Paediatric head injuries

SJH Emergency Medicine
NHS Lothian

Remember that the optimal management of a head injury starts with assessment and control of ABC first. See ‘Management of the Seriously Ill Child’ and ‘Multiply Injured children’ in the old Paediatric Guidelines.

Always consider NAI if the findings are not consistent with the explanation given, the history changes or the child is known to be ‘at risk’. This is particularly so in the very young child with a head injury. Refer to the paediatrician if you are in any doubt.

Assessment of conscious level

The GCS is difficult to apply to children under 5 years old, even with modifications. Use great care in interpreting the GCS in young children.

The ‘AVPU’ score is often more useful (see Disability section in ‘Primary Survey and Resuscitation’ in the old guidelines).

Imaging

Most children who present with a head injury will not require any imaging. This section provides indications for imaging the small number of children who are at risk of associated brain injury / complications. It has been copied from the most recent relevant NHS Lothian guidelines.

Plain x-rays (i.e skull XR) is not routinely indicated in children with head injury

CT scanning should be performed if, after discussion with a senior ED clinician (ideally consultant), there is:

  • Suspicion of non-accidental injury
  • Clinical evidence of base of skull fracture
  • Any new focal neurological deficit
  • A reduced conscious level (aged over 1yr: GCS <14 at presentation, or < 15 after 2 hrs; aged under 1yr GCS <15 at presentation)
  • A suspected open fracture, penetrating brain injury or tense fontanelle
  • A bruise, swelling or laceration of more than 5 cm on the head and the child is aged under 1 year
  • A bleeding disorder or anticoagulation with any neurological symptoms / signs

Children with the following should be discussed with senior ED clinician (ideally consultant), observed for 2- 4 hours and a CT performed if any deterioration / failure to improve / ongoing concern:

  • Loss of consciousness lasting more than 5 minutes (witnessed)
  • Abnormal drowsiness
  • Persistent vomiting
  • Significant mechanism of injury (e.g high energy RTA, fall >3m)
  • Amnesia (antegrade or retrograde) lasting more than 5 minutes
  • Bleeding disorder or anticoagulation with no neurological concerns (must be discussed with haematology team – may need longer period of observation)

Referral to neurosurgery

Any child with an abnormal CT scan, or persisting decreased conscious level or persisting focal neurology should be discussed with the on-call neurosurgical team (via switchboard).

If the child needs to be transferred it is best to discuss the child with the PICU retrieval team although they may recommend transfer by one of the SJH anaesthetists if urgent neurosurgical intervention is required.

Discharge

Children who either do not meet the criteria for CT, or who have a normal CT, can often be safely discharged from the Emergency Department. However, admission may be indicated if there is:

  • Persisting headache / vomiting / lethargy
  • Difficulty in making a full assessment
  • Suspicion of non-accidental injury (d/w child protection)
  • Other significant medical problem
  • Not accompanied by responsible adult or social circumstances considered unsatisfactory

If a patient is discharged, please give them the paediatric head injury leaflet and explain this to the guardian.

Indications for admission

Please discuss with registrar or consultant any child who meets any of the above criteria or for whom you have ongoing concerns, regarding the need for admission.  There is no prerequisite that a scan should be performed prior to admission to the children’s ward if they are still within the 2-4 hour period of observation and do not meet the criteria for an immediate scan. If they are approaching the 4 hour point, it may be more appropriate to make a decision within the ED to help facilitate scanning, etc.

On SJH site these patients can potentially be admitted to the children’s ward, on agreement with the paediatric team.

Editorial Information

Last reviewed: 21/08/2024

Next review date: 19/01/2026

Author(s): Alexis Leal.

Author email(s): alexis.leal@nhs.scot.

Reviewer name(s): Alexis Leal, Deepankar Datta.

References
  1. NHS Lothian. Imaging for children aged <16yrs with head injury and referral for admission. 19/01/2023. Approved by RHCYP Medical Guidelines Group
Evidence method

Imaging section copied directly from NHS Lothian multi-disciplinary guidelines - see the attached document for their evidence base and stakeholders involved.

SJH specific admission policies discussed locally, and based on the 2021 revision of the NHS Lothian "Imaging for children aged <16yrs with head injury and referral for admission"