Head Trauma Protocols

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					     Head     Protocols

                                The guidelines       suggested the Ministry of Healthfor evaluation management head
                                                                 by                                                        and                     of
     LisaAmir,MD,               trauma    havelimited applicability children.A numberof risk factorsfor intra-cranial
                                                                              to                                                                      injury
     MPH,FAAP                   (lCI) do not appear the list andseveral the list require
                                                          on                              on                     significant     modification orderin
     Unitof Emergency           to apply them to children.The guidelines                                               the
                                                                                             also do not address technical                difficultiesof
     Medicine, Schneider        performing headCT in youngchildrenand do not consider role of child abuse head
                                                a                                                                  the                              in
     Children's Medical
                     Center     trauma.    Recent    published   guidelines the evaluation children
                                                                                    for                    of            afterheadtrauma           separate
     of lsrael,
              Petah-Tikva,      theminto two agegroups, l) 0-2 years and(2) 2- l8 years
                                                                  (                    old                        old.
     lsrael                     A number historical
                                              of             elements listedasindicating higherrisk of ICI. The patient
                                                                            are                            a                                          with a
                                depressed      skull fracture,    signsand symptoms basilarskull fracture.
                                                                                                   of                                focal findingson
                                neurologic     examination hypertension
                                                               or                       with bradycardia      clearlyrequires energenthead
                                CT and neurosurgical          consultation. presence a VP shuntor bleeding
                                                                                    The               of                                  diathesis     also
                                increases risk of intracranial
                                             the                              bleeding    and a headCT is indicated            evenin the absence          of
                                othersymptoms ICI. In children
                                                      of                           2-18years a GCSof lessthan l5 is associated a
                                                                                                old                                                  with
                                mu c h h i g herri sk of IC I as compared a GC S of l 5 (3..1)
                                                                                         to                             and a headCT shouldbe
                                performed.     Lossof consciousness,             vomiting,    headache,     scalplacerations seizure
                                                                                                                                  and             havenot
                                beendemonstrated be definitive
                                                         to                       risk factors ICI in olderchildren
                                                                                                 for                             ( in infants
                                 (1 ,9 ,1 0 ).Confusi on amnesi as di ffi cul tor i mpossi bl to assess i nfan t s
                                                             or                 i                                 e             in             and young
                                children. children         lessthan2 yearsold, a bulgingfontanelle                     (afterheadtrauma) highly   is
                                 suggestive ICLof
                                 Children    lessthantwo years areat higherrisk of ICI. The presence a scalphematoma
                                                                        old                                                       of
                                 on physical    examination be the mostsensitive
                                                                may                                   indicator ICL Eightyto 1007r infants
                                                                                                                of                               of
                                 with scalphematomas havea skull fracture
                                                              will                                 and l5-30%o childrenwith skull fractures
                                 haveICI on headCT (l); no othersignor symptom beenshownto be a moreconsistent
                                 predictor ICI in children
                                             of                                                           (
                                                                      agedlessthan l2 months I I ). Parietal temporal       and                hematomas
                                 are frequently      associated     with skull fractures,           whereas    frontal hematomas not (12). are
                                 C o n v e rs el y. absence a scal phematoma
                                                   the               of                                has a hi gh negati ve         predict ivevalue,
                                 particularly children
                                                in             12-24     months age.However.
                                                                                     in                     therehavebeenseveral                    of
                                                                                                                                           cases skull
                                 fracture the absence scalphematomas
                                            in                 of                             reported childrenlessthan l2 monthsof age
                                 (9,10).Skull radiographs          shouldbe obtained childrenlessthan 2 yearsold with a scalp
                                 hematoma a CT performed a skull fracture found.Consideration
                                               and                           if                      is                              should givento
                                 obtaining    skull radiographs       in all childrenlessthan I yearold evenin the absence a scalp               of
                                 hematoma      unless mechanism injury is trivial.
                                                        the                    of
                                 Performance a headCT in youngchildrenis complicated the needfor sedation.
                                                   of                                                                  by                                   A
                                 physician    skillednot only in administration sedative      of             agents in the management the
                                                                                                                      but                              of
                                 pediatric    airwayin the caseof sedation headtraumacomplications
                                                                                         or                                       must accompany          the
                                 child to the    CT. This may be difficult or impossible the evening at night.If a headCT
                                                                                                         in                  or
                                 cannot obtained, patient
                                          be              the                                      in
                                                                           mustbe observed thehospital.
                                 Child abuse not a rarecause headinjury in childrenand is not addressed the Health
                                                  is                         of                                                             in
                                 Ministry guidelines.       The historyis often absent suggests      or               minor blunt traumawhile the
                                 severity injury suggests
                                            of                      serious Retinal
                                                                                 ICI.            hemorrhages present 65-90Va children
                                                                                                                are              in             of
                                 w i t h h e a dt r a u m ar e s u l t i n gf r o m c h i l d a b u s e . n y c h i l d w i t h s u s p e c t e o r p r o v e n
                                                                                                        A                                       d
                                 non-accidental       headtraumashouldhave a fundoscopic                       examination        and a headCT scan
                                 performed, socialwork consultation
                                                a                                     obtained be admitted hospital.
                                                                                                  and                 to
                                 The headtraumaprotocols                 currentlyin use at Schneider             Children's       MedicalCenterare
                                 presented     here.One protocol is for 0-2 year olds and the other for 2-18 year olds. The
                                 protocolfor 0-2 year old childrenreflectsthe higherrisk of ICI in youngerchildren,the
                                 possibilityof occult skull fracturein childrenlessthan one year old, incorporates                                        the
                                  difficulty of performinga headCT in asymptomatic                      childrenwith skull fractures, defines  and
                                  trivial headtrauma.Both protocols                  suggest   neurosurgical    consultation       prior to obtaininga
                                  h e a dC T onl y i n questi onablcases        e                                               of
                                                                                        and expedi te D di scharge asympt om at ic
                                                                                                            E                                             and
                                  minimallysymptomatic          children.

