MIR HEAD INJURY CLINICAL PRACTICE GUIDELINES GOALS Reinforce decision to transfer to Level 1 trauma center if major head injury or polytrauma. Guide decision to admit at local hospital versus transfer to Pediatric Trauma Center in minor head injury. Identify patients that do not need CT scan. List indications for observation at local hospital. DEFINITIONS Minor Head Injury*: MHI is defined as injury within the past 24 hours associated with loss of consciousness, definite amnesia, witnessed disorientation, persistent vomiting more than one episode) or persistent irritability (in a child <2 years of age) in a patient with a Glasgow coma scale of 13-15. Concussion*: Alteration in mental status that may or may not be associated with loss of consciousness with no focal neurological deficits following head injury. *Note: The term concussion has been used interchangeably with mild head injury (MHI) or mild traumatic brain injury (TBI) Severity of head injury based on GCS Severe head injury may be defined as that resulting in a GCS score < 9. Moderate head injury is associated with a score of 9 to 12. Mild head injury is associated with a score of 13 15 Types of Primary brain injury : 1) Contusions. 2) Intracranial bleeding. 3) Fractures. 4) Diffuse axonal injuries. Cerebral contusions are bruises of the cerebral cortex that can occur as a result of: Direct injury (coup injury) Injury at the opposite point where the relatively mobile brain strikes the bone on the other side (contrecoup injury) Diffuse axonal injury refers to damage at the gray-white matter junction, seen with acceleration-deceleration injury.
EPIDEMIOLOGY Traumatic brain injury (TBI) is a leading cause of death and disability in the United States. In the US, head trauma in individuals aged 18 years and younger results in about 7400 deaths, over 60,000 hospital admissions, and over 600,000 emergency department visits every year. HISTORY The possibility of child abuse must be kept in mind. This is suggested when the given history is not proportional to the severity of injury (i.e. children rarely experience a serious injury when they fall out of bed.) Indicators of severe head trauma: Prolong loss of consciousness Seizures Amnesia for the circumstances surrounding the injury Focal neurologic deficits Persistent & severe vomiting. Persistent clouding of consciousness. Duration of posttraumatic amnesia (inability to generate new memories after head injury). CONCUSSION/ Mild traumatic brain injury GCS score of 13 15 and no focal neurologic findings. Most concussion patients can be discharged home after a period of evaluation and observation, if they are back to baseline. Thorough evaluation is important, if focal signs will need further workup. Physician should advise parents regarding the child s return to sports. Guidelines for assessment and management of concussion available from the American Academy of Neurology.
GRADING OF CONCUSSION: Guidelines for the Management of Sport-Related Concussion
HEAD INJURY ALGORITHM (AGE UNDER 2 YEARS) Child presents with head injury ABC D - stabilize Unstable multiple trauma /high impact injury e.g. MV vs. pedestrian / Fall >10 feet or 2-3 times the height of child Bicycle thrown/run over or with significant (>20mph) impact Bleeding diathesis Suspected non-accidental injury Yes Penetrating injury Presence of drugs /alcohol/ Burn injury GCS <14 at 2 hours after injury Follow trauma guidelines (see Mass. statewide trauma point of entry plan) Use individualized patient management Transfer to pediatric trauma center. Head Imaging at Level 1 pediatric trauma center (such as Tufts Medical Center) HIGH RISK Depressed mental status (GCS <15 two hr after injury Focal neurological findings Signs of open, depressed or basilar fracture Post-traumatic seizure Subgaleal hematoma, especially if large, boggy or nonfrontal Irritability Bulging fontanel Vomiting 5 times or > 6 hr Loss of consciousness > 3 min Head CT Positive CT findings If intracranial bleed, fracture, space occupying lesion, concerns of raised ICP then transfer to pediatric trauma center INTERMEDIATE RISK Vomiting 4 times LOC < 1 min History of lethargy or irritability, now resolved Concerns about child's current behavior (irritability, drowsy) Non-acute skull fracture (> 24 48 hr old) Dangerous mechanism of injury (elevation 3 ft or 5 stairs, fall from bicycle with no helmet) Unwitnessed trauma Hourly neurological observations at local hospital for 4 6 hr. Is there Neurological deterioration? Do Symptoms remain after 8 12 hr? Negative CT findings Is there concerning behavior? Inconclusive assessment? May observe at local hospital for extended monitoring (8-12 hours) or until return to baseline. If not returning to baseline after 12 hours, discuss with Neurology, consider Re-imaging CT/MRI LOW RISK Low energy mechanism No signs or symptoms > 2 hr since injury and normal behaving Discharge home with concussion advice
