Head trauma (peds): Difference between revisions
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''This page is for the general approach to <u>pediatric</u> head trauma; see [[head trauma (main)]] for adult patients.''
==Background==
==Background==
*TBI in the pediatric population is rare, occuring in 0.9% of the 42,412 [[PECARN head trauma rule|PECARN population]]
*TBI in the pediatric population is rare, occuring in 0.9% of the 42,412 [[PECARN head trauma rule|PECARN population]]
*[[PECARN head trauma rule|PECARN rules]] have become standard of care
*The primary ED question is whether or not to perform a head CT to assess for intracranial hemorrhage
**Cranial ultrasound is a poor screening tool for bleeding<ref>Elkhunovich, M., Sirody, J., McCormick, T., Goodarzian, F., & Claudius, I. (2018). The Utility of Cranial Ultrasound for Detection of Intracranial Hemorrhage in Infants. Pediatric Emergency Care, 34(2), 96–101.</ref>
*The [[PECARN head trauma rule|PECARN rule]] has become standard of care to determine which patients need CT imaging
**In patients <2 yrs the aid is 100% sensitive with NPV of 100%
**In patients <2 yrs the aid is 100% sensitive with NPV of 100%
**In patient >2 yrs the aid is 96.8% sensitive with NPV of 99.95% (with validation studies showing sensitivity of 100% for TBI and injury requiring neurosurgery
**In patient >2 yrs the aid is 96.8% sensitive with NPV of 99.95% (with validation studies showing sensitivity of 100% for TBI and injury requiring neurosurgery
{{GCS peds}}


==Clinical Features==
==Clinical Features==
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==Differential Diagnosis==
==Differential Diagnosis==
{{Intracranial hemorrhage DDX}}
{{Head trauma DDX}}
 
===[[Concussion]]===
{{Maxillofacial trauma DDX}}


==Evaluation==
==Evaluation==
{{GCS peds}}
{{GCS table}}
===Work-Up===
===Work-Up===
''Rules below are with the application of PECARN <ref>[[EBQ:PECARN_Pediatric_Head_CT_Rule|PECARN Rule]]  Kupperman N, Holmes JF, Dayan PS, et al: Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 374(9696): 1160, 2009</ref>''
{{PECARN Head CT Rule}}


==Management==
==Management==
{{PECARN Head CT Rule}}
''Dependent on diagnosis, see:''
*[[Post-concussive syndrome]]
*[[Intracranial hemorrhage]]
*[[Moderate-to-severe traumatic brain injury]]
**[[Elevated intracranial pressure]]
*[[Mild traumatic brain injury]]


==Disposition==
==Disposition==

Revision as of 04:01, 3 April 2019

This page is for the general approach to pediatric head trauma; see head trauma (main) for adult patients.

Background

  • TBI in the pediatric population is rare, occuring in 0.9% of the 42,412 PECARN population
  • The primary ED question is whether or not to perform a head CT to assess for intracranial hemorrhage
    • Cranial ultrasound is a poor screening tool for bleeding[1]
  • The PECARN rule has become standard of care to determine which patients need CT imaging
    • In patients <2 yrs the aid is 100% sensitive with NPV of 100%
    • In patient >2 yrs the aid is 96.8% sensitive with NPV of 99.95% (with validation studies showing sensitivity of 100% for TBI and injury requiring neurosurgery

Pediatric GCS[2][3]

Eye Opening Verbal Motor
6: Normal spontaneous movement
5: Smiles, coos, babbles 5: Withdraws to touch
4: Opens eyes spontaneously 4: Irritable, crying (but consolable) 4: Withdraws to pain
3: Opens eyes to speech only 3:Inconsolable crying or crying only in response to pain 3: Abnormal flexion to pain (Decorticate response)
2: Opens eyes to pain only 2: Moans in response to pain 2: Abnormal extension to pain (Decerebrate response)
1: Does not open eyes 1: No response 1: No response

Note:

  • For Motor score 4, pain is defined flat, fingernail pressure (often performed with the barrel of a pencil).
  • For Motor scores 2 and 3, pain is defined by pressing hard on the supraorbital notch. If this unsuccessful, sternal pressure may also be attempted.

Clinical Features

Differential Diagnosis

Head trauma

Evaluation

Work-Up

Rules below are according to the of PECARN Head CT Study[4]

<2 years old

PECARN Under Age 2

Any 1 of the following?

Then obtain a Non-Con Brain CT (4.4% risk of cTBI)

1 or more of the following?

  • Non-frontal scalp hematoma
  • LOC ≥ 5 seconds
  • Severe injury mechanism
    • pedestrian or bicyclist without helmet struck by motorized vehicle
    • fall >1m or 3ft
    • head struck by high-impact object
  • Abnormal activity per parents

Then consider a Non-Con Brain CT or Observation (0.9% risk of cTBI)

≥2 years old - 18 years

PECARN Age 2 and Up

Any 1 of the following?

Then obtain a Non-Con Brain CT (4.3% risk of cTBI)

1 or more of the following?

  • History of vomiting^
  • LOC
  • Severe injury mechanism
    • Pedestrian or bicyclist without helmet struck by motorized vehicle
    • Fall >2m or 5ft
    • Head struck by high-impact object
  • Severe headache

Then consider a Non-Con Brain CT or Observation (0.9% risk of cTBI)

^Consider observation in place of imaging in children with isolated vomiting (no other indication) as the sole risk factor (0.2% risk of cTBI)[5]

Management

Dependent on diagnosis, see:

Disposition

  • Discharge if:
    • Asymptomatic after 2-4hr obs (not vomiting, nl neuro exam, nl mental status)
    • Head CT normal (delayed deterioration after normal CT is near zero)
  • Consider discharge if:
    • Nondisplaced fracture with out intracranial injury (in consultation with neurosx)

See Also

General/Adult

Pediatric

External Links

References

  1. ↑ Elkhunovich, M., Sirody, J., McCormick, T., Goodarzian, F., & Claudius, I. (2018). The Utility of Cranial Ultrasound for Detection of Intracranial Hemorrhage in Infants. Pediatric Emergency Care, 34(2), 96–101.
  2. ↑ Holmes JF, Palchak MJ, MacFarlane T, et al. Performance of the pediatric glasgow coma scale in children with blunt head trauma. Acad Emerg Med. 2005 Sep;12(9):814-9.
  3. ↑ James HE. Neurologic evaluation and support in the child with an acute brain insult. Pediatr Ann. 1986 Jan;15(1):16-22.
  4. ↑ PECARN Rule Kupperman N, Holmes JF, Dayan PS, et al: Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 374(9696): 1160, 2009
  5. ↑ Dayan PS, et al. "Association of Traumatic Brain Injuries with Vomiting in Children with Blunt Head Trauma. June 2014. Annals of EM. 63(6):657-665
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