Current controversies in the management of minor pediatric head injuries

Each year hundreds of thousands of children receive care in emergency departments after head injury. Minor head injuries account for a majority of these injuries. The prevalence, morbidity, and costs associated with pediatric minor head injuries make it an important topic. We review the management of pediatric minor head injury, emphasizing current areas of controversy, including criteria for neuroimaging, indications for hospitalization, the role of anticonvulsant therapy, and the long-term neurobehavioral sequelae of pediatric minor head injury.     

Immediate improvement in GCS following needle aspiration of bilateral traumatic subdural effusion in a child in emergency room

A minor head injury can cause traumatic subdural effusion in a child. They often present to pediatric emergencies initially, and there is a delayed referral to neurosurgery. In the emergency room, they should undergo subdural effusion needle aspiration, which can result in an immediate improvement in GCS.     

Minor head injury in the Republic of Ireland: evaluation of written information given at discharge from emergency departments

Most patients presenting to the emergency department with minor head injuries are discharged with written information. Here the quality of minor head injury discharge leaflets in the Republic of Ireland is evaluated against a nationally accepted template. There was great variability in leaflet content. Most provided minimal information on emergency symptoms but 60% contained no information on post-concussional symptoms. No leaflet was available in audio-format or languages other than English. Information provided in minor head injury leaflets should be improved and standardised across Ireland.     

Emergency care of children and adults with head injury

Head injury is common and accounts for a significant proportion of patient attendances at emergency departments and minor injury units. While most injuries will not be serious in nature, some will be severe. Therefore assessment, investigation and early management of head injury are essential to reduce the potential risk of disability or even death. This article focuses on emergency care of children and adults with head injuries. Advice about the signs and symptoms of severe head injury, the importance of computed tomography and after care following head injury are outlined.     

Evaluation of the impact of the Canadian CT head rule on British practice

Background: The Canadian CT head rule has been developed to identify which adults with minor head injuries require computed tomography (CT). This is hoped will reduce the number of CT scans performed for minor head injury in North America. It was unclear whether applying the rule would reduce or even increase the number of CT scans requested in UK emergency departments.

Methods: A retrospective evaluation was conducted of all adults who presented after minor head injuries to Addenbrooke's emergency department. Clinical information about patients with head injuries is collected on standardised forms. A dataset was constructed to predict how many patients would require head CT scans if the Canadian CT rule was applied.

Results: 1489 adults presented after minor head injury over a seven month period. Seventy four of these had CT scans for head injury, applying the Canadian CT head rule would have resulted in 132 CT scans being requested. This is significantly more (p>0.001). This would have resulted in a 68% increase in costs.

Interpretation: The Canadian CT head rule would result in an increase in the number of CT scans requested for minor head injuries. This increased cost must be considered against the 488 skull radiographs that were requested during the study period.

     

Reducing Unnecessary Head Computed Tomographic Scans in an Adult Emergency Department

A computed tomographic (CT) scan of the head is commonly used in the emergency department for patients who present with minor head injury. Frequent use of CT imaging contributes to health care costs, radiation exposure, and emergency department length of stay. The objective of this project was to decrease unnecessary head CT scans for patients presenting with minor head injury. A clinical decision pathway using the Canadian CT Head Rule was implemented. There was a 12% decrease in head CT use over 8 weeks, and no brain injuries were missed. These outcomes support the implementation of a clinical pathway using the Canadian CT Head Rule on a larger scale.     

Ability of Emergency Ultrasonography to Detect Pediatric Skull Fractures: A Prospective,Observational Study

Background

Blunt head trauma is a common reason for medical evaluation in the pediatric Emergency Department (ED). The diagnostic work-up for skull fracture, as well as for traumatic brain injury, often involves computed tomography (CT) scanning, which may require sedation and exposes children to often-unnecessary ionizing radiation.

Objectives

Our objective was to determine if bedside ED ultrasound is an accurate diagnostic tool for identifying skull fractures when compared to head CT.

