Head Injury Presentation

7/26/2019 Head Injury Presentation

1/37

Head I njury in Children

Tina Kendrick

Clinical Nurse Consultant - Paediatrics


2/37

Some Definitions

Newborn < 28 days

Infant < 1 year

Child < 16th

birthday (DoH)


3/37

Head Injury

Leading cause of mortality & morbidity in children: Road trauma, falls, bicycle accidents, abuse and

violence

There are no magic bullets that have significantly

changed outcome in the past decade

Outcome still linked to severity of initial insult


4/37

Head Injury

Children have increased survival but increased

morbidity as diffuse brain injury prevalent

Often associated with spinal injury but lower

incidence in children

Care is focussed on:

Close observation

prevention & minimisation of secondary injuries

rehabilitation


5/37

Secondary Brain Injury

refers to the cascade of

physiological and biochemicalevents that occur after primary

injury and worsen outcome


6/37

Most Frequently Occurring

Hypocapnia

Hypotension

Acidosis


7/37

Associated With Worse

Outcome

Hypocapnia

Hypotensionoccurred twice as

often in non-survivors

Acidosis

Hypoxia

Hyperglycaemia

Hypothermia* in younger

individuals


8/37


9/37

Patterns of Head Injury in children

Some differences from adults thatinfluence patterns include:

Developmental level and age of the childAnatomic differences of the head

Frequency of inflicted injury in < 2s

Response of the childs brain to trauma


10/37

Developmental Considerations

Unwitnessed/unobtainable history of loss

of consciousness

No LOC, especially in < 2s does not

preclude intracranial injury

GCS may not be reliable in young

children; a modified scale should be used

for infants and young children

Parents generally provide most reliable &

trustworthy information


11/37

Anatomic Differences

Characteristics of child skull:

Thinner, provides less protection

Depressed skull # more prevalent

Pliability means underlying brain injury +/-

bleeding in the absence of fracture

Head = 18% of TBSA in infants; 9% in adults

Intracranial and scalp haematomas cantherefore represent significant blood loss


12/37

Anatomic Differences

Blunt trauma can be followed rapidly byacute brain swelling

Can occur despite:

no significant history No visible abnormality of the head

Children more disposed to developing

oedemahigher brain H2O content This requires close monitoring of fluid

balance


13/37

Body Proportions


14/37

Inflicted Injury

Have a high index of suspicion where:

History is inconsistent with physical findings

Infants present with serious head injury after

reportedly minor fall

History changes over time

Another child is blamed

A delay in presentation to ED

Most common cause of head injury in

infants


15/37

Assessment of Conscious Level

AVPU Assessment ToolA: Patient is Alert and

Age-appropriate

V: Patient responds to Voice

P: Patient responds to

Painful stimuli

U: Patient is Unresponsive


16/37

Five Assessment Parameters

Level of consciousness

Motor function

Respiratory patterns Cranial nerve response

Vital signs


17/37

Vital Signs

Temperature SpO2

Pulse and ECG

Respirations

Blood pressure

Standard Paediatric Observation Charts

(SPOC) should be used


18/37

Limitations of the Glasgow Coma

Scale for Children

Teasdale & Jennet did not report patient

ages in their original work

Recognised early on (late 70s) that theGCS was limited in assessing children

under 10 years of age

Preverbal children (under 2 years)particularly challenging


19/37

Eye Opening Response

Spontaneously (4)

To speech (3)

To pain (2)

None (1)


20/37

Eye Opening Response

No age-related modification necessary

Best score is 4


21/37

Best Verbal Response


22/37

Best Verbal Response 4-15 years

Orientated and converses (5)

Disorientated and converses (4)

Inappropriate words (3)

Incomprehensible sounds (2)

None (1)


23/37

Best Motor Response < 4 years

Obeys verbal command or performs normalspontaneous movements (6)

Localises pain or withdraws to touch (5)

Withdraws from pain (4) Abnormal flexion to pain (3)

Abnormal extension to pain (2)

No response to pain (1)


24/37

Best Motor Response 4-15 years

Obeys verbal command (6) Localises pain (5)

Withdraws from pain (4)

Abnormal flexion to pain (3) Abnormal extension to pain (2)

No response to pain (1)


25/37

Classification

Severity classification is traditionally used

Is GCS-based

Mild head injury (GCS 14 - 15)

Moderate head injury (GCS 9 - 13) Severe head injury (GCS 3 - 8)

S it


26/37

Severity

In children, CHALICE criteria is now being

used for management

A more comprehensive system, using risk

factors (including GCS) to more accurately

detect intracranial injury

Places children into Low, Intermediate or

High risk groups, which determines

management


27/37


28/37


29/37


30/37

Low Risk

Consider immediate discharge

I t di t Ri k


31/37

Intermediate Risk

Close observations for 4-6 hours post-injury

until GCS is 15 for 2 hours

May go home if GCS 15, asymptomatic,

responsible carers and normal CT

Any child not asymptomatic and

neurologically normal at 6 hours needs

discussion with paediatric expert orneurosurg


32/37

High Risk

These children require urgent imaging,

neurosurgical and Paed ICU consult via

NETS - regarding transfer, CT decisions

CT abnormalities need Neurosurg input

Those with normal CT should still be

observed for 6 hours min, may require

admission


33/37


34/37

Further Information

Childrens Hospitals websites Fact Sheets for

parents

NSW Institute of Trauma and Injury

Clinical Excellence Commissions Paediatric

Between the Flags

ACCCNs Critical Care Nursing (2012)

DETECT Junior

Frank ShannDRUG DOSES


35/37

References Australian and New Zealand Paediatric Intensive

Care Data Registry Report, 2010

Brady, Cain & Johnston (2012) Justifying referrals

for paediatric CT. MJA 197 (2) p95-98

Guidelines for the Acute Medical Management of

Severe Traumatic Brain Injury in Infants, Children

and Adolescents 2ndEditionJanuary, 2012 PediatricCritical Care Medicine


36/37

Useful References


37/37

Useful References

Documents

Head Injury Presentation