HEAD INJURY ALGORITHM (AGE OVER 2 YEARS) Child presents with head injury ABC D - stabilize Unstable or multiple trauma / high impact injury e.g. MV vs. Yes pedestrian / fall >10 feet or 2-3 times the height of child Bicycle thrown/run over or with significant (>20mph) impact Bleeding diathesis No Suspected non-accidental injury Penetrating injury GCS < 14 at 2 h after injury Suspected open or depressed skull fracture Any sign of basilar skull fracture (bleed / CSF leak from nose /ear) Post-traumatic seizure Focal neurological findings 5 episodes of vomiting Amnesia before impact > 30 min Dangerous mechanism of injury and some LOC or amnesia since injury Follow trauma guidelines (see Mass. statewide trauma point of entry plan) Use individualized patient management Transfer to pediatric trauma center. Head Imaging at Level 1 pediatric trauma center (such as Tufts Medical Center) Head CT Positive CT findings If intracranial bleed, fracture, space occupying lesion, concerns of raised ICP then transfer to pediatric trauma center May observe at local hospital for extended monitoring (8-12 hours) or until return to baseline. Observe: Hourly neurological observations for 6 8h Is there neurological deterioration? Do symptoms remain after 8 12 h? Negative CT Concerning behavior? Inconclusive assessment? If not returning to baseline after 12 hours, discuss with Neurology, consider Re-imaging CT/MRI Discharge home with concussion advice
REFERENCES 1. Atabaki, S.M. et al., 2008. A clinical decision rule for cranial computed tomography in minor pediatric head trauma. Archives of pediatrics & adolescent medicine, 162(5), pp.439 45. 2. Brain, T. & Edition, A et al. Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents-Second Edition. Pediatr Crit Care Med 2012 Vol. 13, No. 1 (Suppl.) 3. Osmond, Martin H, Terry P Klassen et al. 2010. CATCH: a Clinical Decision Rule for the Use of Computed Tomography in Children with Minor Head Injury. CMAJ: Canadian Medical Association Journal 182 (4) (March 9): 341 8. 4. Lyttle MD, Crowe L, Oakley E et al, Comparing CATCH, CHALICE and PECARN clinical decision rules for paediatric head injuries. Emerg Med J. 2012 Oct;29(10):785-94. 5. Nigrovic, Lise E et al. Prevalence of Clinically Important Traumatic Brain Injuries in Children with Minor Blunt Head Trauma and Isolated Severe Injury Mechanisms. Archives of Pediatrics & Adolescent Medicine 166 (4) (April 2012): 356 61. 6. Herring SA, Cantu RC, Guskiewicz KM, et al American College of Sports Medicine. Concussion (mild traumatic brain injury) and the team physician: a consensus statement--2011 update. Med Sci Sports Exerc. 2011 Dec; 43(12):2412-22. 7. Kuppermann, Nathan, James F Holmes, Peter S Dayan et al. Identification of Children at Very Low Risk of Clinically-important Brain Injuries after Head Trauma: a Prospective Cohort Study. The Lancet 374 (9696): 1160 1170. 8. Maguire, Jonathon L, Kathy Boutis, Elizabeth M et al. Should a Head-injured Child Receive a Head CT Scan? A Systematic Review of Clinical Prediction Rules. Pediatrics 124 (1) (July 2009): e145 54. 9. http://www.mass.gov/eohhs/docs/dph/quality/hcq-circular-letters/trauma-hospitaldestinations.pdf 10. Mendelow, a David, Jake Timothy, James W Steers, et al. Management of Patients with Head Injury. Lancet 372 (9639) (August 23 2008): 685 7. 11. Eisenberg MA, Andrea J, Meehan W, Mannix R. Time Interval Between Concussions and Symptom Duration. Pediatrics. 2013 Jun 10. Disclosure: Practice guidelines do not necessarily apply to every patient. A provider s clinical judgment is essential. As always, clinicians are urged to document management strategies. Floating Hospital for Children at Tufts Medical Center contact: Raj Kerur, M.D., Steven Hwang, M.D., Dan Hale, M.D. dhale@tuftsmedicalcenter.org Last updated: 27 December 2013
Statewide Trauma Field Triage Criteria and Point-of-Entry Plan for Adult and Pediatric Patients TE: Additional pediatric-specific information can be found below. Early notification of the receiving facility, even from the scene, will enhance patient care. Preconfigured response initiated/appropriate pre-arrival instructions given based on Local EMD Perform Primary Survey 1) Does the patient have: Uncontrolled airway? Cardiopulmonary arrest? 2) Does the patient have: Persistent loss of consciousness, decreasing level of consciousness, or GCS < 13? Severe respiratory distress (rate < 10 or > 29) or respiratory rate out of range for age? (see next page for pediatric) Flail Chest? Systolic blood pressure < 90 in adults or < 70 to 90 in pediatrics? (see next page) Open or depressed skull fractures? Penetrating trauma to head, neck, torso, or extremities proximal to elbow and knee? Tender or rigid abdomen? Pelvic fractures (excluding simple fractures) Paralysis or motor/sensory deficit? 