Head Injury in Children

Head injury in children Cerebral cortex • Frontal lobe, parietal lobe, occipital lobe and temporal lobe Intracranial pressure (ICP) • Intracranial pressure is the pressure exerted by the volume of the three intracranial components (extra-axial, intra-axial and intraventricular). • The more damage the brain receives, the more it swells resulting leakage from blood vessels. • Increasing the pressure of the brain Cerebral Perfusion Pressure (CPP) 1. Increase ICP approaches level of the main systemic pressure, CPP falls 2. 3. 4. 5. Increase B/P and dilation of cerebral blood vessels Increase cerebral blood volume Increase ICP Decreasing CPP Classification of head injuries Scalp injuries - Abrasion - Contusion - Laceration - Haematoma The Skull - Linear - Depressed skull fractures - Basal fractures - Comminuted fractures ABCDE principles for ill or injured child A - Airway (with cervical spine control) B - Breathing C - Circulation (with haemorrhage control) D - Disability E - Exposure for full examination 1. Airway - Airway management is paramount to prevent hypoxia Guidelines on intubation • Persistant airway obstruction • Predicted airway obstruction • Loss of airway reflexes • Inadequate ventilatory effort or increasing fatigue • Disrupted ventilatory mechanism • Persistent hypoxia despite supplemental oxygen • Controlled ventilation required to prevent secondary brain injury 2. Breathing - Ensure adequate ventilation occurs 3. Circulation - Bradycardia, hypotension, hypertension (sign of raised intracranial pressure) Neurological assessment • What is neurological assessment? Neurological examination is an evaluation of the patient’s nervous system. • Why is a neurological assessment done? To determine whether the nervous system is impaired GCS scale: Eye opening = 1- 4 Verbal response = 1- 5 Motor response = 1 - 6 Mild: GCS Score 14 to 15 Moderate: GCS Score 9 to 13 Severe: GCS Score 3 to 8 AVPU Alert, responds to voice, responds to pain, unresponsive Central stimulus If there is no motor, verbal or eye opening response, apply painful central stimulus. Pupil reaction Pupils should be assessed for size, shape, equality and reaction to light. Temperature Temperature may be disrupted due to the damage to the hypothalamus. Other considerations • • • • • • Mechanism of injury History of loss of consciousness or impaired consciousness Amnesia from the incident or subsequent events Vomiting NAI Drug or alcohol use Suspicious of a non-accidental injury • • • • • • • Inconsistencies is history Injury does not match Evidence of a lack of supervision/ neglect Delayed presentation with no clear rationale Previous attendances Unsafe environment Known to Social Services Alterations to neurology • • • • • • • • • • Trauma Existing neurological condition Previous CVA CNS infections Neoplastic disorders Drugs Alcohol Hypoxia Convulsions Hypoglycaemia Hypoxia • • • • Inadequate supply of oxygen Result of decrease in cerebral blood supply Children with impaired levels of consciousness are at risk of hypoxia Can occur after events like cardiac arrest, obstructed airway, trauma, shock, problematic birth and prolonged epileptic type seizures Poisoning or ingestion • Trycyclic antidepressants: Anticholinergic effect • Beta-blockers: Beta-blockers are used to lower high blood pressure, relieve angina, correct arrhythmias • Opioid: An opioid is any agent that binds to opioid receptors, found principally in the central nervous system. (eg. morphine, codeine, heroin, pethidine and methadone) • Amphetamines: Potent psychomotor stimulants • LSD (lysergic acid diethylamide): Hallucinogenic drug • Magic Mushrooms: Work on the same pharmacological principle as LSD • Cocaine: Central nervous system stimulator • Inhalants: Volatile solvents, aerosols, gases, nitrites Alcohol intoxication • Alcohol is a central nervous system depressant • Moderate intoxication is similar to raised intracranial pressure, diabetic hypoglycaemia and drug overdose • Severe intoxication can cause coma with loss of gag reflex Convulsions • Occurs when there is a disarrangement of the electrical and chemical neurotransmitters in the brain resulting in the brain cells to discharge impulses in an abnormal way • The specific physical activity that occur is dependent on the origin of the electrical activity and its extent within the brain Frequency of neurological observations Perform and record observations on a half-hourly basis until GCS is 15. • Half-hourly for 2 hours • Then 1 hourly for 4 hours • Then 2 hourly thereafter Revert to half hourly if patient deteriorates Review… • • • • • Agitation or abnormal behaviour developed GCS dropped by 1 point and lasted for 30mins (motor response) Severe or increasing headache developed Persistant vomiting New or evolving neurological symptoms such as pupil inequality or asymmetry of limb or facial movements For children who have sustained a head injury and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified: • Suspicion of non-accidental injury • Post-traumatic seizure but no history of epilepsy • On initial emergency department assessment, GCS less than 14, or for children under 1 year GCS (paediatric) less than 15 • At 2 hours after the injury, GCS less than 15 • Suspected open or depressed skull fracture or tense fontanelle • Any sign of basal skull fracture • Focal neurological deficit • For children under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head For children who have sustained a head injury and have more than 1 of the following risk factors, perform a CT head scan within 1 hour of the risk factors being identified: • Loss of consciousness lasting more than 5 minutes (witnessed). • Abnormal drowsiness. • Three or more discrete episodes of vomiting. • Dangerous mechanism of injury • Amnesia lasting more than 5 minutes Children who have sustained a head injury and have only 1 of the risk factors, they should be observed for a minimum of 4 hours after the head injury. If during observation any of the risk factors below are identified, perform a CT head scan within 1 hour: • GCS less than 15. • Further vomiting. • A further episode of abnormal drowsiness. Principles of management of a child with a head injury Maintain oxygenation and ventilation: • Airway management is paramount in preventing hypoxia and therefore secondary brain injury • Suctioning should be kept to a minimum as it raises ICP Circulation • Establish IV access and remember to check glucose • Combat hypotension with crystalloid infusion 10ml/kg Pain assessment & management • Observe changes in behaviour • The use of opioids is controversial because mask signs of altered consciousness or depress respirations • Following initial assessment sufficient analgesia should be administered by careful titration • If conscious level normal intravenous morphine is appropriate • Manage pain effectively because it can lead to a rise in intracranial pressure. Provide reassurance, splintage of limb fractures and catheterisation of a full bladder where needed (NICE 2014) Indication for referral • • • • • • Persisting coma Unexplained confusion lasting more than 4 hours Deteriorating conscious level Focal neurological signs Definite or suspected penetrating injury Cerebrospinal fluid leak Criteria for admission • • • • New clinically significant abnormalities on imaging Not returned to GCS 15, regardless of imaging results Continuing worrying signs (persistent vomiting, severe headaches) Other concerns (drug or alcohol intoxication, other injuries, shock, suspected NAI, cerebrospinal leak) Discharge advice Return if: • Unconsciousness, or lack of full consciousness • Confusion • Drowsiness (when normally would be awake) • Problems with comprehension or verbalisation • Loss of balance • Weakness in limbs • Blurred vision • Painful headache that is not relieved • Vomiting • Fits • New bleeding from one or both ears Not to be concerned by... • • • • • • Mild headache Nausea Dizziness Irritability Tiredness Lack of appetite General advice • • • • • Plenty of rest No contact sport for at least 3 weeks without consulting a doctor Do not return to school unless completely recovered Do not leave alone in the home for the first 48 hours Contact number if concerned