Author: Ashleigh Lawrence-Ball / Editor & Questions: Liz Herrieven / Codes: / Published: 30/01/2024
Walk into any Emergency Department (ED) in the country and you are bound to find at least one child waiting to be seen with a head injury its one of the commonest presenting complaints to EDs in the UK. Approximately 295000 children under the age of 16 will be seen each year (which is why we decided to have an induction blog on it). This blog focuses on paediatric head injury weve got another one on adult head injuries here.
Thankfully, the majority of paediatric head injuries are trivial, but 10% will be classed as moderate to severe. Head injuries account for 30% of traumatic childhood deaths in the UK. The most common causes of moderate to severe head injuries in childhood are falls (in infants) and road traffic collisions (in older children).
Children have several anatomical and physiological difference to adults that make them more likely to sustain head injuries and more complex to assess. In this blog, well go through those differences, talk about the assessment of the child with a head injury and then discuss the treatment of these children, depending on the severity of their head injury.
General principles for assessing children:
Remember that children in hospital are often scared and upset, and dont forget their parents (who will also be scared and upset). Children often regress a stage when they present to hospital, so getting the parents onside is really important. Be calm, be friendly and make sure both the parents and child know what youre going to do before you do it. Assessment of the unwell or injured child often involves things that look unpleasant to the outside world (for example, assessing for a pain response), and its very easy to lose the trust of parents or carers if youre not careful.
Most of the children you will assess will have a minor head injury. Remember proportionality falling a long way for a child is not the same as for an adult, and vice versa. If a toddler falls their own height its not really a long way. And toddlers will fall their own height A LOT, they are fast and nosy.
The way they fall is also different, due to proportionality. A toddler does not fall downstairs in the same way as adults, in that they dont fall down in one projectile movement, but tumble downstairs, meaning they have a collection of small falls, reducing the mechanism of injury (MOI).
You will also have to innovate, extrapolate and economise how you assess them head, shoulders, knees and toes is a great way to assess most of their motor function!
If the child has presented with a head injury as part of a major trauma remember your (C)ABCDE and work systematically. You should always have plenty for friends around to help as part of the major trauma team.
If the child is awake and the parents are present, make sure the child can see them. If the situation allows, let the parent hold the childs hand and offer as much reassurance as possible they will be the best at calming their child down. If the parent is too distressed, or the acuity of the situation means they need to stand away from the bed, assign a member of staff to keep talking to them and keep them calm as this frees you up to deal with the medical side of things.
Why children are not little adults:
Children have a few important anatomical differences to remember when you see them in the ED. Heres a quick run-down of what you need to know for the longer version, check out this blog post we released a while ago.
- Their heads are proportionally bigger to the rest of their bodies compared to adults: this means its more likely to get injured in a trauma.
- The subarachnoid space in thinner, meaning there is less cushioning during any impact.
- The cranial sutures dont fully close until 12-18 months, so in young children theres an increased tolerance for expanding intracranial contents (e.g. haematoma, oedema), which can go unrecognised. Check the fontanelles in all young children presenting with a head injury.
- The unfused cranial sutures also mean a large volume of blood can collect intracranially, leading to hypovolaemic shock.
- Young children can have up to twice the cerebral blood flow of an adult, making them more susceptible to secondary brain injury, particularly due to hypoxia.
- Children are more likely to vomit following a head injury, regardless of their intracranial pressure, and this is reflected in the NICE CT scanning criteria, which well address later.
GCS assessment of children:
As you can imagine, GCS assessment of children, particularly those who are pre-verbal, is tricky. You can use an AVPU score as a general guide, but the NICE criteria work off a formal GCS. Below is a table for grading a young childs GCS. For children over 4, you can use the adult GCS. For children with profound or multiple learning disability, find out from their parents what they are like when well, so you can tell how unwell they may be now.
