Episode 3: Pediatric Head Injury

Dr. Rahim Valani and Dr. Jennifer Riley discuss their approach to the workup and management of both minor and major Pediatric Head Injury.  They review two recent landmark studies (PECARN & CATCH studies) describing clinical decision rules for performing CT head in minor pediatric head injury, as well as practical tips on instructing parents regarding return to sport activities after discharge.  In major pediatric head injury, they discuss key clinical pearls on managing blood pressure, the use of hypertonic saline and managing raised intracranial pressure in the treatment of major head injury.

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Written Summary and blog post by Lucas Chartier, edited by Anton Helman March 2010

Cite this podcast as: Valani, R, Riley, J, Helman, A. Pediatric Head Injury. Emergency Medicine Cases. March, 2010. https://emergencymedicinecases.com/episode-3-pediatric-head-injury/. Accessed [date].

Canadian Pediatric Society’s classification of pediatric head injury

CMAJ 1990;142(9):949-52

• Mild: GCS of 15 and asymptomatic or with mild headache, ≤3 episodes of vomiting, and loss of consciousness

• Moderate: GCS of 11-14, loss of consciousness ≥5 minutes, progressive headache or lethargy, >3 episodes of vomiting, post-traumatic amnesia or seizure, serious facial injury or signs of basilar skull fracture, multiple trauma, possible penetrating injury or depressed skull fracture, or suspected child abuse

• Severe: GCS ≤10 or declining by 2 points without clear cause, focal neurologic signs, penetrating skull injury, palpable depressed skull fracture, or compound skull fracture

Kupperman PECARN vs CATCH study: CT or not in pediatric head injury?

Kuppermann et al. Identification of children at very low risk of clinically- important brain injuries after head trauma: a prospective cohort study. Lancet 2009;374(9696):1160-70

PECARN – NO CT HEAD RECOMMENDED for low-risk criteria for clinically-important traumatic brain injury: (<0.05% of death, neurosurgery, intubation for 24hrs or admission for 48hrs due to traumatic brain injury on CT scan):

• Patient less than 2y.o.: Normal mental status, no scalp hematoma except frontal, no loss of consciousness > 5 seconds, no palpable skull fracture, AND non-severe mechanism
• Patient more than 2y.o.: Normal mental status, no loss of consciousness, no vomiting, no signs of basilar skull fracture, no severe headache, non-severe mechanism
• Definition of severe mechanism: MVA with ejection, death of other passenger or roll-over, pedestrian or cyclist without helmet struck by car, fall >5feet if patient >2y.o. or fall >3feet if patient <2y.o., or head struck by high-impact object

Osmond et al. Canadian Assessment of Tomography for Childhood Injury. CMAJ 2010;182(4):341-8

NO CT HEAD REQUIRED for low-risk criteria: no high-risk AND no medium-risk factors present:

• Four “high-risk” factors (which are 100% sensitive for the need for neurologic intervention):
  1. failure to reach GCS of 15 within 2hrs
  2. suspicion of open skull fracture
  3. worsening headache
  4. irritability
• Three “medium-risk” factors (which are 98.1% sensitive for prediction of brain injury on CT scan)
  1. large, boggy hematoma on scalp
  2. signs of basal skull fracture
  3. dangerous mechanism (MVC, fall from elevation > 3 feet or 5 stairs, fall from bicycle with no helmet)

Differences between Kuppermann PECARN and CATCH studies

• CATCH study recruited sicker patients (GCS of 13-15 vs. 14-15), but has not been validated yet (as opposed to Kuppermann’s)
• Kuppermann study might validate what astute clinicians already do, whereas CATCH study might change practice, as sicker patients fulfilling certain criteria could avoid CT scan
• BOTH studies are only guides and are not absolute, and they DO NOT claim that if a patient does not fill ALL the criteria he/she necessarily needs a CT scan

Update 2014: Annals of Emergency Medicine article finds PECARN more sensitive than CATCH and CHALICE rules for identifying clinically important traumatic brain injuries. Abstract

