There are three different criteria in common use for deciding who to send to the scanner. Canadian, Nexus and New Orleans. All are very sensitive, with varying levels of specificity. Pick your poison. Talk to your friends, make a decision. You don’t need to stick to just one for the rest of your life, but I’ve heard tell it’s better to be consistent than not medical-legally speaking. But be mindful, all three kick out kids (use PECARN) and elderly ( JUST SCAN.)
Predicts need for head CT after blunt head injury.
Predicts need for brain imaging after pediatric head injury.
Predicts intracranial traumatic CT findings in patients with minor head trauma.
Clears head injury without imaging.
Coma severity based on Eye (4), Verbal (5), and Motor (6) criteria.
Criteria for which patients are unlikely to require imaging after head trauma.
Assesses impaired consciousness and coma in pediatric patients.
ICP management and hyperosmolar therapy:
Indication: Impending herniation suggested by deepening coma, asymmetric/fixed pupils, or development of other lateralizing signs.
HTS (3% Saline): 100cc over 10min, or 3mL/kg (?higher to 5cc/kg) over 30min with repeat doses q6h to max sodium of 160mmol/L (AEs = renal failure, central pontine myelinolysis, rebound ICP elevation).
Mannitol 1g/kg q6h to a maximum serum osmolality of 320mosm/kg (AEs – hypotension, renal failure, or increased bleeding into a traumatic lesion by decompressing the tamponade effect of a hematoma).
Traditionally, ketamine was contraindicated for induction in intubation in TBI, but literature suggests that not only is it safe, but it may be beneficial. Ketamine improves cerebral blood flow, and evidence suggests it does not raise ICP.
The PECARN head trauma rule is most frequently utilized in the U.S.
The first step in using the PECARN rules, is to evaluate the patient based on the Glascow Coma Scale (GCS) and assign a score. The PECARN rules apply only to patients with a GCS of 14 or higher. In general, if the child is awake, alert, and interactive, the GCS will be 14 or higher.
Care of HI in older adults is challenging due to comorbidities. Practising evidence-based clinical management and following guidelines is important, but strict adherence is not common practice.
Computed tomography (CT), in the setting of acute trauma,
is indicated for severe TBI (GCS 8), persistent neurologic
deficit, antegrade amnesia, unexplained asymmetric pupillary response, loss of consciousness more than 5 minutes,
depressed skull fracture, penetrating injury, or bleeding diathesis or anticoagulation therapy.
Children also have a larger head-to-body size ratio, making the probability of head involvement in injury consequently higher (in comparison to adults); the head is also relatively heavier in a child, making it more vulnerable (especially in injury caused by sudden acceleration).
Patients with minor TIH can be managed in an EDOU using an mTBI protocol and discretionary neurosurgical consults and repeat HCT. This is associated with a significant reduction in length of stay.
In the child younger than two years of age, and particularly in children younger than 12 months of age, greater caution is advised.
Dr. Rahim Valani and Dr. Jennifer Riley discuss their approach to the workup and management of both minor and major Pediatric Head Injury. They review two recent landmark studies (PECARN & CATCH studies) describing clinical decision rules for performing CT head in minor pediatric head injury, as well as practical tips on instructing parents regarding return to sport activities after discharge.
Head CT scan is the cornerstone of closed head injury diagnostic evaluation. Radiologic
exposure is an equally important consideration. Following the PECARN guidelines will assist in
determining risk of significant brain injury and need for head CT.
With head trauma you have to worry about the primary injury, from the blunt trauma itself, and about secondary injuries, from the swelling, edema, and neurotoxin release... All in all, you will be seeing a lot of blunt head trauma, much of which will require CT. Most of these patients will be safe to go home. But when they aren’t safe for home… they really aren’t safe for home.
TBI is one of the leading causes of mortality and morbidity following trauma. Since younger patients are often involved, this causes a large person-year burden of morbidity. The precise incidence is difficult to quantify, given variable definitions of exactly what constitutes TBI.
Traumatic brain injury is classified as mild, moderate, or severe, based on the Glasgow Coma Scale (GCS) score.