MINOR HEAD INJURY CLINICAL PRACTICE GUIDELINES

GOALS ■■ Reinforce decision to transfer to Level 1 trauma center if major Pediatric Trauma Center in minor head injury. head injury or polytrauma. ■■ Identify patients that do not need CT scan. ■■ Guide decision to admit at local hospital versus transfer to ■■ List indications for observation at local hospital.

DEFINITIONS Minor Head Injury*: MHI is defined as injury within the past 24 Severity of head injury based on GCS hours associated with loss of consciousness, definite amnesia, ■■ Severe head injury may be defined as that resulting in a GCS witnessed disorientation, persistent vomiting more than one score <9. episode) or persistent irritability (in a child <2 years of age) in a ■■ Moderate head injury is associated with a score of 9 to 12. patient with a Glasgow coma scale of 13–15. ■■ Mild head injury is associated with a score of 13–15

Concussion*: Alteration in mental status that may or may not be Types of Primary brain injury : associated with loss of consciousness with no focal neurological 1) Contusions. 2) Intracranial bleeding. 3) Fractures. 4) Diffuse deficits following head injury. *Note: The term concussion has axonal injuries. been used interchangeably with mild head injury (MHI) or mild ■■ Cerebral contusions are bruises of the cerebral cortex that can traumatic brain injury (TBI) occur as a result of: •• Direct injury (coup injury) •• Injury at the opposite point where the relatively mobile brain strikes the bone on the other side (contrecoup injury) ■■ Diffuse axonal injury refers to damage at the gray-white matter junction, seen with acceleration-deceleration injury.

EPIDEMIOLOGY Traumatic brain injury (TBI) is a leading cause of death and dis- In the US, head trauma in individuals aged 18 years and younger ability in the United States. results in about 7400 deaths, over 60,000 hospital admissions, and over 600,000 emergency department visits every year.

HISTORY The possibility of child abuse must be kept in mind. This is sug- Indicators of severe head trauma: gested when the given history is not proportional to the severity ■■ Prolong loss of consciousness of injury (i.e. children rarely experience a serious injury when ■■ Seizures they fall out of bed.) ■■ Amnesia for the circumstances surrounding the injury ■■ Focal neurologic deficits ■■ Persistent & severe vomiting. ■■ Persistent clouding of consciousness. ■■ Duration of posttraumatic amnesia (inability to generate new memories after head injury).

1 CONCUSSION/Mild traumatic brain injury ■■ GCS score of 13–15 and no focal neurologic findings. ■■ Thorough evaluation is important, if focal signs will need ■■ Most concussion patients can be discharged home after a period further workup. of evaluation and observation, if they are back to baseline. ■■ Physician should advise parents regarding the child’s return to sports.

Guidelines for assessment and management of concussion available from the American Academy of Neurology.

GRADING OF CONCUSSION: Guidelines for the Management of Sport-Related Concussion

Symptoms First Concussion Second Concussion Grade 1: no loss of consciousness, Remove from play Allow return to play after 1 wk if there are transient confusion, resolution of no symptoms at rest or with exertion Examine at 5-min intervals symptoms and mental abnormalities in <15 min † May return to play if symptoms disappear and results of mental-function examination return to normal with 15 min Grade 2: as above, but with mental Remove from play and disallow play for rest Allow return to play after 2-wk period of no symptoms for >15 of day symptoms at rest or with exertion Examine for signs of intracranial lesion at Remove from play for season if imaging sidelines and obtain further examination by shows abnormality a trained person on same day Allow return to play after 1wk if neurologic examination is normal Grade 3: any loss of consciousness Perform thorough neurologic examination Withhold from play until symptoms have in hospital and obtain imaging studies when been absent for at least 1 mo indicated Assess neurologic status daily until postconcussive symptoms resolve or stabilize Remove from play for 1 wk if loss of consciousness lasts seconds; for 2 wk if it lasts minutes; must be asymptomatic at rest and with exertion to return to play

*These guidelines reflect consensus opinion, are not evidence-based, and are under revision. Adapted from the American Academy of Neurology guidelines.44 †Testing includes orientation, repetition of digit strings, recall of word list at 0 and 5 minutes, recall of recent game events, recall of cur- rent events, pupillary symmetry, finger-to-nose and tandem-gait tests, Romberg’s rest, and provacative testing for symptoms with a 4 yd (3.5m) sprint, five push-ups, five sit-ups, and five knee bends.