Update 2015: Large prospective study suggests that children with a minor blunt head trauma and a linear skull fracture are at very low risk of neurological deterioration requiring neurosurgery. Abstract

Update 2017: A large prospective observational study found PECARN to be more sensitive than CATCH and CHALICE decision rules for identifying clinically important traumatic brain injuries. Abstract

Update 2018: A planned secondary analysis of the NEXUS Head CT decision instrument (“NEXUS II”) was completed involving 1,018 blunt head injury pediatric patients according to 7 risk-stratifying criteria.  While 100% sensitivity was observed for 27/27 patients deemed  “high risk” and requiring neurosurgical intervention,  a specificity of 33% was seen in 330/991 patients assessed as “low risk”.Abstract

Update 2018:  A secondary analysis of the Australasian Paediatric Head Injury Rule Study demonstrated head injury with isolated vomiting (i.e. vomiting without any of clinical decision rule predictors) was uncommonly associated with TBI on CT, or the presence of clinically important TBI.  This study suggests a strategy of observation without head CT may be appropriate management. Abstract

Update 2018: CATCH was updated to CATCH2 in a CMAJ study of more than 4000 patients which included 4 or more episodes of vomiting and found 100% sensitivity for neurosurgical intervention. CATCH2 requires further validation in an implementation study Abstract

Update 2018: A systematic review conducted by the CDC developed guidelines to diagnose and manage pediatric mild TBI, and help identify features associated with more serious TBI-associated intracranial injury, delayed recovery from mTBI and long-term sequelae. Abstract

Update 2019: An emergency department QI initiative to decrease cranial CT  for children with minor head injuries provided the following imaging guidance using prior PECARN TBI risk factors:  i) Any high-risk or 3 or more intermediate factors – perform CT; ii) 1-2 factors – observe; iii) No factors – discharge. Abstract

Update 2021: Analysis of 1081 infants (< 3 months old) with minor blunt head trauma according to PECARN traumatic brain injury (TBI) low-risk criteria; this criteria accurately identified infants at low-risk of clinically important TBIs (though cautious approach required since infants remained at risk for TBIs on CT imaging). Abstract

Update 2021: Multicenter study of clinically important traumatic brain injury (ciTBI) in Australia and New Zealand of an external cohort of 15,163 children. PECARN algorithm showed ciTBI risk estimates across high-, intermediate-, and low-risk groups of 8.5%, 0.2% and 0.0% for children >2 years, and 5.7%, 0.7% and 0.0% in children <2 years old respectively. Consistent with the original study; signs of “palpable skull fracture” and “basilar skull fracture” were isolated high-risk predictors of ciTBI. Abstract

Update 2022: A secondary analysis of the NEXUS validation study with 1,018 pediatric patients including 128 notable injuries on CT found that the sensitivity and specificity of provider physical examination to detect skull fracture was 18.5% and 96.6% respectively.  The authors concluded that physical exams have a poor sensitivity for skull fractures in the pediatric population. Abstract

Role of skull x-ray for patients under one year old

Controversial: although there is an association between skull fracture and intracranial hemorrhage, the sensitivity is not great even with seasoned clinicians reading them; it could be considered when a hematoma is present but CT scan is not indicated

POCUS for pediatric skull fractures on the EDE Blog

Return to sport after pediatric minor head injury

• Variety of guidelines exist, but every athlete needs an individual approach to prevent 2nd-impact syndrome
• Suggestions include to stay off activities until 1 week after resolution of post- concussive symptoms (headache, amnesia, dizziness), and then to use a step-wise approach: mild exertion to increase HR, sport-related activity with no contact, progressive return to full practice, then return to game situations – if symptoms develop at any of these stages, go back to the previous stage and consult the primary care giver of the patient

Discharge instructions after pediatric minor head injury

• First 6 hours is the “red zone”, then 24hrs is the “yellow zone”
• Waking up patient q2hrs is probably not necessary (and if the clinician believes the patient to be high-risk, he/she should be kept in the department longer)
• Partially waking up the patient once during the night to assure reasonable behaviour might be reasonable, especially if in the “red zone” time

Update 2015: A concise summary on the diagnosis and management of pediatric concussion from TREKK.