Methods

We present a prospective study of bedside ultrasound for diagnosing skull fractures in head-injured pediatric patients. A consecutive series of children presenting with head trauma requiring CT scan was enrolled. Cranial bedside ultrasound imaging was performed by an emergency physician and compared to the results of the CT scan. The primary outcome was to identify the sensitivity, specificity, and predictive values of ultrasound for skull fractures when compared to head CT.

Results

Bedside emergency ultrasound performs with 100% sensitivity (95% confidence interval [CI] 88.2–100%) and 95% specificity (95% CI 75.0–99.9%) when compared to CT scan for the diagnosis of skull fractures. Positive and negative predictive values were 97.2% (95% CI 84.6–99.9%) and 100% (95% CI 80.2–100%), respectively.

Conclusions

Compared to CT scan, bedside ultrasound may accurately diagnose pediatric skull fractures. Considering the simplicity of this examination, the minimal experience needed for an Emergency Physician to provide an accurate diagnosis and the lack of ionizing radiation, Emergency Physicians should consider this modality in the evaluation of pediatric head trauma. We believe this may be a useful tool to incorporate in minor head injury prediction rules, and warrants further investigation.     

Evaluation of minor head trauma in children younger than two years

The recent medical literature emphasizes the limitations of skull films in the evaluation of minor head trauma. However, the emergency medicine literature places little emphasis on the particular risks in children younger than 2 years old with blunt head injury. These children have immature bone and unfused sutures that may increase risk of cranial injury and delayed complications. A case is presented to illustrate this point. Unlike severe head trauma, where evaluation is directed toward computed tomography, the literature continues to be controversial regarding the indications for skull radiographs and computed tomography in minor head trauma. The authors recommend a low threshold for radiographic imaging in blunt heat injuries in children younger than 2 years.     

Management of minor head injuries in the accident and emergency department: the effect of an observation ward.

The management of 483 patients presenting with minor head injury to the accident and emergency (A&E) departments of two Scottish hospitals was studied prospectively. Such patients comprised 5.7 and 3.9% of the total attendances to each department. Of the 277 patients assessed in the former department, 83 (30%) fulfilled at least one of the currently accepted criteria for recommending admission to hospital and 49 (17.7%) patients were actually admitted. Patients in whom head injury was not the principal reason for admission were excluded from the study. In the same time period the second department dealt with 206 patients with minor head injury, 49 (24%) of whom had criteria for admission. However, significantly fewer, 10 (4.9%) patients, were actually admitted. The major relevant factor when comparing the two departments was the existence in the former of an observation ward. These results support the view that easy access to hospital beds is a major determinant of management in patients presenting with minor head injury to the A&E department and may be more influential than clinical findings.     

Head injury instructions: a time to unify.

OBJECTIVE: To compare and contrast the head injury advice give by various hospitals in England after minor head injury, and to draw attention to the need for a national set of head injury instructions. METHODS: 50 accident and emergency departments were contacted by post and asked to supply a copy of their head injury information card or leaflet; 41 hospitals replied (82%). RESULTS: Comparison of the cards showed inconsistencies and conflicting advice given by the departments contacted. CONCLUSIONS: There is a need for a national head injury card and a proposal for such a card is presented.     

An unusual presentation of a minor head injury sustained during a game of rugby

In the UK, about 2% of the population attend the accident and emergency (A&E) department every year after a head injury. A majority of the patients have minor head injury and are discharged. Studies reveal that patients who reattend the A&E after a minor head injury represent a high-risk group. Concussion injuries are common and not all require treatment at the time of presentation. However, some may worsen after initial presentation and develop signs of serious head injury. A case of minor head injury as a result of head butt during a game of rugby, not associated with alteration in conscious state or focal neurological signs, and subsequent development of frontal lobe abscess a month later is reported. It is important that patients fit to be discharged at the time of consultation are discharged in the care of a responsible adult with clear head injury instruction sheets and are advised to return should their symptoms change. A high index of suspicion should be maintained and an early imaging technique, such as CT scan should be considered in patients reattending the A&E with persistent symptoms even after minor head injury.     

