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: MOHD HABROL AFZAM BIN ABD WAHAB : 06 6 091 : MANAGEMENT OF HEAD INJURIES

Assessment

Initial management flowchart Indications for neuroimaging Level Of Consciousness - Glasgow coma scale Assessment of severity Management o Severe Head Injury o Moderate Head Injury o Minor Head Injuries

Background to condition:
Head injuries are common in children of all ages. Causes include falls, sporting accidents, road traffic accidents and non-accidental injuries. A key aim of head injury management is to prevent or minimise secondary brain injury which occurs as a result of hypoxia, poor cerebral perfusion, cerebral bleeding, hypoglycaemia, seizures and fever

How to assess:
Primary survey and Resuscitation:
ABC: ensure that the child's airway, cervical spine, breathing and circulation are secure. Rapidly assess the child's mental state using the AVPU scale. Use firm supraorbital pressure or jaw

thrust as the painful stimulus.

A Alert V Responds to voice P Responds to pain o Purposefully o Non-purposefully Withdrawal/flexor response Extensor response U Unresponsive

Assess pupil size, equality and reactivity

Secondary survey:

Perform a formal Glasgow Coma Score (GCS) Neck and cervical spine o Deformity o Tenderness o Muscle spasm Head o Scalp bruising o Lacerations o Swelling o Tenderness o Raccoon eyes* o Bruising behind the ear (Battles sign)* Eyes o Pupil size o Equality o Reactivity o Fundoscopy for retinal haemorrhage (may indicate non-accidental injury) Ears o Blood behind the ear drum* o CSF leak* Nose o Deformity o Swelling o Bleeding o CSF leak* Mouth o Dental trauma o Soft tissue injuries Face o Focal tenderness o Crepitus Motor function o Reflexes present o Lateralising signs

* Suspect basal skull fracture if these signs present

Features on history:

Time and mechanism of injury Circumstances of injury, e.g. accident, NAI, unexplained fall (consider seizure or arrhythmia) Loss or impairment of consciousness and duration Nausea and vomiting Clinical course prior to consultation - stable, deteriorating, improving Other injuries sustained
Past history of bleeding tendency

Investigations:
Neuroimaging (discuss with senior doctor or neurosurgeon):
Definite indications:

Any sign of basal skull fracture on secondary survey (see above) Focal neurological deficit Suspicion of open or depressed skull fracture Unresponsive or only responding non-purposefully to pain GCS persistently < 8 Respiratory irregularity/loss of protective laryngeal reflexes

Relative indications:

Loss of consciousness lasting more than 5 minutes (witnessed) Amnesia (antegrade or retrograde) lasting more than 5 minutes Persistent vomiting Clinical suspicion of non-accidental injury Post-traumatic seizures (except a brief (<2 min) convulsion occurring at time of the impact) GCS persistently less than 14, or for a baby under 1 year GCS (paediatric) persistently less than 15, on assessment in the emergency department If under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height). Known bleeding tendency

Consider other investigations:

Cervical spine imaging Venous blood gas and blood sugar level (especially in small children and in adolescents who have been drinking alcohol) ECG (query arrhythmia as cause of fall)

Glasgow Coma Scale (GCS) - level of consciousness

4 years Response Eye opening Spontaneously To verbal stimuli To painful stimuli No response to pain Best verbal response Orientated and converses Confused and converses Inappropriate words Incomprehensible sounds No response to pain Best motor response Obeys verbal commands Localises to stimuli Withdraws to stimuli Abnormal flexion to pain (decorticate) Abnormal extension to pain (decerebrate) No response to pain 6 5 4 3 2 1 5 4 3 2 1 4 3 2 1 < 4 years Score Response Eye opening Spontaneously To verbal stimuli To painful stimuli No response to pain Best verbal response Appropriate words or social smile, fixes, follows Cries but consolable; less than usual words Persistently irritable Moans to pain No response to pain Best motor response Spontaneous or obeys verbal commands Localises to stimuli Withdraws to stimuli Abnormal flexion to pain (decorticate) Abnormal extension to pain (decerebrate) No response to pain 6 5 4 3 2 1 5 4 3 2 1 4 3 2 1 Score