2 or more proximal long bone fractures or any open proximal long bond fracture? Amputations, with exception of distal digits? Critical burns? (see note). IMMEDIATELY LIFE THREATENING CRITICAL TRAUMA Transport immediately to nearest hospital Transport to: If < 20 minutes by ground, transport to a level 1 or 2 trauma center (level 1 or 2 pediatric trauma center for pediatrics). If < 20 minutes by ground from a level 3 trauma center and no level 1 or 2 (level 1 or 2 pediatric trauma center for pediatrics) within 20 minutes, transport to a level 3 and/or consider air ambulance, if available. If > 20 minutes by ground to a level 1, 2 or 3 trauma center, activate air ambulance, if available. If patient arriving by air ambulance, transport to closest level 1 trauma center with helipad facilities. If > 20 minutes by ground to a level 1, 2 or 3 trauma center and no air ambulance available, transport to the nearest system hospital. At all times contact with Medical Control re: destination is encouraged 3) Is there evidence of mechanism of injury and/or high energy impact? Ejection from the vehicle Death in same passenger compartment Extrication time > 20 minutes Falls > 15 feet, or > 3 times child s height High speed crash Auto vs. pedestrian, or auto vs. bicycle with significant impact Pedestrian thrown or run over Motorcycle crash > 20 mph, or with separation of rider from bike Near drowning Transport to closest appropriate System Hospital CRITICAL BURNS Partial thickness burns > 10% BSA Extensive burns involving face, genitalia, perineum 3 rd degree burns in any age group Electrical Burns, including lightning injury Chemical Burns Inhalation Burns Any burn in combination with trauma Interfacility Transfer as necessary Co-morbid Factors which may increase severity of injury: Age < 5 or > 70 Significant cardiac or respiratory disease Pregnancy Insulin dependent diabetes, cirrhosis, morbid obesity Immunosuppressed Bleeding disorder or currently taking anticoagulants Consider medical control re: Destination hospital. ** Transport to Level 1, 2, or 3 Trauma Center if no medical control. If > 20 minutes away, go to closest System Hospital. ** At all times, EMS providers are encouraged to contact medical control for direction in triage of trauma patients. Effective 3/4/2010
2001 GLASGOW/COMA SCALES Glasgow Coma Scale Adelaide Pediatric Coma Scale Coded Value Coded Value Eye Opening Eye Opening Spontaneous 4 Spontaneous 4 To speech 3 To speech 3 To pain 2 To pain 2 None 1 None 1 Best Verbal Response Best Verbal Response Oriented 5 Oriented 5 Confused 4 Words 4 Inappropriate words 3 Vocal sounds 3 Incomprehensible sounds 2 Cries 2 None 1 None 1 Best Motor Response* Best Motor Response* Obeys 6 Obeys commands 5 Localizes 5 Localizes pain 4 Withdraws 4 Flexion to pain 3 Abnormal flexion 3 Extension to pain 2 Extensor response 2 None 1 None 1 Total 3-14 Total 3-15 Normal Aggregate Score 0-6 months 9 6-12 months 11 1-2 years 12 2-5 years 13 > 5 years 14 Eye Opening Verbal Response Motor Response* Modified Glasgow Coma Scale for Infants Child Infant Score Spontaneous Spontaneous 4 To verbal stimuli To verbal stimuli 3 To pain only To pain only 2 No response No response 1 Oriented, appropriate Coos and babbles 5 Confused Irritable cries 4 Inappropriate words Cries to pain 3 Incomprehensible words or non specific sounds Moans to pain 2 No response No response 1 Obeys commands Moves spontaneously and purposefully 6 Localizes painful stimulus Withdraws to touch 5 Withdraws in response to pain Withdraws in response to pain 4 Flexion in response to pain Decorticate posturing (abnormal flexion) in response to pain 3 Extension in response to pain Decerebrate posturing (abnormal extension) in response to pain 2 No response No response 1 * If the patient is intubated, unconscious, or preverbal, the most important part of this scale is motor response. This section should be carefully evaluated. Modified from Davis RJ, et al. Head and spinal cord injury. In: Rogers MC, ed. Textbook of Pediatric Intensive Care. Baltimore, Md: Williams & Wilkins; 1987. James H, Anas N, Perkin RM. Brain Insults in Infants and Children. New York, NY: Grune & Stratton; 1985. Morray JP, et al. Coma scale for use in brain-injured children. Crit Care Med. 1984; 12:1018. Reproduced from Hazinski MF. Neurologic disorders. In: Hazinski MF, ed. Nursing Care of the Critically Ill Child. 2 nd ed. St. Louis, Mo: Mosby Year Book; 1992. FILE: Handbook Glasgow Coma Scales
2001