Head Injury Actions
You will or have seen a multitude of pediatric head injuries come into your practice setting with sometimes frantic parents/caretakers with great concern over their loved one’s wellbeing. The first determination to make, which may be done quickly, is taking immediate action or rather reassure and prevent unnecessary intervention/radiation exposure. In situations such as this, there are available evidence-based clinical tools/algorithms to help assist your plan of care.
My personal favorite clinical decision tool for minor pediatric head injury is the PECARN Pediatric Head Injury/Trauma Algorithm, which can be found on many sites. I frequently utilize MDCalc on a daily basis for all clinical decision rules and it serves as a free, rapid and great resource in my everyday practice. PECARN constructed a tool for low-risk head injuries that is intended to aid the provider in making a sound, evidence-based decision that was constructed using the largest study group of all available relevant tools as well as having the best sensitivity for serious intracranial injury.
Head Trauma Injuries
Not surprisingly, head trauma occurs most commonly in childhood and most head trauma is minor and not associated with clinically important traumatic brain injury (ciTBI) or long-term sequelae. However, head trauma accounts for 80% or more of traumatic injuries leading to death for children over the age of 1 in the US. Most life-threatening pediatric head injuries are the result of motor vehicle collisions, falls, assaults, recreational activities and child abuse. The biggest challenge is to identify those in the pediatric population with ciTBI while
limiting or abstaining from radiation exposure. While your clinical acumen plays a major role, having the backup of the PECARN Pediatric Head Injury/Trauma Algorithm really solidifies your confidence as well as provides reassurance to family/caretakers.
PECARN Trial Statistics
The PECARN trial included over 42,000 children presenting to US emergency departments with head injuries. 0.9% of the population studied had ciTBI defined as: death from TBI, neurosurgical intervention for TBI such as ICP monitoring, elevation of depressed skull fracture, lobectomy, tissue debridement, dura repair, ventriculostomy, intubation for >24 hours, hospital admission of 2 nights or more for the TBI found on CT. Neurosurgery was performed in 0.1% of the group and zero patients died. The PECARN study has been validated by two separate studies showing 100% sensitivity in ruling out ciTBI. Interestingly, contrary to general belief, a vomiting episode, number of vomiting episodes and timing of vomiting were of not predictive value for ciTBI.
Taking a detailed history of the injury itself, such as mechanism of injury, loss of consciousness and if so for how long, height of fall, or the object that struck head is vital to your history.
- Was there any seizure activity or vomiting?
- Does the child have a headache?
- Are there any pre-existing disorders placing
higher risk for ciTBI such as AVM or bleeding disorders?
- In addition, it is important to ask the parent or caretaker if the child is acting appropriately per
their usual baseline and if acting differently, how so?
- Moving to physical exam, be sure to obtain and document GCS if able,
otherwise document your observation of the child. For example, are they active,
running around the room playing in no apparent distress?
- Are they conversing appropriately?
- Are they somnolent, with repetitive questioning, or slow to respond?
Physical exam findings and documentation, at a minimum, should focus on neuro, cervical vertebrae, skull findings (Battle’s sign, raccoon eye(s), hematoma, crepitus, obvious fracture), respiratory, eye, and ENT exams. The idea is to create a clinically relevant and clear picture when deciding to obtain imaging for the pediatric head injuries. It is important to involve the parent(s)/caretakers(s) in this decision as well to provide them with as much information to help them both understand and to make the correct decision when it comes to observation or obtaining imaging. Regardless, a discussion about concussion secondary to head injury before discharge as well as ensuring proper education, handouts, and follow up is a “no-brainer.” When it comes to pediatric head injuries, PECARN is invaluable and documentation of a PECARN score directly copied and pasted from the MDCalc site is a routine practice of mine. I highly recommend you do this as well moving forward.
-Lucas Marlatt, ARNP