How to assess severity of head injury:

Minor

Moderate

Severe

No loss of consciousness Up to one episode of vomiting Stable, alert conscious state May have scalp bruising or laceration Normal examination otherwise Brief loss of consciousness at time of injury Currently alert or responds to voice May be drowsy Two or more episodes of vomiting Persistent headache Up to one single brief (<2min) convulsion occurring immediately after the impact May have a large scalp bruise, haematoma or laceration Normal examination otherwise Decreased conscious state responsive to pain only or unresponsive Localising neurological signs (unequal pupils, lateralising motor weakness) Signs of increased intracranial pressure: Uncal herniation: Ipsilateral dilated non-reactive pupil due to compression of the oculomotor nerve Central herniation: Brainstem compression causing bradycardia, hypertension and widened pulse pressure (Cushing's triad) Irregular respirations (Cheynes-Stokes) Decorticate: arms flexed, hands clenched into fists, legs extended, feet turned inward Decerebrate: head arched back, arms extended by the sides, legs extended, feet turned inward Penetrating head injury CSF leak from nose or ears

Management
Minor head injury:

The patient may be discharged from the Emergency Department to the care of their parents (see Discharge Requirements). If there is any doubt as to whether there has been loss of consciousness or not, assume there has been and treat as for moderate head injury. Adequate analgesia

Moderate Head Injury:

If, on the history from the parents and ambulance, the child is not neurologically deteriorating they may be observed in the Emergency Department for a period of up to 4 hours after trauma with 30 minutely neurological observations (conscious state, PR, RR, BP, pupils and limb power). The child may be discharged home if there is improvement to normal conscious state, no further vomiting and child able to tolerate oral fluids. A persistent headache, large haematoma or possible penetrating wound may need further investigation, discuss with consultant. Adequate analgesia Consider anti-emetics, but consider a longer period of observation if anti-emetics are given.

Severe Head Injury:

The initial aim of management of a child with a serious head injury is prevention of secondary brain damage. The key aims are to maintain oxygenation, ventilation and circulation, and to avoid rises in intracranial pressure (ICP).

Urgent CT of head and c-spine. Ensure early neurosurgical and ICU intervention.
Cervical spine immobilisation should be maintained even if cervical spine imaging is normal. Intubation and ventilation: o o o o Child unresponsive or not responding purposefully to pain GCS persistently <8 Loss of protective laryngeal reflexes Respiratory irregularity

In consultation with the neurosurgeon consider measures to decrease intracranial pressure:

o o o o o

Nurse 20-30 degrees head up (after correction of shock) and head in midline position to help venous drainage. Ventilate to a pCO2 35mmHg 4-4.5 kPa (consider arterial catheter). Ensure adequate blood pressure with crystalloid infusion or inotropes (e.g. noradrenaline) if necessary. Consider mannitol (0.5-1 g/kg over 20-30 min i.v.) or hypertonic saline (NaCl 3% 3 ml/kg over 10-20 min i.v.). Consider phenytoin loading dose (20 mg/kg over 20 min i.v.).

Control seizures: see Afebrile seizures Correct hypoglycaemia Analgesia: sufficient analgesia should be administered by careful titration. Head injured children are often more sensitive to opioids.

REFERENCES http://www.nhs.uk/Conditions/Head-injury-severe-/Pages/Diagnosis.aspx http://www.emedicinehealth.com/head_injury/page8_em.htm#head_injury_diagnosis http://www.mayoclinic.com/health/traumatic-brain-injury/DS00552/DSECTION=treatments-anddrugs http://emedicine.medscape.com/article/433855-treatment