14 lsraeliJournalof EmergencyMedicine                      2003
                                     Vol 3, No. 3, September
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    CI i n ical Controversies

                                           Headinjury protocol 2-18
                                                             tor   yearsold

                                       s the child have:
                                  l . A clotting disorderor ITP?
                                  2 . A VP shunt?
                                  3 . G C S< 1 5 ?
                                  4. Basilar Skull Fracture?
                                  5 . LOC for more than I minute?
                                     High blood pressurewith bradycardia?
                                     More than 5 separateepisodesof vomiting or vomfirng,/
                                     that have continuedmore than 6 hours post injury?


              l.   StabilizeABCs                                           Is there a suspicion of abuseor
              2.   Rigid cervicalcollar as needed                          decreased   level of consciousness
              3.   Head CT without contrast                                as a result of drug use?
              4.   Neurosurgical consultation

               Consultationwith a senior attending                       Are there any acute symptoms?
                as to the needfor urgent headCT                          1. LOC of lessthan I minute
                                                                         2. Short seizure at the time of the

                                                         I               3. Five or more episodes vomiting
                                                                         4. Headachethat is resistant to
                                                                            tylenol - acamol
                   Six hour observationin the ED
                                                                         5. Lethargyor restlessness
                                                                         6. Dangerous   mechanism *

                                                                          Releasefrom the ED with


                                                                    *DangerousMechanism                          ,
                                                                    l. Falling from a moving vehicle
                                                                    2. MVA at high speed
            Reasons do a skull film
                    to                                              3. Falling from more than 2 meters(6.4 feet)
            l. Penetratingheadinjury                                4. An unwitnessedfall that may be from a
            2. Possibility of depressed skull fracture                 dangerousmechanism
            3. Possibility of foreign body                          5. Falling down more than 3 stairs           I
            4. Considera sinus fracture                             6. Car vs. bicycle                           I

16 lsraeliJournalof Emergency                             2003
                                    Vol 3, No. 3, September
                                                                                                                            CIi n i c a l C o n t r o v e r s i e s

