EARLY MANAGEMENT OF HEAD INJURY IN CHILDREN

EARLY MANAGEMENT OF HEAD INJURY IN CHILDREN This guidance does not override the individual responsibility of health professionals to make appropriate decision according to the circumstances of the individual patient in consultation with the patient and /or carer. Health care professionals must be prepared to justify any deviation from this guidance. INTRODUCTION The guideline covers management of infants, children and teenagers suffering from a recent head injury. This guideline only refers to the acute management from arrival in A&E Acute Resuscitation if necessary; indications for admission for observation; indications for discharge. Although most children sustain relatively minor head injury and are either discharged direct from A&E or admitted for observation without sequelae the guideline follows the triage system of dealing with the most serious cases first. The list of children subject to a child protection plan is checked for ALL children who are assessed in A&E. MIU Kidderminster follow the section in the NICE guideline Community Health Services and NHS minor Injury Clinics Head injury maybe associated with multiple injuries. It is not the aim of this guideline to cover management of all such injuries but to emphasise that such injuries may contribute to secondary brain injury if not properly managed. It has been agreed to use BCH guideline for CT scan. I have recently reviewed the guideline with BCH A/E consultant in relation to CT scan and they continue as per this guideline. They use a cradle mattress for young children who need CT as it may offset the need for sedation. NICE are currently reviewing HI guideline and there will probably be a new guideline later this year. Potential incorporation of new information arising from an ongoing study, the Risk Adjustment in Neurocritical Care (RAIN) Study co-ordinated by ICNARC (likely to be published by 2013). The reason why some Trusts are not following the NICE guideline for CT: It leads to a greater number of CT when observation in some cases is good enough. GA or Sedation may be needed for CT of young child and child is therefore admitted anyway. The best available evidence suggests that paediatric CT will result in increased lifetime risks of cancer compared to adult CT due to both the higher radiation doses currently delivered to children and their increased sensitivity to radiation-induced cancer over a longer life span. New CT scanners may reduce this risk. THIS GUIDELINE IS FOR USE BY THE FOLLOWING STAFF GROUPS : Appropriately trained medical staff in A&E and Paediatrics. See Competencies required section in guideline. Dr M Hanlon Approved by Accountable Director on: Lead Clinician(s) 08 th June 2015 Extended by Trust Management Committee on: 22 nd July 2015 This guideline should not be used after end of: 08 th September 2016 WAHT-PAE-041 Page 1 of 26 Version 3.2

Key amendments to this guideline Date Amendment Approved by: 19.12.05 Approved by Dr Newricks on behalf of the Clinical Effectiveness Dr Newrick Committee 18.11.09 Adoption of BCH guidance on CT scans on children Incorporation of NICE guidance algorithms for management. M Hanlon / Paediatric CG 18.04.13 Reasons for not following NICE CT guidelines. KIDS retrieval team. Emphasise if CT guideline not followed must discuss with consultant. Emphasise importance of documenting all vomits. Awareness that pituitary dysfunction may result from head injury. Appendix 4 Nursing care plan on the ward for monitoring head injury. Altering level of consciousness included as a worrying clinical sign in nurse documentation. 09.06.15 Document extended for 3 months whilst being transferred into treatment pathway format 14.09.15 Document extended for 12 months as per TMC paper approved on 22 nd July 2015 Committee M Hanlon / Paediatric CG Committee Dr Gallagher TMC WAHT-PAE-041 Page 2 of 26 Version 3.2

EARLY MANAGEMENT OF HEAD INJURY IN CHILDREN DEFINITION Head injury can be defined as any alteration in mental or physical functioning relating to a blow to the head. Loss of consciousness does not need to occur. SIGNIFICANCE About 500,000 children per year attend A&E in the UK with head injury. The mortality is 6-10/100,000 so physicians rarely see life threatening head injury. In general children have a remarkable capacity for physical recovery. It is increasingly recognised from neuro-rehabilitation research that children who sustain even mild to moderate head injury can have subtle but significant cognitive deficits that can affect educational achievement. Pituitary dysfunction is a potential risk after traumatic brain injury. Prompt and effective early assessment and treatment is essential for all patients presenting to A&E. In the past decade several rules for assessing clinical severity in adults have been developed but the quality of studies on children with Head Injury have been very poor (NICE 2003). The advice regarding children in the NICE guidelines 2007 on Head Injury is based on the CHALICE study. This study, the world s largest prospective study of 22,772 children (<16 year old) with head injury from 10 UK centres, devised the CHALICE Rule. This Rule has a 98% sensitivity and 87% specificity for prediction of clinically significant Head Injury. However it has been agreed we will use the Birmingham Children s Hospital guideline for CT scan rather than NICE guideline. This decision is made following consultation with PICU and A&E at Birmingham Children s Hospital and the consensus of Professionals from Worcestershire Acute Hospitals Trust who reviewed this guideline. NB. Consider Non Accidental Injury particularly in non-ambulant children. Check for Child Protection Plan. Competencies required - Training in basic life support. - Resuscitation team trained in APLS, EPLS - All those involved in the assessment b of infants and children with head injury should be trained to detect non-accidental injury. This includes having knowledge of child development. - Observations of patients with head injury should only be carried out by professionals competent in the assessment of head injury and assessing the presence or absence of risk factors for significant head injury. (CHALICE Rule) Patients covered - The guideline covers management of infants, children and teenagers suffering from a recent head injury. This guideline only refers to the acute management from arrival in A&E Acute Resuscitation if necessary; indications for admission for observation; indications for discharge. WAHT-PAE-041 Page 3 of 26 Version 3.2

