CLINICAL PRACTICE

GUIDELINE:HEAD INJURY
The priorities when assessing a child with head injury are to identify those with:

1. Moderate to severe head injury who need immediate management,

Key points urgent investigation and referral
2. Mild head injury who can be immediately discharged home
3. Head injury who need observation and/or neuroimaging
4. Other significant injuries or suspected child abuse

Background

Most head injuries are mild

A head injury may still be significant without loss of consciousness
Consider non-accidental injury, especially in infants ( child abuse)
Concurrent cervical spine assessment is required
Non-verbal children, particularly those under 6 months, require a more cautious
assessment approach and may require longer observation
Children with suspected drug or alcohol intoxication may be more difficult to assess –
assume conscious level relates to injury and have a lower threshold for referral and
neuroimaging

Assessment

Initial assessment of severity

Determines those that can be discharged promptly, versus those that need a period of
observation or those requiring active management
Severity may change – all children being observed should be regularly reassessed for
signs or symptoms of deterioration
*Risk factors:

Severe headache
Persistent altered mental status/acting abnormally
Abnormal neurology
Suspected child abuse
Palpable skull fracture
Signs of base of skull fracture
Non-frontal scalp haematoma (occipital, parietal or temporal) in child <2 years
Severe mechanism
Post-traumatic seizure
Loss of consciousness
Persistent vomiting
Known bleeding disorder/anticoagulation
Ventriculoperitoneal shunt
Neurodevelopmental disability

Primary survey and resuscitation:

Glasgow Coma Score (GCS)

History
Past history

Bleeding tendency, anticoagulation or antiplatelet therapy

VP shunt

Injury

Timing
Mechanism of injury
Severe mechanism includes:
 motor vehicle accident with patient ejection or rollover, death of another passenger
pedestrian or cyclist struck by motor vehicle
falls of ≥1 m (<2 yr)
fall >1.5 m (>2 yr)
head struck by high impact object
Circumstances of injury, eg accident, suspected child abuse, unexplained fall
(consider syncope), intoxication

Clinical course and associated symptoms

Stable, deteriorating, improving

Loss or impairment of consciousness and duration
Abnormal behaviour, including agitation, confusion and drowsiness
Headache
Nausea and vomiting
Other injuries sustained
Presence of amnesia
Post injury seizure

Examination

Neurological examination, including signs of raised intracranial pressure:

unilateral or bilateral pupillary dilatation

drop of more than 2 points in GCS
development of focal neurological signs
abnormal posturing
Irregular respirations, hypertension and bradycardia (Cushing reflex – late sign)
Feel specifically for palpable skull fractures
Look for signs of fractured base of skull (haemotympanum, cerebrospinal fluid otorrhoea
or rhinorrhoea, periorbital bruising (raccoon eyes), bruising over mastoid area (Battle sign))
Assess for other injuries (see secondary survey)

Management
Investigations

Neuroimaging

The need and timing of neuroimaging requires balancing the clinical benefit with the risk of
radiation exposure and sedation – discuss with a senior doctor or neurosurgeon
For children with mild head injury, a decision about whether to image should be based on
the presence or absence of risk factors (as described below)
Indications for neuroimaging may be present on initial assessment, or may evolve during
the period of observation
Risk factors as indications for imaging

Neuroimaging for children with special conditions

Children with any of the following conditions, although not at increased risk of intracranial injury, require greater
consideration of neuroimaging:

Age <6 months

Bleeding disorder, or taking either anticoagulation or anti-platelet therapy
Immune thrombocytopenia
Ventriculoperitoneal shunt
Neurodevelopmental disorders
Drug or alcohol intoxication

If no other risk factors are present, structured observation may be considered over immediate neuroimaging. Seek
advice from a senior clinician, haematologist or other relevant subspecialist

Type of neuroimaging

Plain skull X-ray or head ultrasound should not be performed in lieu of a CT

MRI may be equivalent in terms of clinical utility, but should only be considered in settings
where it can be performed quickly and safely

Consider other investigations

If other injuries are present, investigate as clinically indicated

Consider investigation for causes of falls eg alcohol, other ingestions, arrhythmias, hypoglycaemia (see Syncope)

Treatment

Mild head injury without other risk factors

GCS 15 and meets the following criteria:

no concern about abusive head trauma
age over 6 months
no special conditions (bleeding tendency, neurodevelopmental disorder, VP shunt)
 non-severe mechanism
If on the basis of history and examination there are no other clinical concerns, the child
has returned to normal conscious state, and is acting normally, they may be discharged to
the care of their parents
Treat pain with simple analgesia
Ensure discharge advice given to parents

Mild head injury with other risk factors

Child should be observed for up to 4 hours post injury, with:

