HWN Suggests

Pediatric head injury: a pain for the emergency physician?

The majority of the head injured patients presenting to the ED are mild and can be observed. Clinical prediction rules assist the ED physician in deciding if neuroimaging is warranted. In cases of major head injury, prompt airway control and careful use of sedation are necessary to minimize the chance of hypoxia, while avoiding hyperventilation. Hyperosmolar agents should be started in these cases and normothermia maintained. The majority of the evidence is derived from adult studies, and most treatment modalities are still controversial.

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  Pediatric Head Injury in the ED: Is Imaging Necessary?

Bottom line: in children presenting to the ED with minor head injuries, use a clinical decision making tool in addition to clinical judgment when deciding if CT is warranted.

 Blunt Head Trauma

How can we sort out the overtly ok from the sneakily serious?

Articles of Interest

Episode 3: Pediatric Head Injury

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.

Predicting paediatric traumatic brain injuries

The biggest challenge in managing a child with a mild to moderate head injury is deciding whether to organise a CT scan or not. Balancing the risk of ionising radiation (and with it the small, but definite, risk of a future brain tumour or leukaemia) against the risk of missing a significant brain injury is mitigated to some extent by using a clinical decision rule, like the PECARN, CATCH or CHALICE rules. These rules are extremely sensitive with very few false negatives and excellent negative prediction values, meaning if you follow them, you’re unlikely to miss a clinically important brain injury (cTBI). Their problem is their specificity is low with plenty of false positives, meaning most of the children who have a scan won’t actually have a brain injury.

Child Head Injury

Parents and caretakeers should note that vomiting is more common in young children, and they should only seek medical attention for a suspected head injury if a child vomits repeatedly in a brief period of time (e.g., more than once or twice within an hour) after a head injury.

Delayed presentation of head injuries – should we be worried?

We have a clear algorithm for when to CT children who present with head injuries immediately after the injury. However, when children present more than 24 hours after an injury, we aren’t really sure what the best practice is. This paper, by the PREDICT group, looks at the rates of traumatic brain injury in this patient group.

Emergency Department Evaluation of Young Infants With Head Injury

The youngest infants with head injuries are significantly more likely to undergo cranial imaging, be diagnosed with brain injuries, and die, highlighting the need for a specialized approach for this vulnerable population.

Head Injuries Module

If the child’s head is being imaged with CT, best practice would be to extend to the cervical spine if concern exists regarding injury. Teams should use judgement of the mechanism, presence of abnormal neurology and GCS to help make this decision).

Head injury – the 4-hour observation clock…

What evidence is 4 hrs observation based on? Umm, not a lot. Like many practices in medicine, it’s based on consensus and pragmatism. Many institutions follow a 4-hour target for patients to be admitted or discharged from the emergency department. Children with asthma/wheezing seem to require inhalers every 3-4 hours until discharge, too, and there are, no doubt, countless other examples within the medical world. Four hours of observation post-injury is the consensus view and currently established practice from experts with specialist knowledge in this field. It probably came about when you had to sell your kidney to the Radiologist for a CT scan, and radiation doses delivered per scan were much higher than present ‘modern’ machines. It was easier to observe the child, and if they deteriorated, you could more easily argue for a scan. This is my best guess but it is probably not far from the mark. Could this time be shortened in these at-risk groups? Probably. But trying to research this would, no doubt, be an ethical minefield.

Isolated vomiting in pediatric head injuries

Bottom line: TBI on CT is uncommon and clinically important traumatic brain injury is very uncommon in children with minor blunt head trauma when vomiting is their only sign or symptom. Observation in the emergency department before determining the need for CT appears appropriate for these children to observe for deterioration.

Multiple Pediatric Head Injury Decision Rules but What Should the Clinician Use?

Low risk decision rules, such as the PECARN rules, set a floor for CT scan use, so that CT scans are obviated for those at lowest risk. For those not at lowest risk, decision rules do not necessarily imply that the patient is at high risk or requires a CT. The literature now includes a substantial amount of data to help clinicians determine the risk of important TBI in patients who do not meet PECARN low risk criteria but who nevertheless do not necessarily need CT imaging...

Non-ionizing Imaging for the Emergency Department Assessment of Pediatric Minor Head Trauma

Minor blunt head trauma (MHT) represents a common reason for presentation to the pediatric emergency department (ED). Despite the low incidence of clinically important traumatic brain injuries (ciTBIs) following MHT, many children undergo computed tomography (CT), exposing them to the risk associated with ionizing radiation. The clinical predictions rules developed by the Pediatric Emergency Care Applied Research Network (PECARN) for MHT are validated accurate tools to support decision-making about neuroimaging for these children to safely reduce CT scans. However, a few non-ionizing imaging modalities have the potential to contribute to further decrease CT use.