- Although most children sustain relatively minor head injury and are either discharged direct from A&E or admitted for observation without sequelae the guideline follows the triage system of dealing with the most serious cases first. - The list of children subject to a child protection plan should be checked for ALL children who are assessed in A&E. - MIU Kidderminster follow the section in the NICE guideline Community Health Services and NHS minor Injury Clinics - Head injury maybe associated with multiple injuries. It is not the aim of this guideline to cover management of all such injuries but to emphasise that such injuries may contribute to secondary brain injury if not properly managed. GUIDELINE See references for basis for guideline. This guideline refers to the Status Epileptics guideline and the Child Protection Protocol and Safeguarding Children Policy. The list of children subject to a child protection plan should be checked routinely for all children who attend A&E. If concerned about possible child abuse the Consultant Paediatrician on call should be informed. (See child protection protocol) Appendix 1 Glasgow Coma Score for 4-15year old and < 4 year old. Appendix 2 Head Injury Proformas. For use in A&E. Appendix 3 Head Injury Observations For use in A&E. Appendix 4 Nursing Care plan for Head Injury - For use on the ward. Causes of Head Injury: The commonest mechanisms are: (in order with the commonest first) RTAs Pedestrians Bicycle Accidents Passengers in Motor Vehicles Falls NB. Consider Non Accidental Injury particularly in non-ambulant children WAHT-PAE-041 Page 4 of 26 Version 3.2

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ASSESSMENTMENT /EXAMINATION - Resuscitation using ABCDE as per APLS guidelines. - Assessment of significance of head injury includes mechanism of injury. NB Contact on call if Non Accidental Injury suspected. See Child Protection Protocol. - Complete Head Injury Proforma. (See below) The Primary Survey - Use GCS can use Modified GCS for children < 4year old but it is not validated. It can be helpful to ask parents opinion of child s level of response. - Pupils examined for: Size and reactivity to light Sluggish responses occur prior to inequality Pupil inequality is only significant if > 1mm. 10% of the normal population may have this difference normally. Transient post-traumatic blindness can occur. If there is a dilated non-reactive pupil it represents an ipsilateral haematoma until proven otherwise. - Listen Normal cry is unusual in severe head injury. High-pitched cry can mean significant head injury - Cervical collar if appropriate. The Secondary Survey - N.B. Top to Toe examination to identify all injuries. Include log roll. - Look Identify bruises Lacerations Penetrating injury or depressed skull fractures. Racoon Eyes (Like black eyes confined to the orbital margins) Battle s sign (Bruising with swelling over the mastoid process) WAHT-PAE-041 Page 6 of 26 Version 3.2

Otorrhoea or Rhinorrhoea Clear discharge. Dip for glucose. If present it is probably CSF Haemotympanum (Blood behind the tympanic membrane) Sclera Haemorrhage (Difficult to see with an ophthalmoscope) Retinal haemorrhage (Seen in Non-accidental injury) - Feel Fontanelle Lacerations Boggy swelling Base of skull fracture Identify fractures Depressed skull fractures Penetrating injury - Use the Glasgow Coma Scale (see below) to assess the conscious level. This should be repeated frequently. - Re-examine the pupils and assess the vision as transient post-traumatic blindness can occur. If there is a dilated non-reactive pupil it represents an ipsilateral haematoma until proven otherwise. - The peripheral nervous system should be examined to identify lateralising signs in the limbs and the face. Lateralising signs indicate an intracranial lesion. Cerebellar signs are impossible to elicit in an unconscious patient. Beware absent limb movements may equal spinal cord injury. WAHT-PAE-041 Page 7 of 26 Version 3.2