30-minutely neurological observations (conscious state, PR, RR, BP, pupils and limb
power) for the first 2 hours
one-hourly neurological observations thereafter
Treat pain with simple analgesia
Consider anti-emetics
A persistent headache, ongoing vomiting, GCS of 14 or persistent altered mental status
requires further observation and likely investigation. Discuss with a senior clinician
The child may be discharged home if there is return to normal conscious state for at least
one hour, is acting normally, and they can tolerate oral fluids

Concussion and return to activity

A concussion is a mild injury which temporarily alters brain function

Post concussive symptoms are common, and advice should be given regarding rest and
gradual return to activity (See parent information)

Moderate head injury

Consult a senior doctor or neurosurgeon for advice

Urgent CT of head (and consideration of imaging of c-spine if relevant)
Ensure early specialist consultation
Low threshold to escalate care as per severe head injury below

Severe head injury:

Look for signs of severe head injury which may include presence of focal neurological
deficit, signs of increased intracranial pressure or signs of basal skull fracture
The initial aim of management of a child with a serious head injury is prevention of
secondary brain damage
The key aims are to maintain oxygenation, ventilation, and circulation, and to avoid rises in
intracranial pressure (ICP)
Urgent CT of head (and consideration of c-spine imaging if relevant)
Ensure early neurosurgical consultation
 Cervical spine movement should be minimised until formal assessment occurs.
See Cervical spine assessment

Intubation and ventilation

Consider intubation if:

Child unresponsive or not responding purposefully to pain
GCS persistently <8
Loss of protective laryngeal reflexes
Respiratory irregularity or suspected hypoventilation
Avoid hypotension, hypoventilation and hypoxia during intubation and minimise cervical
spine movement. See Cervical spine assessment
If possible, a neurological examination should be performed before intubation and any
motor deficits or cranial nerve signs documented
Intubation should be performed by the most skilled clinician available. For children
requiring mechanical ventilation:
Analgesia and sedation with morphine and midazolam should be administered by
careful titration. Children with head injury are often more sensitive to opioids
Consider muscle paralysis (eg pancuronium or vecuronium)

Maintain circulation and cerebral perfusion

Uncorrected hypotension is a significant factor in secondary brain damage

Ensure adequate blood pressure with crystalloid infusion (eg 0.9% sodium chloride) or
inotropes if necessary
isotonic fluids (eg 0.9% sodium chloride) recommended (see Intravenous fluids)

Treat signs of raised intracranial pressure

In consultation with neurosurgical team, consider measures to decrease intracranial pressure:

Maintain head position: Nurse 30 degrees head up (after correction of shock) with head in
midline position to help venous drainage
Ventilate to PaCO2 35-40 mmHg
Consider hypertonic saline (sodium chloride 3% 3 mL/kg IV over 10-20 min) or 20%
mannitol (0.25-0.5 g/kg IV over 20-30 min)

Control seizures

Treat with benzodiazepines to immediately control seizures

Seek neurosurgical advice early
Give phenytoin or levetiracetam loading dose
Observe closely for subsequent hypotension or hypoventilation and manage appropriately
See afebrile seizures

Other measures:

Maintain normal sodium and glucose levels

Maintain normothermia
Check for coagulopathy
Consider consultation with local paediatric or paediatric neurosurgical
team when

Failure to return to normal within 4 hours

Suspected child abuse
Uncertainty surrounding when to perform neuroimaging
Any child with a ventricular shunt
Any child with a bleeding disorder, or who is taking anticoagulant or anti-platelet therapy
(discuss with paediatric haematologist)

Consider transfer to a tertiary centre when

All severe head injuries

Deteriorating conscious level (especially motor response changes)
Focal neurological signs
Seizure without full recovery
Definite or suspected penetrating injury
Cerebrospinal fluid leak
Child requiring care beyond the comfort level of the hospital

For emergency advice and paediatric or neonatal ICU transfers, call Retrieval Services

Consider discharge when

The child is acting normally for at least one hour as per the parent, has a normal
neurological examination and can tolerate fluids
There are no other factors warranting admission or longer observation (eg other injuries or
underlying medical concerns, drug and alcohol intoxication, social factors, possible
abusive head injury)

Concussion and return to activity

A concussion is a mild injury which temporarily alters brain function

Post concussive symptoms are common, and advice should be given regarding rest and
gradual return to activity (See parent information)

Parent advice and follow-up

Ensure the parents have clear instructions regarding the management of their child at
home, and when to seek medical attention
Children discharged following a mild to moderate head injury should consider follow-up
with a primary care doctor within 1 to 2 weeks to assess post-concussive symptoms
Advise parents that children with anything other than a trivial head injury may take up to 4
weeks to recover, and graded return to activity is recommended