Head trauma in the child
Cranial-brain injury resulting from a traumatic event
Head trauma in the child
2
Main causes of head trauma
< 5 years (particularly <2 years): accidental falls and abuse > 5 years: sports and road accidents Most of the child’s head injuries are minor and have no consequences; however, it is extremely important to identify those traumas that pose a risk of death or disabling sequele.
Head trauma in the child
3
Triage methodology
On the door assessment: • ABC sequence • Glasgow Coma Scale/pGCS (if < 1 year) • A(lert) V(erbal) P(ain) U(nresponsive) • Gross neurological deficits
Head trauma in the child
4
GLASGOW COMA SCALE (GSC) FOR MORE DETAILED ASSESSMENT OF NEUROLOGICAL STATUS, MODIFIED FOR PEDIATRIC AGE EYE OPENING Score 4 3 2
1
Age > 1 year Spontaneous In command To pain No response
Age < 1 year Spontaneous To noise To pain No response
BEST MOTOR RESPONSE Score 6 5 4 3 2
1
Age > 1 year Obeys Localizes the pain Flexes/retracts from pain Decorticated flexure Brainless extension No response
Age < 1 year Normal spontaneous Localizes the pain Flexes/retracts from pain Decorticated flexure Brainless extension No response
BEST VERBAL RESPONSE Score 5 4 3 2
1
Head trauma in the child
Age > 5 years
Age 2-5 years
Age 0-23 years
Oriented, converse Disoriented, converse Disconnected words Incomprehensible sounds No response
Appropriate words/phrases Inappropriate words Persistent crying/yelling Incomprehensible sounds No response
Vocals/laughs Cries/is inconsolable Persistent crying/yelling Incomprehensible sounds/agitated No response
5
Head trauma in the child
CODE
GCS
PUPILS
1
≤9
anisocoria
2
10-13
miosis/mydriasis
3
14
normal
4
14
normal
5
15
normal
6
Triage methodology
Data collection (patient/companion): • Trauma modality and elapsed time • Symptoms following the trauma (including possible amnesia) • Possible pathologies or taking drugs predisposing to bleeding (thrombocytopenia, hemophilia, taking aspirin or anticoagulants, etc.) • Previous NCH interventions
Head trauma in the child
7
Triage methodology
Vital parameters collection: • • • • • •
Blood pressure Heart rate Respiratory frequency Body temperature SpO2% Pain (FLACC/VAS)
Head trauma in the child
8
Triage methodology
During the physical examination, evaluate: • • • • • •
Skull depressions Penetrating or bleeding wounds Floating swellings Oto- or rhinorrhea Periorbital or retroauricular ecchymosis Stability of the dentition and facial bones
Head trauma in the child
9
Head trauma in the child ON THE DOOR ASSESSMENT • ABC, AVPU, GCS • Presence of neurological deficits
CODE 1 Emergency
• • • • •
YES
Loss of consciousness ≥ 30 sec Drowsiness Difficulty waking up and/or speaking Motor and/or sensory deficits Anisocoria or non-reactive pupils
• • • • •
Pulsating bleeding from the scalp Oto-rhinorrhea Coagulation deficit DVP presence GCS ≤ 9
CODE 2 Urgency
NO
SHOCK ROOM
• • • • • • • •
Reported loss of consciousness <30 sec. • • Vomit ≥ 4 episodes • Inconsolable crying • Irritability • Severe headache • Amnesia • Visual impairments • Dizziness
N.B: if the Triage nurse suspects cervical trauma, he/she will apply a rigid cervical collar. Head trauma in the child
NO
Recent seizure Retroauricular or periorbital bruising Multiple wounds/lacerations Severe depressions in the cranial case Age < 6 months Inappropriate history Greater dynamics GCS 10-13
15 minutes have passed and the patient still has not accessed the treatment area?
YES • Direct observation with constant condition monitoring • Revaluation of Vital Parameters • GCS, AVPU, Pain revaluation • Associated signs and symptoms 10
Head trauma in the child NO
Deferrable urgency CODE 3
YES
• • • • •
Headache Slight irritability Vomit < 4 episodes Localized wounds/lacerations GCS 14
Minor urgency CODE 4
NO
•
60 minutes have passed and the patient still has not accessed the treatment area?
• Repetition of parts or all of the assessment steps as judged by the Triage nurse or the patient/carer • Vital parameters revaluation • GCS, AVPU, Pain revaluation • Associated signs and symptoms
• • • •
Minor head injury without loss of consciousness Absence of vomiting episodes Sensory intact Non neurological deficits “Minor” wounds 120 minutes have passed and the patient still has not accessed the treatment area?
Patient access to the examination room
Head trauma in the child
11
PEDIATRIC TRIAGE OF TRAINING TRAUMA TRIAGE CODE
1
2
3
4
5
Vital parameters
from code 1
from code 2
from code 3
from code 4
from code 5
Characteristics of the main symptom/sign
Reported prolonged loss of consciousness ≥30 sec. Drowsiness. Difficulty waking up and/or speaking. Motor and/or sensory deficits. Anisocoria or non-reactive pupils. Pulsating bleeding from the scalp. Oto Rhinoliquorhea.