2 HEAD INJURY ALGORITHM (AGE UNDER 2 YEARS)

Child presents with head injury ABC…D—stabilize

Any of the following: ££Follow trauma guidelines (see Mass. statewide trauma point of entry plan) ■■ Unstable multiple trauma/high impact injury e.g. MV vs. ££Use individualized patient management pedestrian/Fall >10 feet or 2–3 times the height of child YES ££Transfer to pediatric trauma center. ■■ Bicycle thrown/run over or with significant (>20mph) ££Head Imaging at Level 1 pediatric trauma center impact (such as Tufts Medical Center) ■■ Bleeding diathesis ■■ Suspected non-accidental injury ■■ Penetrating injury ■■ Presence of drugs/alcohol/Burn injury Positive CT findings ■■ GCS <14 at 2 hours after injury If intracranial bleed, fracture, NO space occupying lesion, concerns of raised ICP then transfer to Any of the following: HIGH RISK pediatric trauma center

■■ Depressed mental status (GCS <15 two hr after injury) ■■ Focal neurological findings ■■ Signs of open, depressed or basilar fracture YES ■■ Post-traumatic seizure Head CT ■■ Subgaleal hematoma, especially if large, boggy or nonfrontal Negative CT findings

■■ Irritability YES ■■ Bulging fontanel Is there concerning behavior? ■■ Vomiting ≥ 5 times or >6 hr Hourly ■■ Loss of consciousness >3 min neurological Inconclusive assessment? observations at NO local hospital YES for 4–6 hr. Any of the following: INTERMEDIATE RISK Is there May observe at local ■■ Vomiting ≥ 4 times Neurological hospital for extended ■■ LOC <1 min deterioration? monitoring (8–12 hours) ■■ History of lethargy or irritability, now resolved Do Symptoms or until return to baseline. ■■ Concerans about child’s current behavior (irritability, YES remain after drowsy) If not returning to 8–12 hr? ■■ Non-acute skull fracture (>24–48 hr old) baseline after 12 hours, ■■ Dangerous mechanism of injury (elevation ≥ 3 ft or discuss with Neurology, 5 stairs, fall from bicycle with no helmet) consider Re-imaging ■■ Unwitnessed trauma CT/MRI NO NO

Any of the following: LOW RISK Discharge home ■■ Low energy mechanism with concussion ■■ No signs or symptoms advice ■■ >2 hr since injury and normal behaving

3 HEAD INJURY ALGORITHM (AGE OVER 2 YEARS)

Child presents with head injury ABC…D—stabilize

Any of the following:

■■ Unstable or multiple trauma/high impact ££Follow trauma guidelines (see Mass. state- injury e.g. MV vs. pedestrian/fall >10 feet or wide trauma point of entry plan) YES 2-3 times the height of child ££Use individualized patient management ■■ Bicycle thrown/run over or with significant ££Transfer to pediatric trauma center. (>20mph) impact ££Head Imaging at Level 1 pediatric trauma ■■ Bleeding diathesis center (such as Tufts Medical Center) ■■ Suspected non-accidental injury ■■ Penetrating injury ■■ GCS <14 at 2 h after injury Positive CT findings If intracranial bleed, fracture, space occupying NO lesion, concerns of raised ICP then transfer to pediatric trauma center Any of the following:

■■ Suspected open or depressed skull fracture YES ■■ Any sign of basilar skull fracture (bleed/CSF Head CT leak from nose/ear) ■■ Post-traumatic seizure ■■ Focal neurological findings May observe at local

■■ ≥ 5 episodes of vomiting YES hospital for extended ■■ Amnesia before impact >30 min monitoring (8–12 ■■ Dangerous mechanism of injury and some hours) or until return to LOC or amnesia since injury baseline.

Negative CT NO Concerning If not returning to behavior? YES baseline after 12 hours, discuss with Neurology, Observe: Inconclusive consider Re-imaging assessment? CT/MRI ■■ Hourly neurological observations for 6–8h YES ■■ Is there neurological deterioration? ■■ Do symptoms remain after 8–12 h?

NO NO

Discharge home with concussion advice

4 Statewide Trauma Field Triage Criteria and Point-of-Entry Plan for Adult and Pediatric Patients

NOTE: Additional pediatric-specific information can be found below.