INVESTIGATIONS Radiography Guideline for CT Scan of the Head-Injured Child in ED A CT scan should be requested only after discussion with the ED consultant Child with Head Injury Resuscitation Indications for immediate CT Scan of the head (should be within 1 hour of arrival in ED) Indication Comments GCS 12/15 or less on Hospital assessment Adequate resuscitation must be ensured Focal neurological signs Tense fontanelle or suture diastasis In baby before fontanelle closure has completed Post-traumatic seizure Open skull fracture Depressed skull fracture Base of skull fracture Penetrating skull injury Suspected or confirmed Suspected or confirmed Haemotympanum, panda eyes, CSF rhinorrhoea/otorrhoea Battle s sign (post-auricular bruising) with fracture on SXR or altered neurological examination Indications for urgent CT Scan of the head (as soon as lack of improvement becomes apparent) Indication Comments GCS 13 or 14 two hours after resuscitation* Persistence of: a. Headache* b. or vomiting* c. or irritability* Beware of fluctuating level of consciousness a. After adequate resuscitation, >6hrs postinjury b. Discuss at 3 discrete episodes or continued vomiting 4 hrs post-injury Consider CT within 8 hours, admission and observation may suffice Significant mechanism of injury (e.g. RTA/ fall) with GCS <15 Coagulopathy Amnesia Haemophilia/ patient on anticoagulant Of greater than 30 minutes prior to injury Documented LOC at scene *In many of these cases, admission without CT may be preferable if a general anaesthetic would be required to achieve CT, only to result in post-anaesthetic admission anyway. NB Discuss with senior doctor. WAHT-PAE-041 Page 8 of 26 Version 3.2

Bloods - where appropriate (e.g. GCS<8, deterioration GCS, other injuries) include: FBC Coagulation U&E Glucose Arterial PaO2 and PaCO2. Cross match Urine - Toxicology screen if suspicions of drug misuse. MANAGEMENT ABCDE Assessment and investigations as noted above. Cervical spine stabilisation if necessary. WAHT-PAE-041 Page 10 of 26 Version 3.2

Patients who are to be transferred and have either bilateral fractured mandible or base of skull fracture or deteriorating GCS or have had a seizure need intubation and ventilation prior to transfer. If GCS is 9 or greater secure the airway with basic airway manoeuvres. If the child is not intubated then treat with high flow O 2 with re-breathe mask providing 90-95% inspired O 2 concentrations. WAHT-PAE-041 Page 11 of 26 Version 3.2

Hypotension from Hypovolaemia - This under-perfuses the brain. Resuscitate with fluids to a normal blood pressure and heart rate. - Fluid overload can cause or worsen cerebral oedema but is unlikely if CVP is monitored and fluid boluses are given according to clinical response.. - Control bleeding from scalp wounds. - Assess for other causes of blood loss e.g. intra-abdominal injuries. Surgical assessment and may need urgent CT abdomen with CT head. Analgesia Do not be afraid to give this as pain upsets the child and raises intra-cranial pressure. IV narcotics are safe. N.B. If standard doses are given any alteration in conscious level is due to head injury and not narcotic. Although BNF says opioids contraindicated in head injury PICU and Neurosurgery at Birmingham Children s Hospital would not agree. Regional and local anaesthetic blocks are helpful. Deteriorating Conscious Level This needs prompt treatment. Tilt the trolley to 30 head-up position. After intubation and ventilation consider IV mannitol (0.5-1.0g/kg). Consult the neurosurgical centre first as they have their own policies. Steroids have no place in acute head injury management Fitting A brief convulsion post head injury might be of little significance. If it is prolonged or focal in nature it is more sinister. After 5 minutes of fitting an anticonvulsant should be started. Status epilepticus protocol should be followed Scalp Lacerations These are treated by cleaning and debridement. The wound is closed with sutures staples or tissue glue. Bleeding from scalp wounds can sometimes be difficult to stop, under sew or clip the vessel if pressure or simple suture fails to stop bleeding. Remember scalp laceration in infants and babies may cause significant blood loss +/- hypotension. WAHT-PAE-041 Page 12 of 26 Version 3.2