 Update 2021: Randomized tertiary center trial of post-concussion screen time recommendations in 162 patients (12-25 years old) seen within 24 hours of sustaining a concussion. Participants who engaged in screen time within 48 hours post-concussion had a significantly longer recovery time of 8.0 days, compared to 3.5 days in the screen time abstinent group. Abstract

 Update 2021: Tertiary pediatric center study of using rapid sequence brain magnetic resonance imaging (RS-MRI) as a feasible screening tool in 105 children (<12 years old) with persistent/recurrent headaches. 77% out of 105 cases were normal, 23% were abnormal; notably, 75% diagnosed with sinusitis, and 1 case with an abnormal brain mass.  Abstract

For an evidence-based analysis on the best clinical decision rule, significance of isolated loss of conciousness and whether strict bed rest is required after minor head injury go to BEEM Cases 1 – Pediatric Minor Head Injury

Pediatric Major head injury

• Consider pre-medication of fentanyl or lidocaine as part of rapid-sequence intubation (RSI) algorithm to blunt the body’s sympathetic response to intubation, which results in increased intracranial pressure (ICP) – these medications need to be given a full 2 minutes before intubation to be effective, therefore not suitable in ‘crash’ intubation

• Induction agent should aim at preventing drop in blood pressure given that CPP = MAP – ICP [cerebral perfusion pressure equals mean arterial pressure minus ICP]
  • Etomidate probably remains the best agent given that there is not enough data as of yet on Ketamine (which offers neuroprotective effect but raises ICP)

• Clinical clues of increased ICP: worsening headache, visual or neurologic complaints, persistent vomiting, as well as abnormal pupillary reflexes, decreasing level of awareness, lateralizing features, Cushing’s triad

• Methods of decreasing ICP: elevation of head of bed 30 degrees, medications to cause osmotic pull, and hyperventilation, which is only used as a temporizing measure in a patient who is coning (target pCO2 is 30-35mmHg)

• Mechnism of mannitol: decrease in blood viscosity, as well as osmotic pull to decrease brain swelling given that it does not cross the BBB (provided it is intact)

• Dose of medications:
  • Mannitol: bolus of 0.25-1g/kg
  • Hypertonic saline 3%NS (used when patient hypotensive because it has no osmotic diuretic effect): bolus of 2-6cc/kg, then infusion of 0.1-1cc/kg/hr

Dr. Valani, Dr. Helman and Dr. Riley have no conflicts of interest to declare.

Key References

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• Kuppermann et al. Identification of children at very low risk of clinically- important brain injuries after head trauma: a prospective cohort study. Lancet 2009;374(9696):1160-70 www.ncbi.nlm.nih.gov/pubmed/19758692
• Management of children with head trauma. Emergency Paediatrics Section, Canadian Paediatric Society. CMAJ 1990;142(9):949-52 www.ncbi.nlm.nih.gov/pubmed/2183919
• Osmond et al. Canadian Assessment of Tomography for Childhood Injury. CMAJ 2010;182(4):341-8 www.ncbi.nlm.nih.gov/pmc/articles/PMC2831681/

For more on Paediatric Emergencies download our free interactice eBook EM Cases Digest Vol. 2 Pediatric Emergencies

For more on paediatric head injuries on EM cases:
Best Case Ever 55 Pediatric Cerebral Herniation

For more Pediatric EM learning visit trekk.ca – Translating Emergency Knowledge for Kids (TREKK) is a growing network of researchers, clinicians, health consumers and national organizations who want to accelerate the speed at which the latest knowledge in children’s emergency care is put into practice in general EDs – rural, remote or urban.