Head injury – Emergency management in children

Purpose

This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) in Queensland with a head injury.

This guideline has been developed by senior ED clinicians and Paediatricians across Queensland, with input from Neurosurgery and Pharmacy, Queensland Children’s Hospital, Brisbane. It has been endorsed for statewide use by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.

Introduction

Head injuries are a common paediatric ED presentation, accounting for 1 – 2% of all presentations to specialist children’s emergency services within Australia¹. Although most are minor, head injuries remain a significant cause of morbidity and mortality.

Children sustaining head injuries at the more severe end of the head injury spectrum are usually readily identifiable and should immediate (and concurrent) intervention, investigation and referral for definitive management.

Children with clinical features of head injury at the “milder”, and by far more prevalent end of the spectrum, present their own challenges. Differentiating the child with the truly low risk head injury from those at risk of a clinically significant injury, such as an intracranial bleed or a depressed skull fracture, can be problematic. While a CT (Computed Tomography) scan is the investigation of choice to exclude such injuries in the acute setting, it is neither feasible nor ethical to scan every child presenting given concerns with radiation exposure, the potential need for sedation and/or transfer, and resource costs.

Several clinical decision rules (CDRs) have been derived to risk stratify children with isolated head injuries and thus to guide clinicians in imaging and discharge decisions. This guideline is informed by the highest performing CDRs in our setting and adopts the concept of the clinico-radiological rule to enable an evidence-based approach to the decision making around head injury management in Queensland.

Clinical decision rules

Clinical decision rules (CDRs) in paediatric head injury have been derived to guide imaging decisions. The most well known and highest quality CDRs are PECARN² (US study, 33,785 children), CHALICE³ (UK, 22,772) and CATCH⁴ (Canada, 3688). PECARN and CHALICE CDRs are outlined below. PECARN is designed for children with a GCS >13, offers different rules for those less than two years and those greater than two years and is a clinico-radiological rule with the option to observe or image children at intermediate risk. CHALICE considers all children presenting with a head injury and CATCH was designed for a higher risk cohort. Both PECARN and CHALICE have a negative predictive value of 99.9%, meaning that children who are negative for the rule i.e. low risk, are estimated to have less than 0.1% risk of significant intracranial injury.

An Australian and New Zealand observational multicentre study, APHIRST⁵ published in 2017, examined the performance of all three of these CDRs in our context. All three rules performed well, PECARN had the highest sensitivity, and all three rules had a negative predictive value over 99% (PECARN – 100% (95%CIs 99.9-100; 99.8-100 for each age group); CHALICE 99.8% (95%CI 99.7-99.9). It is important to recognise though, that strict application of the rules would likely have resulted in a much higher imaging rate than currently exists in the 10 tertiary and large mixed hospitals that were part of the study. The APHIRST baseline imaging rate among all children was 10.5%; PECARN if strictly applied could result in an imaging rate as high as 46.6% (depending on whether intermediate risk children were observed or scanned), CHALICE 22% and CATCH 30%. Furthermore, in the APHIRST study, clinician gestalt in children with milder head injuries (GCS 13-15) was found to perform better than any rule (no missed injuries).⁷ The ten APHIRST sites are either tertiary children’s hospitals or large mixed centres with a strong paediatric focus, and clinician decisions are likely informed by factors including awareness of the CDRs, clinician experience, and the use of observation instead of immediate CT scan as a management option in some cases.

There is considerable overlap between the CDRs in clinical assessment variables (history, mechanism of injury, examination), albeit with some discrepancy over exact details e.g. height of fall, number of vomits and length of any loss of consciousness. These features and the CDRs have been used to inform the statewide guideline. Scope has also been given to allow for observation as an initial option in some children deemed at intermediate risk.

The PREDICT (Paediatric Research In Emergency Department International Collaborative) head injury management algorithm, underpinned by an extensive evidence and consensus based binational guideline, employs a similar approach to risk stratification ⁶ for mild to moderate head injuries

The children’s head injury algorithm for the prediction of important clinical events rule (CHALICE)

*Equivalent to over 64km/hour
Reproduced from Dunning J, Daly JP, Lomas J, et al.  Derivation of the children’s head injury algorithm for the prediction of important clinical events decision rule for head injury in children.  Archives of Disease in Childhood 2006; 91:885-891 with permission from BMJ Publishing Group Ltd. Link to article

Assessment

Emergency care should always involve a rapid primary survey with evaluation of (and immediate management of concerns with) airway, breathing, circulation and disability (ABCD). This includes level of consciousness and Glasgow coma score (GCS).