TRANSFER Children who need ventilation will be transferred to a neurosurgical unit with Paediatric ITU facilities. KIDS Retrieval Team from Birmingham Children Hospital 0300 200 1100. They will organise a 3 way conversation with the neurosurgical team. The decision may be that Worcester/Redditch transfer the child with anaesthetic cover to comply with the Golden hour. The NICE guidelines recommend transfer should be undertaken by staff experienced in the transfer of critically ill children. Otherwise the retrieval team, if available, will come for transfer. If no neurosurgical bed at Birmingham Children Hospital then the KIDS team will advise on availability of beds in other Neurosurgical Units. Bristol PICU 0117 3428437/ Fax 348538. John Radcliffe PICU 01865 220632/633 / Fax 222061. Parents should be kept informed of progress with resuscitation and transfer plan. They should be given directions/maps and hospital contact phone numbers. WAHT-PAE-041 Page 13 of 26 Version 3.2

MONITORING TOOL How will monitoring be carried out? Clinical Audit Who will monitor compliance with the guideline? Paediatric Clinical Governance Committee STANDARDS % CLINICAL EXCEPTIONS Appendix 2 and 3 should be used by A/E 100% Appendix 4 should be used if admitted. 100% If patient had a scan - check correct indications 100% If no scan check correct indications. 100% If no scan but indicated check the case was discussed 100% with consultant. Was NAI considered in non-ambulant child 100% Was register checked for Child Protection Plan 100% Discharge was patient fit for discharge. 100% REFERENCES Archives of Diseases in Childhood CHALICE Study 2006 91:885-891 Advanced Life Support Group. APLS the practical approach 3 rd edition Paediatric Emergency Medicine; A Comprehensive Study Guide. Ahrens W, Lelyveld S, Schafermeyer R, Strange G. McGraw-Hill Health 1995 Clinical Manual of Emergency Paediatrics Crain & Gershel. McGraw-Hill Edu. 4 th Ed 2002 NICE Head Injury Guidelines, 2007. SIGN Guidelines. www.pier.ac.uk/guidelines WAHT-PAE-041 Page 19 of 26 Version 3.2

Appendix 1 Glasgow Coma Scale. Glasgow Coma Scale (4-15 years) Paediatric Coma Scale (<4 years) Response Score Response Score EYES EYES Open spontaneously Verbal Command React To Pain No Response 4 3 2 1 Open spontaneously React To Speech React To Pain No Response 4 3 2 1 BEST MOTOR RESPONSE Obeys verbal command. Painful Stimulus Localises Pain Flexion With Pain Flexion Abnormal Extension No Response BEST VERBAL RESPONSE Oriented and Converses Disorientated and converses Inappropriate Words Incomprehensible Sounds No Response 6 5 4 3 2 1 5 4 3 2 1 BEST MOTOR RESPONSE Spontaneous or obeys verbal commands. Painful Stimulus Localises Pain Withdraws In Response To Pain Abnormal Flexion To Pain (Decorticate Posturing) Abnormal Extensor To Pain (Decerebrate Posturing) No Response BEST VERBAL RESPONSE 6 5 4 Smiles, oriented to sounds, follows objects, interacts. 6 Crying (baby) Consolable Inconsistently consolable. Inconsolable No response Interacts (child) Inappropriate Moaning Irritable No response 3 2 1 4 3 2 1 Note The Glasgow Coma Scale is difficult to apply to the young (under 5 years) child. Although modifications exist, great care needs to be taken with its interpretation and this should be done by those with experience in the management of the young child. The paediatric Glasgow Coma Scale has not been validated. WAHT-PAE-041 Page 20 of 26 Version 3.2

Appendix 2 Worcestershire Acute Hospitals NHS Trust Paediatric Head Injury Proforma Age 0-16 years HISTORY FROM PATIENT: IF NOT, BY WHOM MECHANISM / HISTORY OF INJURY: Patients name DOB Hospital Number: Injury Exam n DOCTOR: Date: Time: Date: Time: Other injuries: Witnessed l.o.c > 5 mins Amnesia [antegrade >30 mins] Abnormal drowsiness/fluctuating GCS 3/more discrete episodes vomiting (record these) or persistent vomiting 4 hours after injury Clinical suspicion of NAI Post-traumatic seizure [No PMH epilepsy] Age >1yr: GCS<14 2 hours post resuscitation Age <1yr: GCS<15 on assessment in A&E Suspicion of open or depressed skull fracture or tense fontanelle Any sign of base of skull fracture Focal neurological deficit Age <1yr: presence of bruise, swelling, or laceration >5 cm on head Dangerous mechanism of injury* * High speed road traffic accident: pedestrian, cyclist or vehicle occupant Fall from >1m or 5 stairs High speed injury from a projectile or object Yes No Details TETANUS covered needs booster needs course not known RTA Fall Pedestrian School Home Assault Play DISCUSS NEED FOR CT IMMEDIATELY with a senior doctor if any of above positive If not for CT admit and document reasons why. PRE-EXISTING DISORDERS ALCOHOL HOW MUCH PICTURES DRUGS TYPE WAHT-PAE-041 Page 21 of 26 Version 3.2