Evaluation and Management of Moderate to Severe Pediatric Head Trauma

A case of pediatric head trauma is presented with a detailed discussion of current concepts in evaluation and treatment. Management of the moderate to severe head-injured child is reviewed, and best practices for emergency department treatment are discussed. Background: Pediatric head trauma is a common and potentially devastating injury. Thorough knowledge of the clinical evaluation and treatment will assist the emergency physician in providing optimal care. Discussion: Using a case-based scenario, the initial management strategies along with rationale evidence-based treatments are reviewed. Conclusions: Computed tomography scan is the diagnostic test of choice for the moderate to severe head-injured pediatric patient. Several unique scales to describe and prognosticate the head injury are discussed, although currently, the Glasgow Coma Scale is still the most commonly accepted one. Similar to the adult patient, avoidance of hypotension and hypoxia are key to decreasing mortality. Etomidate and succinylcholine remain the choice of medications for intubation. Hyperventilation should be avoided.     

Necessity of hospital admission for pediatric minor head injury

The objective of this study was to evaluate the need for mandatory hospital admission of all pediatric patients with minor head injury (MHI) and negative computed tomographic (CT) scans for head injury. The study was a retrospective chart review of all patients admitted to a pediatric trauma service over a period of 4 years. MHI was defined as blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and a nonfocal neurological examination. Only patients < or = 13 years of age and with a negative head CT scan were included, and during hospitalization all patients were observed for delayed complications. A total of 197 patients met the inclusion criteria. The patients' mean age was 7.1 years, with a range of 2 months to 13 years. The most common mechanisms of injury were being struck by a motor vehicle while walking (82 patients), and falling (75 patients). No complications were observed, and although persistent symptoms occurred in 5 patients, they did not delay discharge. We conclude that pediatric patients with MHI and negative CT scans of the head do not require routine admission for observation for delayed complications.     

Warfarin and the apparent minor head injury.

Two cases of patients on warfarin who developed intracranial haematoma after an apparently minor head injury are described. There is a 10-fold increase in the likelihood of developing an intracranial haematoma in these patients. Recommendations are made regarding the management of this type of patient seen in the accident and emergency department.     

Pediatric sledding trauma: avoiding the collision

During 2006-2007, a midwest pediatric level I trauma center and affiliated urgent care centers treated 181 children for sledding-related trauma. Twenty-one children required hospitalization for injuries. Some children sustained injuries that were severe including cervical fracture with spinal cord injury, splenic laceration, pulmonary contusion, and head injury. The most frequent mechanism of injury was collision with an object or a person. Although most injuries are minor, some are serious and may have life-changing outcomes. Sledding in unobstructed areas may decrease injuries. An increased public awareness of the risks of serious injury associated with sledding is needed.     

A secondary analysis to inform a clinical decision rule for predicting skull fracture and intracranial injury in children under age 2

The purpose of this study was to identify factors associated with the risk of closed head injury (CHI) in children under age 2 years with suspected minor head injuries based on age-appropriate, or near age-appropriate, mental status on an exam. The study was a secondary data analysis of a public-use dataset from the largest prospective, multicenter pediatric head injury study found in the current literature. An existing, validated clinical decision rule was examined using a sample of 3,329 children under age 2 to determine whether it, or the individual variables within it, could be utilized alone, or in conjunction with other variables to accurately predict the risk of underlying CHI in this sample. Results indicated that the keys to an accurate triage assessment for children under age 2 with suspected minor head injuries include the ability to identify the specific skull region injured, the ability to assess for the presence and size of any scalp hematoma, the ability to identify signs of altered mental status in this age group, and having access to accurate information regarding the child's age and the details of the injury mechanism. The findings from this study add to the body of knowledge regarding what factors are associated with CHI in children under age 2 with suspected minor head injuries and could be used to inform age-specific recommendations for children under age 2 in triage, educational resources, and national trauma criteria.     