                     I.   SchutzmanSA. BarnesP, Dunham AC. et al. Evaluation and Managementof Children Younger Than
                          Two Years Old With Apparently Minor Head Trauma: Proposed Guidelines. Pediatrics
                          2001: 07(5):983-993
                     2. Committee on Quality Improvementand AAP and Commissionson Clinical Policiesand Research.                                                                   and
                          AAFP. The Management Minor Closed Head Injury in Children. Pediatrics1999: (X(6): 1407-l4l5
                                                                   of                                                                                      I
                     3. Dietrich AM, Bowman MJ, Ginn-PeaseME, Kosnik E, King DR. Pediatrichead injuries: can clinical
                          factorsreliably predict an abnormalityon computedtomography?Ann Emerg Med 1993:22:1535-1540
                     4. Wang MY, Griffith P. Sterling J. McComb JG, Levy ML. A prospectivepopulation-based-study                                                                     of
                          p e d i a t r i ct r a u m a p a t i e n t sw i t h m i l d a l t e r a t i o n si n c o n s c i o u s n e s ( G l a s g o w C o m a S c o r e o f l 3 - 1 4 ) '
                          Neurosurgery            2000146(5 I 093- I 099
                     5. Davis. Rt, Mullen N. Makela M, et al. Cranial ComputedTomography Scansin Children after Minimal
                          Head Injury with Loss of Consciousness.Ann Emerg Med 1994:24(1):640-62t5
                     6. Schunk. JE. RodgersonJD, Woodward GA. The Utility of Head Computed Tomographic Scanningin
                          PediatricPatientsWith Normal Neurologic Examinationin the EmergencyDepartment.                                                        Ped Emerg Care
                       . Quayle KS. Jaffe DM. KuppermanN. et al. DiagnosticTesting for Acute Head Injury in Children: When
                          are Head ComputedTomographyand Skull Radiographs                                          Indicated?       PediatricsI 997:99( ):eI I5
                     8 . R a m u n d o M L . M c K n i g h t T , K e m p g J , e t a l . C l i n i c a l P r e d i c t o r so f C o m p u t e d T o m o g r a p h i c
                          AbnormalitiesFollowing PediatricTraumatic Brain Injury. Ped ErnergCare 1995: I ( I ): I -'l                                    I
                     9. GreenesDS. SchutzmanSA. ClinicalJadicatorsof IntracranialInjury in Head Injured Infants.Pediatrics
                           I 999: I 04(4):86l -867
                      10. Gruskin KD. SchutzmanSA. Head Traunra in Children Younger than 2 Years: Are There Predictorsfor
                          Complications?            Arch PediatrAdolesc Med 1999:153:                           l5-20
                      ll. Greehes         DS. Schutzman           SA. Occult Intracraniallnjury in lnfants.Ann Emerg Med 1998:32(6):680-686
                      12. GreenesDS. SchutzmanSA. Clinical significanceof scalp abnormalitiesin asymptomatichead-injured
                          infants.Ped Emers Care 2001:l7(2):88-92

TheIsraeli         Room        of

                     Emergency room managementof head injured patients is guided by the severity of
ZeevT.Feldm?fr,      injury.
MD                   The severityof head injury is definedby the initial Glasgow Coma Scalescore(GCS).
Department           Patientswith a GCS of 3-8 are severelyinjured, patientswith scoresof 9-13 have
Neurosurgery,        moderateheadinjury and a scoreof l4- l 5 definesmild headinjury.
Sheba      Center,
     Medical         The management     protocolsfor severehead-injured  patientsare very well defined (1,2).
                     After the initial resuscitationaccording to the ATLS protocols, all patients undergo
                     head CT and are managedin, or should be transferredto, a neurosurgical       trauma unit
                     for further care.
                     Moderatehead injury should be managedin the ER accordingto the sameguidelines:
                     All patientsshouldundergoheadCT and be admittedfor observation        until they recover
                     to a GCS of 15.
                     The highest load on the ER physician comes from managingpatientswith mild head
                     Most ERs in Israel encounterdozensof mild head injuries a day and they comprise
                     about 80 Vo of all head injuries. Most patientswith a mild head injury should be
                     managedby the ER team without the assistance neurosurgeons neurologistand
                     the       Israeli Guideline for EmergencyRoom Managementof Head Injury" is most
                     helpful in that respect.

                                                                                  2003 llDU9O ,3 lI)U ,3 i'l9ln] i'lNl9'l) r)N'lUri'l nyil ln)                                               t1

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