3 m in height High-speed injury from a projectile or an object

81 Four high-risk factors GCS < 15 within 2 hrs, suspected open skull #, worsening headache, irritability High-risk factors 100% sensitive for predicting need for neurosurgical intervention

82 3 Medium risk factors large boggy scalp haematoma, signs of basal skull #, dangerous mechanism of injury Medium-risk factors 98.3% sensitive

83 Management Observation Until well, 4 hours post HI Discharge with RESPONSIBLE ADULT Clear instructions Head injury advice- written

84 Prevention Helmets On the golf course In the pram In the shopping trolley In the playground

85 Surgery Options Decompressive craniectomy ICP refractory to other treatments Patients who deteriorate after admission NAI

2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY

2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY Measure #416: Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 through 17 Years - National Quality Strategy Domain: Efficiency and Cost Reduction