Nursing care of patients with minor head injury

During the past two decades the subject of severe head injury has received much time, attention, and research funding. Although the number of persons in the United States suffering minor head injury is at least four times greater than the number with severe head injury, it has received less attention and resource allocation. The patient with minor head injury presents a clinically different picture as compared to severe head injury; posttraumatic problems also differ. Nursing care differs accordingly and will be the focus of this article.     

A review of health professional attitudes and patient perceptions on 'inappropriate' accident and emergency attendances. The implications for current minor injury service provision in England and Wales

Increasing attendances in accident and emergency (A and E) departments in the United Kingdom have been attributed to a greater number of patients presenting with minor injuries. A and E staff believe this type of patient is suitable for primary care, and is 'inappropriate' for A and E management. Thus, A and E staff find 'inappropriate' attenders time-consuming and unrewarding, and are less motivated to help them, whilst 'inappropriate' patients believe they have attended the appropriate service for their medical needs and expectations. This review examines research into health professional and patient attitudes towards 'inappropriate' attendances in accident and emergency. It identifies a discrepancy between health professional and patient perspectives regarding 'inappropriate' attendances. However, the change in accident and emergency services with the development of minor injury units and nurse practitioners within A and E to treat minor injury patients away from the mainstream A and E service, appears to be based on the professional attitude of what constitutes an appropriate A and E attendance, and not on the patients' perspective. As negative attitude formation towards 'inappropriate' A and E attendances has occurred, there is concern that such attitudes could remain or develop again in the new units. Patients are generally not medically trained and may experience difficulty in ascertaining the severity of their own condition and attending the 'appropriate' service, as defined by trained professionals. This is exacerbated by the unclear boundaries and roles of minor injury units, nurse practitioners and general practitioners in minor injury care. Therefore research is required into current attendances in minor injury units, A and E departments and general practice, in order to develop clear roles and boundaries for these services. More importantly, research is warranted into the attitudes of all minor injury care providers towards attending patients, and into patient perceptions of the services offered.     

Effects of pediatric head trauma for children, parents, and families

Severe pediatric head injury has negative consequences for children of all ages. Even mild and moderate head injury results in residual impairment for school-age children and adolescents. Data are needed on the effects of these less severe insults, especially for preschoolers. Although research on the impact of the child's head injury on the parent-child relationship and family functioning is limited, the experience is likely to be very stressful for the parent and the family. Indeed, family integrity may be at risk. Research is needed that examines the effects of a child's head injury for the parent and the family over time and identifies factors related to these outcomes.     

The incidence of post minor traumatic brain injury syndrome: a retrospective survey of treating physicians.

There is a relative lack of information in the literature regarding the epidemiology, functional significance, and clinical resolution of the consequences of minor traumatic brain injury (MTBI). Most retrospective studies to date have been elicited by direct patient interview. Because it was supposed that a minor, but significant, traumatic brain injury would require continuing medical intervention beyond the emergency room contact, a survey was conducted of primary care physicians who were believed to be providing continuing medical care. Had their patients required reevaluations for symptoms of the post-MTBI syndrome? Two hundred fifty-six patients with traumatic brain injury initially seen in the emergency room of two community hospitals were reviewed. One hundred ninety-two (75%) had MTBIs (Glasgow coma scale more than 12 and a negative head CAT scan). One hundred twenty-two physicians were surveyed by mail; 67 (55%) responded. Twenty-one percent of their patients were experiencing symptoms of the post-MTBI syndrome from two to six months after their injuries. Studies relying on patient interviews have also estimated the post-MTBI syndrome at 20%. This correlation implies that "suggestion" does not bias patient interview style research in evaluating the post-MTBI syndrome.