Early notification of the receiving facility, even from the scene, will enhance patient care.

Preconfigured response initiated/appropriate pre-arrival instructions given based on Local EMD

Perform Primary Survey 1) Does the patient have: YES IMMEDIATELY Transport immediately ■■ Uncontrolled airway? ■■ Cardiopulmonary arrest? LIFE to nearest hospital THREATENING NO

2) Does the patient have: ■■ Persistent loss of conscious- ■■ Penetrating trauma to head, Transport to: ness, decreasing level of neck, torso, or extremities YES ■■ If <20 minutes by ground, consciousness, or GCS <13? proximal to elbow and knee? transport to a level 1 or 2 ■■ Severe respiratory distress ■■ Tender or rigid abdomen? CRITICAL trauma center (level 1 or (rate <10 or >29) or respira- ■■ Pelvic fractures (excluding TRAUMA 2 pediatric trauma center tory rate out of range for age? simple fractures) for pediatrics). (see next page for pediatric) ■■ Paralysis or motor/sensory ■■ If <20 minutes by ground ■■ Flail Chest? deficit? from a level 3 trauma ■■ Systolic blood pressure <90 ■■ 2 or more proximal long CRITICAL BURNS center and no level 1 or in adults or <70 to 90 in bone fractures or any open ■■ Partial thick- 2 (level 1 or 2 pediatric pediatrics? (see next page) proximal long bond fracture? ness burns trauma center for pediat- ■■ Open or depressed skull ■■ Amputations, with exception >10% BSA rics) within 20 minutes, fractures? of distal digits? ■■ Extensive transport to a level 3 ■■ Critical burns? (see note). burns involving and/or consider air am- face, genitalia, bulance, if available. NO perineum ■■ If >20 minutes by ground 3) Is there evidence of mechanism of injury and/or high energy ■■ 3rd degree to a level 1, 2 or 3 trauma impact? burns in any center, activate air am- ■■ Ejection from the vehicle ■■ Auto vs. pedestrian, or auto age group bulance, if available. ■■ Death in same passenger vs. bicycle with significant ■■ Electrical ■■ If patient arriving by air compartment impact Burns, includ- ambulance, transport to ■■ Extrication time >20 minutes ■■ Pedestrian thrown or run over ing lightning closest level 1 trauma cen- ■■ Falls >15 feet, or >3 times ■■ Motorcycle crash >20 mph, injury ter with helipad facilities. child’s height or with separation of rider ■■ Chemical ■■ If >20 minutes by ground ■■ High speed crash from bike Burns to a level 1, 2 or 3 trauma ■■ Near drowning ■■ Inhalation center and no air ambu- Burns lance available, transport NO ■■ Any burn in to the nearest system Transport to closest appropriate System Hospital combination hospital. with trauma At all times contact with Medical Control re: destination is encouraged Interfacility Transfer as necessary Co-morbid Factors which may increase severity of injury: YES ■■ Age <5 or >70 ■■ Insulin dependent diabetes, ■■ Significant cardiac or cirrhosis, morbid obesity Consider medical control re: Destination hospital. ** respiratory disease ■■ Immunosuppressed ■■ Pregnancy ■■ Bleeding disorder or current- Transport to Level 1, 2, or 3 Trauma Center if no medical ly taking anticoagulants control. If >20 minutes away, go to closest System Hospital.

** At all times, EMS providers are encouraged to contact medical control for direction in triage of trauma patients.

5 Glasgow Coma Scale Adelaide Pediatric Coma Scale Coded Value Coded Value Eye Opening Eye Opening Spontaneous 4 Spontaneous 4 To speech 3 To speech 3 To pain 2 To pain 2 None 1 None 1 Best Verbal Response Best Verbal Response Oriented 5 Oriented 5 Confused 4 Words 4 Inappropriate words 3 Vocal sounds 3 Incomprehensible sounds 2 Cries 2 None 1 None 1 Best Motor Response* Best Motor Response* Obeys 6 Obeys commands 5 Localizes 5 Localizes pain 4 Withdraws 4 Flexion to pain 3 Abnormal flexion 3 Extension to pain 2 Extensor response 2 None 1 None 1 Total ‡ 3–14 Total 3–15 ‡ Normal Aggregate Score 0–6 months 9 6–12 months 11 1–2 years 12 2–5 years 13 >5 years 14