Reported loss of consciousness <30 sec. Vomiting ≥4 episodes. Inconsolable crying, irritability. Dizziness. Recent seizure. Retroauricular or periorbital bruising. Multiple wounds/lacerations, severe skull case depressions.
Headache, mild irritability. Vomiting <4 episodes. Localized wounds/lacerations.
Minor head injury, without loss of consciousness or vomiting. Sensory intact, no neurological deficits. «Minor» wounds.
Associated symptoms/signs
Coagulation disorders (thrombocytopenia, hemophilia); V-P derivation
Age <6 months. Inappropriate story. Greater dynamics.
Specific scores
GCS
GCS Pain
GCS Pain
GCS Pain
Head trauma in the child
12
TRIAGE PROCEDURES Activities Consulting activity
Pain therapy Revaluation
Other
Head trauma in the child
1
2
3
4
5
Venous access, blood tests
from code 4
from code 5
Exceeded the 60 minute wait according to protocol According to local protocol Direct or videomediated observation with constant condition monitoring.
Repetition of part or all of the evaluation phases on the decision of the triagist, at the request of the patient, once the maximum recommended waiting time has elapsed.
See associated symptom tabs
13
Head trauma in the child Clinical cases
Head trauma in the child
14
Clinical case 1
• 8 month old patient • Conducted in PS due to falling from bed (about 50 cm high) which occurred one hour before arrival • The mother reports that she was present not directly witnessing the dynamics while hearing the baby’s cry • No loss of consciousness reported • One episode of vomiting
Head trauma in the child
15
Clinical case 1
• • • • • • •
Good general conditions Alert and responsive pGCS 15 AVPU=A Absence of swelling of the scalp Isochoric pupils, isocyclic cells that react normally to the light stimulus Absence of strength deficit
Head trauma in the child
Vital parameters: • • • • • •
PA 91/54 FC 130 FR 30 TC 36.4 SpO2 100% in AA FLACC 1
16
Clinical case 1 PEDIATRIC TRIAGE OF TRAINING TRAUMA TRIAGE CODE
1
2
3
4
5
Vital parameters
from code 1
from code 2
from code 3
from code 4
from code 5
Characteristics of the main symptom/sign
Reported prolonged loss of consciousness ≥30 sec. Drowsiness. Difficulty waking up and/or speaking. Motor and/or sensory deficits. Anisocoria or non-reactive pupils. Pulsating bleeding from the scalp. Oto Rhinoliquorhea.
Reported loss of consciousness <30 sec. Vomiting ≥4 episodes. Inconsolable crying, irritability. Dizziness. Recent seizure. Retroauricular or periorbital bruising. Multiple wounds/lacerations, severe skull case depressions.
Headache, mild irritability. Vomiting <4 episodes. Localized wounds/lacerations.
Minor head injury, without loss of consciousness or vomiting. Sensory intact, no neurological deficits. «Minor» wounds.
Associated symptoms/signs
Coagulation disorders (thrombocytopenia, hemophilia); V-P derivation
Age <6 months. Inappropriate story. Greater dynamics.
Specific scores
GCS
GCS Pain
GCS Pain
GCS Pain
Head trauma in the child
17
Clinical case 2
• 9 year-old patient • Road accident (vehicle collision) • Rear passenger with protective equipment (seat belts) • Amnesia • One episode of vomiting 30 minutes after the trauma
Head trauma in the child
18
Clinical case 2
• • • • •
•
Headache GCS 13 AVPU=V Scalp swelling Presence of tender swelling in the left zygomatic region and ipsilateral superior periorbital region Isochoric pupils, isocyclic cells that react normally to the light stimulus
Head trauma in the child
Vital parameters: • • • • • •
PA 118/69 FC 83 FR 22 TC 36 SpO2 100% in AA VAS 4
19
Clinical case 2 PEDIATRIC TRIAGE OF TRAINING TRAUMA TRIAGE CODE
1
2
3
4
5
Vital parameters
from code 1
from code 2
from code 3
from code 4
from code 5
Characteristics of the main symptom/sign
Reported prolonged loss of consciousness ≥30 sec. Drowsiness. Difficulty waking up and/or speaking. Motor and/or sensory deficits. Anisocoria or non-reactive pupils. Pulsating bleeding from the scalp. Oto Rhinoliquorhea.
Reported loss of consciousness <30 sec. Vomiting ≥4 episodes. Inconsolable crying, irritability. Severe headache. Amnesia. Visual impairments. Dizziness. Recent seizure. Retroauricular or periorbital bruising. Multiple wounds/lacerations, severe skull case depressions.
Headache, mild irritability. Vomiting <4 episodes. Localized wounds/lacerations.
Minor head injury, without loss of consciousness or vomiting. Sensory intact, no neurological deficits. «Minor» wounds.
Associated symptoms/signs
Coagulation disorders (thrombocytopenia, hemophilia); V-P derivation
Age <6 months. Inappropriate story. Greater dynamics.
Specific scores
GCS
GCS Pain
GCS Pain
GCS Pain
Head trauma in the child
20