Head Trauma Protocols

Lisa Amir, MD,MPH, FAAPUnit of EmergencyMedicine, SchneiderChildren's Medical Centerof lsrael, Petah-Tikva,lsrael

The guidelines suggested by the Ministry of Health for evaluation and management of head

trauma have limited applicability to children. A number of risk factors for intra-cranial injury(lCI) do not appear on the list and several on the list require significant modification in orderto apply them to children. The guidelines also do not address the technical difficulties ofperforming a head CT in young children and do not consider the role of child abuse in headtrauma. Recent published guidelines for the evaluation of children after head trauma separatethem into two age groups, ( l) 0-2 years old and (2) 2- l8 years old.A number of historical elements are listed as indicating a higher risk of ICI. The patient with adepressed skull fracture, signs and symptoms of basilar skull fracture. focal f indings onneurologic examination or hypertension with bradycardia clearly requires an energent headCT and neurosurgical consultation. The presence of a VP shunt or bleeding diathesis alsoincreases the risk of intracranial bleeding and a head CT is indicated even in the absence ofother symptoms of ICI. In children 2-18 years old a GCS of less than l5 is associated with amuch higher r isk of ICI as compared to a GCS of l5 (3. .1) and a head CT should beperformed. Loss of consciousness, vomiting, headache, scalp lacerations and seizure have notbeen demonstrated to be definitive risk factors for ICI in older children (5.6.7.8t or in infants(1,9,10). Confusion or amnesia is di f f icul t or impossible to assess in infants and young

children. In children less than 2 years old, a bulging fontanelle (after head trauma) is highlysuggestive of ICLChildren less than two years old are at higher risk of ICI. The presence of a scalp hematomaon physical examination may be the most sensitive indicator of ICL Eighty to 1007r of infantswith scalp hematomas will have a skull fracture and l5-30%o of children with skull fractureshave ICI on head CT (l); no other sign or symptom has been shown to be a more consistentpredictor of ICI in children aged less than l2 months ( I I ). Parietal and temporal hematomasare frequently associated with skull fractures, whereas frontal hematomas are not (12).

Conversely. the absence of a scalp hematoma has a high negat ive predict ive value,particularly in children 12-24 months in age. However. there have been several cases of skullfracture in the absence of scalp hematomas reported in children less than l2 months of age(9,10). Skull radiographs should be obtained in children less than 2 years old with a scalphematoma and a CT performed if a skull fracture is found. Consideration should be given toobtaining skull radiographs in all children less than I year old even in the absence of a scalphematoma unless the mechanism of injury is trivial.Performance of a head CT in young children is complicated by the need for sedation. Aphysician skilled not only in administration of sedative agents but in the management of thepediatric airway in the case of sedation or head trauma complications must accompany thechild to the CT. This may be difficult or impossible in the evening or at night. If a head CTcannot be obtained, the patient must be observed in the hospital.Child abuse is not a rare cause of head injury in children and is not addressed in the HealthMinistry guidelines. The history is often absent or suggests minor blunt trauma while theseverity of injury suggests serious ICI. Retinal hemorrhages are present in 65-90Va of childrenwi th head t rauma resu l t ing f rom ch i ld abuse. Any ch i ld w i th suspec ted or p rovennon-accidental head trauma should have a fundoscopic examination and a head CT scanperformed, a social work consultation obtained and be admitted to hospital.The head trauma protocols currently in use at Schneider Children's Medical Center arepresented here. One protocol is for 0-2 year olds and the other for 2-18 year olds. Theprotocol for 0-2 year old children reflects the higher risk of ICI in younger children, thepossibil i ty of occult skull fracture in children less than one year old, incorporates thedifficulty of performing a head CT in asymptomatic children with skull fractures, and definestrivial head trauma. Both protocols suggest neurosurgical consultation prior to obtaining ahead CT only in quest ionable cases and expedi te ED discharge of asymptomat ic andminimally symptomatic children.

14 lsraeli Journal of Emergency Medicine Vol 3, No. 3, September 2003

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l .2 .3 .4.5 .

Head injury protocol tor 2-18 years old

s the child have:A clotting disorder or ITP?A VP shunt?GCS < 15?Basilar Skull Fracture?LOC for more than I minute?High blood pressure with bradycardia?More than 5 separate episodes of vomitingthat have continued more than 6 hours post

or vomfirng,/injury?

l. Stabilize ABCs2. Rigid cervical collar as needed3. Head CT without contrast4. Neurosurgical consultation

Consultation with a senior attendingas to the need for urgent head CT

Six hour observation in the ED

Neurosurgical consultation

Reasons to do a skull filml. Penetrating head injury2. Possibility of depressed skull fracture3. Possibility of foreign body4. Consider a sinus fracture

I

No

Are there any acute symptoms?1. LOC of less than I minute2. Short seizure at the t ime of the

injury3. Five or more episodes of vomiting4 . Headache tha t i s res i s tan t t o

tylenol - acamol5. Lethargy or restlessness6. Dangerous mechanism *

Release from the ED withrecommendations

Is there a suspicion of abuse ordecreased level of consciousnessas a result of drug use?

