TRAUMA - PAEDIATRIC
HEAD INJURY - PAEDS
May be rural = Retrieve!!
Prompt
ResponseLeft frontal extradural haematoma/left anterior cranial fossa, approximately 1.5 x 4cm
Left frontal lobe compressed slightly
Fluid in left frontal sinus
Air bubble
External soft tissue swelling
Debatable presence of midline shift
Left frontal lobe compressed slightly
Fluid in left frontal sinus
Air bubble
External soft tissue swelling
Debatable presence of midline shift
Prompt
ResponseAcute left parietal extradural haemorrhage 2 cm x 8 cm
Midline shift 1cm
Effacement of left lateral ventricle
Effacement of sulci
Loss of grey-white differentiation.
Midline shift 1cm
Effacement of left lateral ventricle
Effacement of sulci
Loss of grey-white differentiation.
PromptList validated CT head rules and compare research/evidence
ResponsePECARN prospectively validated
CATCH , CHALICE uses ‘rule in ‘ criteria (decides who NEEDS CT)
PECARN uses ‘rule out’ criteria (decides who NOT to CT)
PECARN has highest point sensitivity
CATCH , CHALICE more specific but less sensitive
Also Nexus 2…
Decision rules exclude patients with bleeding disorder, pre-existing neuro disorder/tumour/shunt
CATCH , CHALICE uses ‘rule in ‘ criteria (decides who NEEDS CT)
PECARN uses ‘rule out’ criteria (decides who NOT to CT)
PECARN has highest point sensitivity
CATCH , CHALICE more specific but less sensitive
Also Nexus 2…
Decision rules exclude patients with bleeding disorder, pre-existing neuro disorder/tumour/shunt
PromptList definite indications for CTB in paeds head injury
ResponseGCS <14 or declining GCS
focal neurology;
seizures
signs of basilar skull #
penetrating skull injury.
CT highly encouraged
NAI
Significant progressive symptoms
focal neurology;
seizures
signs of basilar skull #
penetrating skull injury.
CT highly encouraged
NAI
Significant progressive symptoms
PromptIndications for CT brian in child (By rule)
THIS IS GOING TO BE ASKED
THIS IS GOING TO BE ASKED
Response
- CHALICE:
- HISTORY: Witnessed LOC >5 mins, Amnesia >5mins, Abnormal Drowsiness, >2 vomits, Suspected NAI, Traumatic Seizure
- EXAM: GCS <14, suspected Skull injury, Signs of BOS#, Focal Neurology, Bruise>5cm
- MECHANISM: High Speed MVA, Fall >3m, Hit by projectile
- PECARN:
- CATCH: Similar – GCS <15 at 2hrs, Suspected Skull#, Worsening headache, Irritability are the HIGH risk features.
PromptComponents to safely perform a CT brain in paediatric patients
ResponseConsent
Sedation/Access – IV: ketamine 0.5-1mg/kg or other suitable agent
Antiemesis – ondansetron 0.15mg/kg
Monitoring – at least Sats and Cardiac/NIBP
Sedation/Access – IV: ketamine 0.5-1mg/kg or other suitable agent
Antiemesis – ondansetron 0.15mg/kg
Monitoring – at least Sats and Cardiac/NIBP
PromptDescribe discussion points with parent about a CTB/Concussion
ResponseNot required as per best evidence
CTB performed to diagnose injury that requires neurosurgical intervention
Concussion managed conservatively
Risk of radiation: lifetime cancer mortality risk from a single head CT is about
1 in 1,500 in a 1 year old; 1 in 10,000 in a 10 year old
Risk related to sedation if required
CTB performed to diagnose injury that requires neurosurgical intervention
Concussion managed conservatively
Risk of radiation: lifetime cancer mortality risk from a single head CT is about
1 in 1,500 in a 1 year old; 1 in 10,000 in a 10 year old
Risk related to sedation if required
PromptDealing with a parent demanding inappropriate CTB
ResponseIdentify yourself and role
Ensure that all relevant communication is clear to ensure no mismatch in understanding
Explain basis of clinical decision – NOT for CT – supported by decision rules
Identify their concerns re: no CT – explore their concerns; attempt reassurance
Offer alternate options – SSW for observation etc
Ensure that all relevant communication is clear to ensure no mismatch in understanding
Explain basis of clinical decision – NOT for CT – supported by decision rules
Identify their concerns re: no CT – explore their concerns; attempt reassurance
Offer alternate options – SSW for observation etc
PromptManagement of minor head injury in child
ResponseObservation period- ED SSU with hourly neuro obs
If any deterioration- CT
If remains well, discharge
Discharge advice on ongoing management
Return to ED advice
If any deterioration- CT
If remains well, discharge
Discharge advice on ongoing management
Return to ED advice
PromptDiscussion with parents about retrieval to neurosurgery centre
ResponseCritically unwell.
Prognosis – guarded.
Treatment so far.
Expected treatment.
Time frame / method for transfer.
Where to go. / How to get there.
Supports available at referring / receiving sites / with parent transport.
Prognosis – guarded.
Treatment so far.
Expected treatment.
Time frame / method for transfer.
Where to go. / How to get there.
Supports available at referring / receiving sites / with parent transport.