Guideline 46: Summary of Paediatric Practice Points

Early Management of Patients with a Head Injury
Summary of Paediatric Practice Points

ASSESSMENT AND CLASSIFICATION

The Glasgow Coma Scale is difficult to apply to the young (under 5 years) child. Although modifications exist, great care needs to be taken with its interpretation and this should be done by those with experience in the management of the young child.

IMAGING

Skull fractures in children, though significantly associated with an increased risk of intracranial injury, are not as discriminating as in adults. In children with a head injury, significant intracranial injury occurs more frequently in the absence of a skull fracture than is the case in adults. Clinical features (e.g. tense fontanelle) are an equally important factor in determining the need for a CT scan to rule out intracranial injury.

In the absence of clinical signs of intracranial injury, observation by experienced paediatric medical and nursing staff in an appropriate unit/ward is an alternative to urgent CT scan.

ADMISSION OR DISCHARGE?

Children should be admitted if any of the following risk factors apply:

history of loss of consciousness
neurological abnormality or persisting headache or vomiting
clinical or radiological evidence of skull fracture or penetrating injury
difficulty in making a full assessment
suspicion of non-accidental injury
other significant medical problem
not accompanied by responsible adult or social circumstances considered unsatisfactory.

In injured children, especially the very young, the possibility of non-accidental injury must be considered when findings are not consistent with the explanation given, if the history changes, or if the family is known to be on the "At Risk" register. In such a case a medical practitioner with experience in the care of children should be involved and should contact the duty social worker to allow early investigation. Locally agreed guidelines and protocols should be followed.

Children can be discharged from A&E if none of the risk factors noted above apply. Clear written instruction should be given to and discussed with parents or carers before a child is discharged.

INPATIENT OBSERVATION

Children <3 years old who have sustained a head injury are particularly difficult to evaluate and clinicians should have a low threshold of suspicion for early consultation with a Specialist Paediatric Surgical Unit. Children requiring admission should be admitted under the care of a paediatrician or paediatric surgeon with experience in the care of children with a head injury and should be observed in a children’s ward.

REFERRAL TO A NEUROSURGICAL UNIT

Transfer of a child to a specialist neurosurgical unit should be undertaken by staff experienced in the transfer of critically ill children – i.e. a (Regional) Paediatric Transfer Team.

FOLLOW UP

Children suffering significant head injury should be followed up by a specialist multidisciplinary team to assess the need for rehabilitation and should include notification to the school medical service and the primary health care team.

Early Management of Patients with a Head Injury Summary of Paediatric Practice Points

Early Management of Patients with a Head Injury
Summary of Paediatric Practice Points