see: [ Dunn - paediatric head trauma](x-devonthink-item://5C860993-442A-44DB-B28B-12EE9FC21737), [Rosen pediatric trauma](x-devonthink-item://E800562E-10BF-4F78-97FD-B811FFEF2079), [RCH - Head injury](https://www.rch.org.au/clinicalguide/guideline_index/Head_injury/) see also: [PREDICT - paediatric research in Emergency Departments International Collaborative - mild-to-moderate head injuries](https://www.predict.org.au/head-injury-guideline/) [[paediatric c-spine]] #trauma > [!key points] > - most head injuries are mild > - mod to severe head injury need immediate mgmt, investigation, and referral > - can be significant without loss of consciousness > - mild head injury can be immediatly discharged home > - identify if needing 4 hours observation > - assess for other significant injuries or suspected [[Non-accidental injury|Child abuse]] # RCH guidelines **Definite indications** - Any moderate or severe head injury (GCS ≤13) - Focal neurological deficit - Signs of base of skull fracture - Palpable skull fracture - Suspected non-accidental injury - Persistent signs of altered mental status (agitation, drowsiness, repetitive questioning, slow response to verbal communication) **Relative indications** (if >1, observe and consider neuroimaging) - GCS persistently 14 - Severe mechanism of injury - History of loss of consciousness - Post-traumatic seizure - Severe headache - Persistent vomiting - Non-frontal scalp haematoma (<2 years) - Acting abnormally as per parent (<2 years) > special considerations: > - age <6 mo > - bleeding disorder / on anticoagulant or anti-platelet > - [[ITP]] > - [[VP shunt]] > - neurodevelopmental disorder > - drug or EtOH intoxication ![[Pasted image 20240510165856.png|PREDICT algorithm]] <u>details to aid PREDICT algorithm interpretation</u> 1. Always consider possible cervical spine injuries and abusive head trauma in children presenting with head injuries. 2. Children with delayed initial presentation (24-72 hrs post head injury) and GCS 15 should be risk stratified the same way as children presenting within 24 hours. They do not need to be assessed with a further 4 hrs of observation. 3. Remember to use an age-appropriate Glasgow Coma Scale (GCS). 4. Risk factors adapted from Kuppermann N et al. Lancet 2009;374(9696):1160-70. 5. Other signs of altered mental status: agitation, drowsiness, repetitive questioning, slow response to verbal communication. 6. Severe mechanism of injury: motor vehicle accident with patient ejection or rollover, death of another passenger, pedestrian or cyclist without helmet struck by motor vehicle, falls of ≥ 1m (< 2 yrs), fall > 1.5m (≥ 2yrs), head struck by high impact object. 7. Palpable skull fracture: on palpation or possible on the basis of swelling or distortion of the scalp. 8. Non-frontal scalp haematoma: occipital, parietal, or temporal. 9. Loss of consciousness. 10. Signs of base of skull fracture: haemotympanum, ‘raccoon’ eyes, cerebrospinal fluid (CSF) otorrhoea or CSF rhinorrhoea, Battle’s signs. 11. Isolated vomiting, without any other risk factors, is an uncommon presentation of clinically important traumatic brain injury (ciTBI). Vomiting, regardless of the number or persistence of vomiting, in association with other risk factors, increases concern for ciTBI. 12. Observation to occur in an optimal environment based on local resources. Frequency of observation to be 1⁄2 hourly for the first 2 hours, then 1-hourly until 4 hours post injury. After 4 hours, continue 2-hourly as long as the patient is in hospital. Observation duration may be modified based on patient and family variables. These include time elapsed since injury/symptoms and ability of child/parent to follow advice on when to return to hospital. 13. Shared decision-making between families and clinicians should be considered. 14. Do not use plain X-rays, or ultrasound of the skull, prior to or in lieu of CT scan, to diagnose or risk stratify a head injury for possible intracranial injuries. 15. Other factors warranting hospital admission may include other injuries or clinician concerns e.g. persistent vomiting, drug or alcohol intoxication, social factors, underlying medical conditions, possible abusive head trauma. # PECARN - only prospectively validated paediatric head injury decision rule - patients with none of the criteria do not require CTB - pts with only one criteria may need CTB; apply clinical judgement vs. prolonged period of observation **exclusions** - GCS <14 - trival mechanism eg ground level fall - no features of head rauma - penetrating trauma - known brain tumour - pre-existing neuro disorder complicating assessment - VP shunt - bleeding disorder ## PECARN flowchart ![[Pasted image 20240311235442.png| Rosen]] ## age 2-18 - abnormal mental status - agitation - somnolence - repetitive questioning - slow response to verbal questioning - any or suspected LOC - vomiting - severe headache - severe injury mechanism - MVA with pt ejection, death of another passenger, rollover - fall >1.5m - head struck with high impact object ## age <2 - abnormal mental status - GCS <14 - agitation - somnolence - repetitive questioning - not acting normally according to parent - severe injury mechanism - MVA - fall > 0.9m for children <2 - head struck with high impact object - palpable or unclear skull fracture - occipital, parietal, or temporal scalp haematoma # Treatment ## mild head injury without other risk factors - GCS 15 and meets following criteria: - no concern about abusive head trauma - age >6 months - no special conditions (eg bleeding disorder, VP shunt, neurodevelopmental disorder) - non-severe mechanism ## mild head injury with other risk factors - observe for up to 4 hours post injury with: - 30 min neuro obs (conscious state, PR, RR, BP, pupils, limb power) for first 2 hours; Q1 hour thereafter - a persistent headache, ongoing vomiting, GCS 14, or persistent altered mental status requires further observation and likely investigation - the child may be discharged home if there is return to normal conscious state for at least 1 hour, is acting normally, and can tolerate oral fluids ## Concussion and return to activity a [[Concussion]] is a mild injury which temporarily alters brain function post concussive symptoms are common, and advice should be given regarding rest and gradual return to activity - no exact consensus - guidelines are conservative -- now 21 days for community sport - must not return to sport until have gone through return to play procedure and "cleared by doctor" - SCAT 6 (sports concussion assessment tool) or SCOAT 6 (at 72 hours) give some information and symptoms should be absent prior to return to sport # Related questions - [ ] [unresponsive infant](x-devonthink-item://0987D972-A221-4F8A-B7D7-B0DCC349A2B3?page=4) -- [Answer](x-devonthink-item://C7FCB01A-E668-44AF-8C95-C298A40F8D68?page=2)