Modified Glasgow Coma Scale for Infants Child Infant Score Eye Opening Spontaneous Spontaneous 4 To verbal stimuli To verbal stimuli 3 To pain only To pain only 2 No response No response 1 Verbal Response Oriented, appropriate Coos and babbles 5 Confused Irritable cries 4 Inappropriate words Cries to pain 3 Incomprehensible Moans to pain 2 words or non specific sounds No response No response 1 Motor Response* Obeys commands Moves spontaneously and purposefully 6 Localizes painful Withdraws to touch 5 stimulus Withdraws in Withdraws in response to pain 4 response to pain Flexion in response Decorticate posturing (abnormal 3 to pain flexion) in response to pain Extension in response Decerebrate posturing (abnormal 2 to pain extension) in response to pain No response No response 1 * If the patient is intubated, unconscious, or preverbal, the most important part of this scale is motor response. This section should be carefully evaluated. ‡ Modified from Davis RJ, et al. Head and spinal cord injury. In: Rogers MC, ed. Textbook of Pediatric Intensive Care. Baltimore, Md: Williams & Wilkins; 1987. James H, Anas N, Perkin RM. Brain Insults in Infants and Children. New York, NY: Grune & Stratton; 1985. Morray JP, et al. Coma scale for use in brain-injured children. Crit Care Med. 1984; 12:1018. Reproduced from Hazinski MF. Neurologic disorders. In: Hazinski MF, ed. Nursing Care of the Critically Ill Child. 2nd ed. St. Louis, Mo: Mosby Year Book; 1992.

FILE: Handbook Glasgow Coma Scales

6 REFERENCES 1. Atabaki, S.M. et al., 2008. A clinical decision rule for cranial computed tomography in minor pediatric head trauma. Archives of pediatrics & adolescent medicine, 162(5), pp.439–45.

2. Brain, T. & Edition, A et al . Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents-Second Edition. Pediatr Crit Care Med 2012 Vol. 13, No.1 (Suppl.)

3. Osmond, Martin H, Terry P Klassen et al. 2010. “CATCH: a Clinical Decision Rule for the Use of Computed Tomography in Children with Minor Head Injury.” CMAJ: Canadian Medical Association Journal 182 (4) (March 9): 341–8.

4. Lyttle MD, Crowe L, Oakley E et al , Comparing CATCH, CHALICE and PECARN clinical decision rules for paediatric head injuries. Emerg Med J. 2012 Oct;29(10):785-94.

5. Nigrovic, Lise E et al. “Prevalence of Clinically Important Traumatic Brain Injuries in Children with Minor Blunt Head Trauma and Isolated Severe Injury Mechanisms.” Archives of Pediatrics & Adolescent Medicine 166 (4) (April 2012): 356–61.

6. Herring SA, Cantu RC, Guskiewicz KM, et al American College of Sports Medicine. Concussion (mild traumatic brain injury) and the team physician: a consensus statement--2011 update. Med Sci Sports Exerc. 2011 Dec; 43(12):2412-22.

7. Kuppermann, Nathan, James F Holmes, Peter S Dayan et al. “Identification of Children at Very Low Risk of Clinically-important Brain Injuries after Head Trauma: a Prospective Cohort Study.” The Lancet 374 (9696): 1160–1170.

8. Maguire, Jonathon L, Kathy Boutis, Elizabeth M et al. “Should a Head-injured Child Receive a Head CT Scan? A Systematic Review of Clinical Prediction Rules.” Pediatrics 124 (1) (July 2009): e145–54.

9. http://www.mass.gov/eohhs/docs/dph/quality/hcq-circular-letters/trauma-hospitaldestinations.pdf

10. Mendelow, a David, Jake Timothy, James W Steers, et al . “Management of Patients with Head Injury.” Lancet 372 (9639) (August 23 2008): 685–7.

11. Eisenberg MA, Andrea J, Meehan W, Mannix R. Time Interval Between Concussions and Symptom Duration. Pediatrics. 2013 Jun 10.

Disclosure: Practice guidelines do not necessarily apply to every patient. A provider’s clinical judgment is essential. As always, clinicians are urged to document management strategies. Floating Hospital for Children at Tufts Medical Center contact: Raj Kerur, M.D., Steven Hwang, M.D., Dan Hale, M.D. ([email protected])

7 Update 030315 | 15-0028 PD-HS Last updated: 27 December 2013