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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, July 2, 2018

Paediatric Head Trauma

Head injury in a common presentation in children and 0 to 4 years of age is the most commonly affected group. The vast majority of head trauma is caused by blunt force (assaults, abuse, Non-Accidental Injury). t is estimated that only about 5% have an intracranial injury, and <1% of those with intracranial injury require surgical intervention. Clinically significant injuries are rare in children and thus it is a challenge to conclude who needs imaging. Head injuries resulting in a GCS score of 8 are severe, those with scores of 9 to 13 are moderate, and those with scores of 14 or 15 are mild. 

Head Injury Pattern in children

  • In children, diffuse injuries are proportionally more common whereas, in adults, focal injuries such as epidural and subdural hematomas and cerebral contusions are more common.
  • Compared to adults, skull fractures in children are more common but less frequently associated with underlying brain injury.
  • A growing fracture can present months on the injury and requires neurosurgical repair.  It can occur when the leptomeninges are torn beneath the fracture, leading to a CSF leptomeningeal cyst that forces apart the fracture edges and leads to nonunion. Growing skull fractures typically present weeks to months following an injury resulting in skull fracture. 



Specific Injuries 
Epidural hematoma - Collection of blood between the inner skull and the dura. Usually results from rapid arterial bleeding from the middle meningeal artery or the dural or diploic vasculature. Generally good prognosis if surgical evacuation can be done in a timely fashion. 


Subdural hematomas - More common than epidural hematomas in children. Bleeding results from the tearing of the subdural veins. These injuries are frequently associated with underlying brain injury and have a worse prognosis. 

Subarachnoid hemorrhage - Often associated with significant trauma and diffuse axonal injury (DAI). Children with DAI present with a depressed level of consciousness with a normal appearing CT scan. 

Cerebral contusions are located in the cortex underlying the area of direct impact (coup lesions) or on the opposite side (contrecoup lesions). 



History and Physical
Mechanism, Time of the incident
Any Witness
LOC, seizure, changes in behavior, or vomiting, ENT Bleed
Medications, Previous Head trauma
Suspect NAI if the history is incompatible with the child’s age 


Particularly in the young child, symptoms of neurologic injury may be subtle. Lethargy, irritability, seizures, and alterations in muscle tone or level of consciousness, as well as vomiting, poor feeding, breathing abnormalities and apnea, raise the suspicion of significant head injury.



Assessment

  • ABCs
  • GCS
  • Pupils
  • Head - Inspect, Palpate, Check Fontanelles 
  • ENT Exam
  • Maxillofacial Exam
  • Neck exam 
  • Quick Head to toe exam

The big question is about when to image and when to observe? Most of us are minimalists when it comes to imaging in children as ionizing radiation is a long-term carcinogen. 
There are several clinical decisions rules have been developed to guide imaging. 


  1. CHALICE (Children’s Head Injury Algorithm for the Prediction of Important Clinical Events)
  2. CATCH (Canadian Assessment of Tomography for Childhood Head Injury)
  3. PECARN (Pediatric Emergency Care Applied Research Network)
  4. NICE guidelines 

PECARN is considered the “best for children and infants, with the largest cohort, highest sensitivity and acceptable specificity of clinically significant  injury


Take Home:
Head injuries requiring surgical intervention are rare in children. Most of them need reassurance and good discharge advise. Be mindful of the various clinical decision rules for risk stratification. 


Posted by:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic






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