Age <4:
| Eye opening: | |
| -Spontaneous | 4 |
| -To verbal stimuli | 3 |
| -To pain | 2 |
| -None | 1 |
| Best motor response: | |
| -Spontaneous / obeys command | 6 |
| -Localises to pain or withdraws to touch | 5 |
| -Withdraws from pain | 4 |
| -Abnormal flexion to pain (decorticate) | 3 |
| -Abnormal extension to pain (decerebrate) | 2 |
| -No response | 1 |
| Best verbal response: | |
| -Alert, babbles and coos, words to normal ability | 5 |
| -Fewer words than usual, spontaneous irritable cry | 4 |
| -Cries only to pain | 3 |
| -Moans to pain | 2 |
| -No response | 1 |
NICE CT criteria for children:
As for adults, NICE have very particular criteria for performing a CT scan in children with a head injury. These are based on the CHALICE study and, as children are different to adults, are slightly different to the adult guidance. Theres a definite (although difficult to quantify) risk of malignancy when carrying out CT scanning in small children, so its important to weigh up the risks and benefits, bearing in mind the pre-test probability of an abnormal finding, and aiming to stick to the ALARA (as low as reasonably achievable) principle of radiological investigations.
Children taking anticoagulants or anti-platelet medication (except aspirin monotherapy) should be considered for a CT scan. NICE doesnt say much about this, so you might want to speak to a senior, or discuss with their haematologist.
NICE have recently updated their guidance about who should get a scan, so weve updated this blog and our infographics too.
A word on vomiting:
A lot of children vomit after a head injury. We dont know why and there has been a fair bit of research into the significance of isolated vomiting in children following a head injury, which suggests that the likelihood of a significant intracranial injury is very low. However, my advice would be to always follow the guidelines and discuss with a senior when unsure.
Make sure you take a good history from the parents when it comes to any vomiting as children will often retch and vomit several times in quick session. This would be classed as one discrete episode, rather than several separate ones. Giving analgesia and anti-emetic to help with this is generally considered a good thing to do.
Dont forget the C-Spine:
As with adults, you should always consider a concurrent C-spine injury in all children presenting with a head injury, although the incidence is low. NICE have a full set of criteria regarding imaging selection but, essentially, if the child has a significantly reduced GCS or neurology they should have an immediate CT scan of their neck. If they have pain with a dangerous mechanism but normal neurology, they should have plain films. We have a blog on Paediatric trauma imaging which covers this here.
Safeguarding issues:
Unfortunately, there will be a proportion of children who present with head injury who will have had a Non-Accidental Injury (NAI). We have a duty of care to all children and you should consider the possibility of NAI in all children you see. We have a whole blog on safeguarding in this iBook, but for head injuries making sure the mechanism of injury meets the childs milestones is imperative!
Treating and discharging childhood head injuries in the ED:
The aim in managing those with a moderate or severe head injury is to limit secondary brain injury. Children should be treated using the same principles as adults: maintain normothermia, normocapnia and normoglycaemia. Nurse with a 30 degree head up tilt and avoid hard collars if a C-Spine injury cant be ruled out, as they can prevent venous drainage, increasing ICP further. Neurosurgical intervention in children with traumatic brain injury is rare but paediatric trauma centre referral is mandated.
Lots of children with a head injury will have a wound of some description. Superficial grazes can be cleaned and left alone. Small, superficial lacerations can often be glued but some will need sutures. Depending on the age of the child, you may be able to do it in the department, either with subcutaneous local anaesthetic or, if you dont think theyll tolerate multiple injections, you can consider a topical local anaesthetic (for example LAT gel). Ultimately some children, especially those who are very young, wont tolerate awake closure of the wound and will need referral for closure under general anaesthetic.
Thankfully, the vast majority of children will go home straight from the ED. They should be discharged with written head injury advice which should include information on when to return and who to contact for advice and dont forget to give them a sticker on the way out!
References
- RCEMLearning blog Head Injury in Adults
- RCEMLearning blog Paediatric Trauma Anatomy Easy as AcBC
- National Institute for Health and Care Excellence (NICE). Head injury: assessment and early management. [NG232] 2023.
- RCEMLearning blog Shedding light on Paediatric Trauma Imaging
- St Emlyns APLS Updates 2015 By Simon Carley.