The aim of the assessment is to:

• identify a child with a severe head injury at risk or showing signs of raised intracranial pressure (ICP) to enable immediate investigation, management and prompt referral
• differentiate children at low risk of a clinically significant head injury (who can be safely discharged without the need for a CT scan) from those who require further management (CT scan or observation).
• identify children with other concerns e.g. non-accidental injury (NAI), alternate diagnoses or potentially higher risk e.g. bleeding diatheses, ventriculoperitoneal shunts.

An integration of clinical assessment features into low, intermediate and high risk is included in head injury management (see table on risk stratification in Management section).

History and mechanism of injury

Important factors to elicit on history include:

• abnormal behaviour such as agitation or drowsiness, repetitive questioning, slow verbal response, not acting normally as per parents
• loss of consciousness
• vomiting
• post traumatic seizure
• amnesia: retrograde and antegrade
• headache
• mechanism of injury – significant mechanisms of injury include:
  • fall from a significant height
  • motor vehicle accident (especially if high-speed, ejected from vehicle or others significantly injured in the same crash)
  • pedestrian/cyclist impacted by a motor vehicle
  • impact from high-speed projectile e.g. golf ball, ceiling fan, or from an object with significant force e.g. golf club/cricket bat strike, dog bite with significant head shake.
• any special circumstances to consider including injuries of potential NAI concern, those occurring in children with patient specific risk factors e.g. bleeding diatheses, ventriculoperitoneal shunts, and alternate diagnoses (refer to Further Assessment Considerations below)

Some differences exist between CDRs in symptoms and signs included as important, and the degree e.g. height of fall, number of vomits, length of loss of consciousness. PECARN defines a significant fall height as >0.9m for children less than 2 years, and greater than 1.5m for children 2 years and older.² Impact surface should also be considered.

Examination

Following the primary survey, a thorough head-to-toe examination (secondary survey) should occur with specific attention paid to the maintenance of neutral positioning if there are cervical spine injury concerns (refer to Cervical spine injury guideline).

Particular features on examination to identify are:

• level of consciousness (LOC), including GCS or AVPU score. All CDRs consider that a child with a diminished or decreasing LOC is at significant risk of intracranial injury. If present, examination should be made for other signs of raised intracranial pressure (ICP)
• suspicion of an open or depressed skull fracture (including boggy haematomas, palpable depressions)
• signs of a basal skull fracture (raccoon eyes, haemotympanum, Battle’s sign, CSF leak via nose, ears)
• penetrating injury
• presence of focal neurological deficit
• other features suggestive of more extensive injury (e.g. other significant trauma, NAI)
• in infants and young children: size and location of a haematoma, swelling or laceration should be noted, as should a bulging fontanelle (see PECARN and CHALICE CDRs). Non frontal (parietal/temporal/occipital) haematoma may be associated with increased risk .²

Seek urgent paediatric critical care/neurosurgical advice for a child with signs of raised ICP or decreased level of consciousness (onsite or via Retrieval Services Queensland (RSQ).

Further assessment considerations

Consider special circumstances in the presentation, or the possibility that the clinical presentation is unrelated to the head injury.

Investigations

CT scan remains the gold standard investigation of intracranial injury in the acute setting. Scanning is not recommended in all children due to the associated radiation risks (dependent on the machine and site-specific protocols), the need for sedation and/or transfer and resource costs. Repeat neuroimaging may be required if there is clinical deterioration or failure to improve; consultation with neurosurgery advised.

Pharmacological sedation,⁷ if required, should be performed by senior medical staff experienced with the agents used and airway management in children. Small doses of Midazolam (intravenous / buccal), intravenous Ketamine or intranasal dexmetomidine are often used. Anaesthetic assistance may be required.

Very young infants may settle sufficiently with swaddling / wrapping after a feed if the clinical situation permits. Oral sucrose may facilitate comfort during the scan.

Management according to risk stratification

Refer to flowchart [PDF 464.81 KB] for a summary of the emergency management in children who present with a head injury

Risk stratification heavily informs the management of the head injured child. CDRs (PECARN, CHALICE) may be used to assess this risk, accepting that strict application of these rules in our setting is likely to significantly increase baseline imaging rates with no appreciable increase in identification of significant intracranial injury.⁵ The following approach is proposed to guide imaging, observation and discharge decisions, incorporating the CDRs, and allowing for clinical judgement.