Paediatric Traumatic Brain Injury

trauma series (lateral c-spine, CXR and pelvis). transcranial Doppler -> quantification of cerebral blood flow, can compare both sides, provides info regarding systolic, diastolic and mean blood flow velocity.

Pediatric Emergency Medicine Tips for Treating Closed Head Injuries...

A single, large retrospective study suggests that giving ondansetron in the PED for a child with a head injury, even when you’re not imaging the brain, probably does not mask a significant intracranial injury. With regard to giving a home prescription for ondansetron and masking significant intracranial injuries, we found no current literature on that topic.

Pediatric Head Trauma: To CT or not to CT?

How Do I Decide Who to CT? Clinical decision rules help determine who is low risk for clinically important traumatic brain injury. The Pediatric Emergency Care Applied Research Network (PECARN) clinical decision rule is the largest study on minor pediatric head injury and has undergone external validation.2-4 PECARN has separate criteria for children under 2 and for children age 2 and above. Aspects of the history and physical examination divide patients in to high, intermediate, and low risk criteria.

Pediatric Minor Head Injury and Concussion

We see about 750,000 pediatric patients annually with traumatic head injury in EDs across North America. That’s a lot of kids. While most of these kids will be fine regardless of what we do in the ED, even minor pediatric head injury may require neurosurgical intervention, investigating is not without serious risk, there may be long term consequences even with trivial bonks and the signs can be devilishly subtle. Recent literature suggests that pediatric patients take longer to recover from mild traumatic brain injury compared to adults and persistent post-concussive symptoms (PPCS) after 1 month occur in up to 30% of children after minor head injury.

Pediatric Trauma Brain Injury

Most pediatric head injuries do not result in significant traumatic brain injury (TBI). However, this case highlights the importance of early recognition of severe pediatric TBI and aggressive management of increased ICP.

Pediatric traumatic brain injury—a review of management strategies

Many domains of pediatric TBI management are consensus driven and lack strong evidence. Developing individualized strategies based on age, clinical presentation, presence of raised ICP, within the limitations of each healthcare resource setting, would enable emergency and critical care physicians to manage children with TBI more effectively.

Prehospital and emergency management of pediatric traumatic brain injury: a multicenter site survey

Traumatic brain injury (TBI) is a common cause of death and disability worldwide. Globally, pediatric TBI is reported to occur in between 47 and 280 per 100,000 children. In particular, children with moderate to severe TBI may have poor functional outcomes, experience neurocognitive delays, and depend on their caregivers for activities of daily living, placing a significant burden on individuals, families, and communities.

To CT or Not to CT – PECARN, CHALICE, and CATCH Algorithms

In this 16-minute lecture from Rebellion in EM 2021, Dr. Hilary Fairbrother focuses on the description of PECARN, CHALICE, and CATCH algorithms with best practices for use in pediatric patients with head trauma.

Resources

PREDICT

The PREDICT Algorithm: Imaging & Observation Decision-Making for Children with Head Injuries accompanies the PREDICT Australian and New Zealand Guideline for Mild to Moderate Head injuries in Children. It incorporates the core imaging and observation guideline recommendations for use by clinicians assessing a child with head injury in an acute care setting. This video provides an introduction to the algorithm and how it can be used during clinician decision-making.

Core EM

Most head trauma is minor, but it is crucial to identify patients with clinically important traumatic brain injury who require further evaluation and management. Always consider non-accidental trauma.

SAEM

It is the most common type of injury requiring medical evaluation in children. While most injuries are mild, brain injury is the leading cause of death and disability in pediatric trauma patients.

StatPearls

The pediatric GCS is similar to the adult GCS, with the main difference being the verbal component of the scoring system. In the 0 to 23 month age group, a 5 is designated for babbling, cooing, or smiling appropriately, 4 points if crying but consolable, 3 points for inconsolable crying, 2 points for moaning or grunting, and 1 point for no verbal response. In the 2 to 5 age group, a 5 is designated if the child is verbalizing appropriate words and phrases, a 4 is designated if the child is verbalizing inappropriate words, a 3 if the child is crying or screaming, a 2 for moaning or grunting and a 1 for no verbal response. GCS in the >5 age group is similar to that in an adult patient.