*Dangerous Mechanism ,l. Falling from a moving vehicle2. MVA at high speed3. Falling from more than 2 meters (6.4 feet)4 . An unwi tnessed fa l l tha t may be f rom a

dangerous mechanism5. Falling down more than 3 stairs I6. Car vs. bicycle I

16 lsraeli Journal of Emergency Medicine Vol 3, No. 3, September 2003

C I i n ica l Controvers ies

References

I . Schutzman SA. Barnes P, Dunham AC. et al. Evaluation and Management of Children Younger ThanTwo Yea rs O ld W i th Appa ren t l y M ino r Head T rauma : P roposed Gu ide l i nes . Ped ia t r i c s2001: I 07(5):983-993

2. Committee on Quality Improvement and AAP and Commissions on Clinical Policies and Research. andAAFP. The Management of Minor Closed Head Injury in Children. Pediatrics 1999: I (X(6): 1407- l4l5

3. Dietrich AM, Bowman MJ, Ginn-Pease ME, Kosnik E, King DR. Pediatric head injuries: can clinicalfactors reliably predict an abnormality on computed tomography? Ann Emerg Med 1993:22:1535-1540

4. Wang MY, Griffith P. Sterling J. McComb JG, Levy ML. A prospective population-based-study ofpediatr ic t rauma pat ients wi th mi ld a l terat ions in consciousness (Glasgow Coma Score of l3-14) 'Neurosurgery 2000146(5 ): I 093- I 099

5. Davis. Rt, Mullen N. Makela M, et al. Cranial Computed Tomography Scans in Children after MinimalHead Injury with Loss of Consciousness. Ann Emerg Med 1994:24(1):640-62t5

6. Schunk. JE. Rodgerson JD, Woodward GA. The Utility of Head Computed Tomographic Scanning inPediatric Patients With Normal Neurologic Examination in the Emergency Department. Ped Emerg Care1996 ;12 ( -1 ) : 160 -165'1

. Quayle KS. Jaffe DM. Kupperman N. et al. Diagnostic Testing for Acute Head Injury in Children: Whenare Head Computed Tomography and Skull Radiographs Indicated? Pediatrics I 997:99( 5 ):e I I

8 . Ramundo ML . McKn igh t T , Kempg J , e t a l . C l i n i ca l P red i c t o r s o f Compu ted Tomograph i cAbnormalities Following Pediatric Traumatic Brain Injury. Ped Ernerg Care 1995: I I ( I ): I -'l

9. Greenes DS. Schutzman SA. ClinicalJadicators of Intracranial Injury in Head Injured Infants. PediatricsI 999: I 04(4):86 l -867

10. Gruskin KD. Schutzman SA. Head Traunra in Children Younger than 2 Years: Are There Predictors forComplications? Arch Pediatr Adolesc Med 1999:153: l5-20

ll. Greehes DS. Schutzman SA. Occult Intracranial lnjury in lnfants. Ann Emerg Med 1998:32(6):680-68612. Greenes DS. Schutzman SA. Clinical significance of scalp abnormalities in asymptomatic head-injured

infants. Ped Emers Care 2001: l7(2):88-92

The Israeli Emergency Room Management ofHead Iniury GuidelinesEditorial

Zeev T. Feldm?fr,MDDepartment ofNeurosurgery,Sheba Medical Center,Tel-Hashomer, lsrael

Emergency room management of head injured patients is guided by the severity ofinjury.The severity of head injury is defined by the initial Glasgow Coma Scale score (GCS).

Patients with a GCS of 3-8 are severely injured, patients with scores of 9-13 have

moderate head injury and a score of l4- l 5 defines mild head injury.The management protocols for severe head-injured patients are very well defined (1,2).

After the initial resuscitation according to the ATLS protocols, all patients undergohead CT and are managed in, or should be transferred to, a neurosurgical trauma unitfor further care.Moderate head injury should be managed in the ER according to the same guidelines:

All patients should undergo head CT and be admitted for observation until they recoverto a GCS of 15.The highest load on the ER physician comes from managing patients with mild headinjury.Most ERs in Israel encounter dozens of mild head injuries a day and they compriseabout 80 Vo of all head injuries. Most patients with a mild head injury should bemanaged by the ER team without the assistance of neurosurgeons or neurologist andthe "The Israeli Guideline for Emergency Room Management of Head Injury" is mosthelpful in that respect.

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