*PECARN² considers a significant height as  0.9m for children younger than 2 years, and greater than 1.5m for children aged 2 years and older.

Low-risk children

Children may be considered at “low risk” if they have all of the following:

• history of head trauma with no concerning features on history, examination or mechanism of injury (i.e. no risk factors for intermediate or high-risk head injury)
  AND
• normal level of consciousness (GCS 15).

As per evidence available from published decision rules,^2,3 these children are considered to be at very low risk of having a clinically significant head injury (<0.1%) and may be discharged home with head injury advice if other discharge criteria are met (see Disposition).

Post-concussive symptoms and adverse neuropsychological sequalae can occur following a minor head injury.^{9, 10} Carers should always be advised to seek medical attention if low grade or vague symptoms persist. Return to sport advice, if applicable, should also be provided.

Intermediate-risk children

Seek senior emergency/paediatric advice as per local practice prior to requesting a CT scan for a child at intermediate risk of an intracranial injury.

Seek urgent paediatric neurosurgical advice (onsite or via RSQ) if abnormalities are identified on CT scan.

Seek paediatric neurosurgical/local paediatric advice as per local practice for a child with significant persistent symptoms and no abnormality detected on CT scan.

Intermediate risk patients include those with a GCS 14 – 15 but concerning features on history, examination or mechanism of injury. Children who have any concerning features are at increased risk of a clinically significant head injury compared to those who do not, and further investigation or observation should be considered.

While CT scan is the gold standard investigation to exclude clinically significant head injuries in the acute situation, scanning all children who have concerning features is likely to result in an unacceptably high rate of CT use in our population, and may necessitate transfer.  As such, a period of observation may be an acceptable alternative in some situations. This decision should be made in consultation with senior medical staff and can only occur where appropriate facilities and experienced staff are available to monitor the child during the period of observation with timely intervention / investigation if required.

Factors that may influence this decision include:

• clinician experience
• presence of multiple risk factors
• worsening or unresolved symptoms
• age of the child (need for sedation in younger children)
• availability of local resources for imaging and where relevant, sedation

Examples of situations that may be appropriate for observation include an otherwise well child subjected to a significant mechanism of injury; or a child with a history of isolated infrequent vomiting who appears completely well.

The optimal time for observation is unclear. Most guidelines, including NICE, recommend a minimum period of at least four hours from the time of injury.¹¹ A large Canadian retrospective review found that most children with a significant intracranial injury are symptomatic within six hours of injury.¹²

High-risk children and those with life-threatening injuries

Seek senior emergency/paediatric advice as per local practice if symptoms persist, worsen or progress within the observation period. A CT scan is recommended.

Seek urgent paediatric critical care/neurosurgical advice (onsite or via RSQ) if significant clinical deterioration occurs within the observation period. Emergency management may be required.

Indications for immediate CT scan with high-risk patients include:

• GCS <14
• suspicion of a depressed, open or basal skull fracture
• penetrating injury
• NAI concerns
• presence of focal neurological deficit

In infants and young children, the size or location of a haematoma, swelling or laceration (suspicious for skull fracture) or a bulging fontanelle may also warrant consideration of immediate CT scan.

Concurrent investigation, management and referral may be required for the child or infant presenting with a high-risk of a significant intracranial injury. Priorities include:

• ABC assessment and management
• active management of raised ICP if suspected
• consideration of other serious injuries
• frequent clinical reassessment to examine for signs of deterioration
• urgent CT scan if available OR urgent transfer if required
• consideration of early liaison with neurosurgical and critical care services (onsite or via RSQ)

Immediate management of raised ICP

Both generalised cerebral oedema and focal haemorrhage / swelling may produce raised ICP in children. Management aims to prevent further rises in ICP and/or remove its cause (surgical evacuation of haematoma) whilst maintaining adequate cerebral perfusion.

Other measures in ICP management

• actively manage seizures according to Status epilepticus guideline. Post-traumatic seizure management may include use of second-line agents for stabilisation and avoidance of further seizures (e.g. Levetiracetam; Phenytoin); seek critical care advice. Current evidence does not support prophylaxis with second-line agents if a seizure has not occurred.
• provide adequate analgesia and sedation
• consider neuromuscular blockade (note that paralysis may mask seizure activity)
• avoid hyperthermia

Further considerations in head injury management

Pain management

• appropriate attention should be given to pain relief.