Appendix 3 HEAD INJURY OBSERVATIONS At least one full set must be completed TIME hrs R EYES spontaneous 4 E OPEN speech 3 S to voice 2 P to pain 1 O BEST orientated 5 N VERBAL confused 4 S RESPONSE inappropriate words 3 I Incomprehensible sounds 2 V None 1 E BEST obeys commands 6 N MOTOR localises pain 5 E RESPONSE normal flexion 4 S abnormal flexion 3 S abnormal extension 2 none 1 PUPILS L M I O M V B E M E N T Total Glasgow Coma Score 15 RIGHT Size (mm) Reaction LEFT Size (mm) Reaction Normal power ARMS Mild weakness Severe weakness Extension No response Normal power LEGS Mild weakness Severe weakness Extension No response Eyes closed by swelling = C ET tube or tracheotomy = E Dysphasia = D Record the best arm response Paralysed = P + = reacts - = no reaction C = eyes closed SL = sluggish Pupil Scale 1 2 3 4 5 6 7 Resp rate O2 sats Revised trauma score Nurses initials Time Hrs Blood Pressure 230 220 210 200 190 180 170 160 150 140 130 120 110 100 90 80 70 60 50 40 30 Temp 0 C 40 39 38 37 36 35 34 33 32 31 30 Neurological examination yes no yes no Evidence of dysphasia Hearing loss Inappropriate/abnormal behaviour Evidence of abnormal gait Loss of eye movement/visual Evidence of abnormal fine movement disturbance EVIDENCE OF INJURY TO NECK: Y: N: Details Description of injuries: HEAD INJURY TREATMENT CT SCAN: RESULTS OF SCAN: D/W NEUROSURGEONS: Y: N: Abnormality on imaging: GCS not 15 after imaging CT unavailable: Continuing worrying signs E.g. Vomiting/ severe headache Other concerns E.g. Alcohol, NAI, CSF leak IF YES TO ANY ADMIT yes no MANAGEMENT: Tick as appropriate: HOME WITH HEAD INJURY INSTRUCTIONS: RESPONSIBLE PERSON AT HOME: HEAD INJURY ADVICE EXPLAINED AND GIVEN ADMIT FOR OBSERVATION: OTHER TREATMENT EG. sutures, tetanus, antibiotics Diagnosis: Doctors signature: WAHT-PAE-041 Page 22 of 26 Version 3.2

Appendix 4 WAHT-PAE-041 Page 23 of 26 Version 3.2

CONTRIBUTION LIST Key individuals involved in developing the document Name Designation Dr M Hanlon Circulated to the following individuals for comments Name Designation Dr A Short Clinical Director/ Dr N Ahmad Dr M Ahmed Dr T Bindal Dr D Castling Dr Tom Dawson Dr A Gallagher Dr M Hanlon Dr K Nathavitharana Dr C Onyon Dr Baylon Kamalarajan Dr Liza Harry Dr J E Scanlon Dr V Weckemann Dr S Crawford Consultant A&E Dr J France Consultant A&E Dr C Hetherington Consultant A&E Dr I Levett Consultant A&E Dr R Morrell Consultant A&E Dr G O Byrne Consultant A&E Dr B Williams Consultant A&E Dr J Berlet Consultant Anaesthetist Dr T Smith Consultant Anaesthetist Dr L Leong Consultant Anaesthetist Dr G Sellors Consultant Anaesthetist D Picken Matron, Paediatrics M Chippendale Specialist Nurse N Pegg Ward Manager, Riverbank Rebecca Delves Sister Riverbank L Greenway Ward Manager, Ward 1 S Courts Orchard Services Manager P Byrne Matron A&E S Smith Matron A&E G Bradford Childrens Nurse, A&E Christine Parry Reece Sister and Childrens Nurse, A&E N Meddings Sister and Childrens Nurse, A&E Sarah Scott Clinical Pharmacists A Crohill Named Nurse for Safeguarding Children Circulated to the heads of department/chair of the following committee s / groups for comments Name Alison Smith Chris Doughty Dr U Udeshi Committee / group Medicines Safety Committee Senior Resuscitation Officer Clinical Director Radiology WAHT-PAE-041 Page 26 of 26 Version 3.2