Anti-emetic therapy

Control of nausea and vomiting following a head injury with anti-emetic use (Ondansetron) should be strongly considered when the decision to CT scan has already been made. Its use prior to this decision remains under some debate, although use is increasing. Two US retrospective studies ^31,36 found that its use was not associated with an increase in missed diagnoses, however, both were not powered to definitively make this conclusion and the use of Ondansetron in children not scanned was very low (2%). One study found an increased representation rate with use.³¹

A secondary analysis of both PECARN and APHIRST studies, showed clinically significant intracranial injury was very uncommon when isolated vomiting was the only risk factor present, and that observation rather than immediate CT appears to be an appropriate management strategy in these children.^33-34 Careful history and examination should be undertaken to ensure that vomiting is truly an isolated risk factor, with consideration for close observation where required. <

Post Traumatic Amnesia (PTA) assessment^35,36

After closed head injury a return to GCS 15 does not always signify a return to normal cognitive function.³⁷ The abbreviated Westmead PTA Scale (A-WPTAS) to assess orientation and memory has been validated for use in adults ³⁷ with a GCS of 13-15 within 24 hours of a head injury resulting in confusion, disorientation, amnesia or brief loss of consciousness.³⁸

Children aged seven years and over are typically able to complete the A-WPTAS ³⁹ and use should be considered. Referral for admission, specialist team review or occupational therapy assessment according to local pathways is recommended if concerns persist or children fail to return to baseline behaviour.

For children < 7 years, or those not developmentally capable of A-WPTAS completion, referral should be considered if persisting concerning symptoms are present including inability to form new memories.

Escalation and advice outside of ED

Clinicians can contact the services below if escalation of care outside of senior clinicians within the ED is needed, as per local practices. Transfer is recommended if the child requires a higher level of care.

Critically unwell or rapidly deteriorating child

Non-critical child

Inter-hospital transfers

Disposition

When to consider discharge

A child may be safely discharged after a head injury if ALL of the following criteria are met:

• one of the following:
  • low risk, or intermediate risk with unremarkable period of observation
  • negative CT Scan and no significant persistent symptoms / signs
  • well child with cranial injury deemed suitable for discharge following neurosurgical review e.g. some non-depressed linear skull fractures without intracranial injury.
• GCS remains at 15
• no NAI concerns
• no concerns of serious alternate / concurrent diagnosis
• parental / carer concerns adequately addressed
• parent/carer can safely manage the child at home and can return in the event of deterioration. Time of day, language barriers and other demands on a caregiver’s time should be considered.

Written and verbal information should be provided to parents/carers on discharge, including on possible post concussive symptoms. Advice on return to sport and school should also be provided where indicated. Parents should be advised to seek medical review if any concerns arise.

Post Concussive Symptoms

Children experiencing mild traumatic brain injury are at risk of developing persistent post concussive symptoms, with a prevalence estimated at between 11 and 29%. ⁴⁰

A full discussion of post concussive symptoms, risk factors and management is beyond the scope of this guideline.  Symptoms include ongoing headache, neck pain, confusion/disorientation, reduced concentration/attention, memory issues, nausea, tiredness, emotional lability/changes, dizziness/vertigo or balance issues and sensitivity to external stimuli. Previously identified factors that may be predictive of prolonged post concussive symptoms are age 8-12 years, female sex, prior concussion symptoms of greater than one week duration, history of migraine or headaches, depression, anxiety, learning disability, ADHD and sleep disorders. ^35,36

Parents and carers should be provided with appropriate post discharge advice on graded return to normal activity, school and sport, with early GP review recommended if concerns arise. Individualised plans and adherence to specific sporting code guidelines may be required. Early specialist referral/follow up should be considered for children and adolescents experiencing prolonged or severe symptoms and those considered at higher risk of developing prolonged post concussive symptoms.

Additional resources can be found here ANZ Concussion Guidelines and the PREDICT binational head injury guideline.⁷

When to consider admission

Admission to an inpatient service and/or transfer is advised if children fail to meet discharge criteria; neuroimaging, if not already undertaken may be indicated.

Related documents

Guidelines

• Cervical spine injury

Factsheet

• Head injury
• ANZ Concussion Guidelines
  • What to expect in recovery
  • Returning to School
  • Safe Return to Sport
  • Headaches
  • Sleep and fatigue
  • Dizziness
  • Mood and Feelings
• Westmead PTA (A-WPTAS)