Going Home After a Head Injury Jacqueline McPherson Paediatric Neurology Nurse Specialist Ward 7 Neuroscience Department RHSC

Head Injuries April 2011 – March 2012 Attended A&E Admitted from A&E – 113 Classified into mild = GCS moderate = GCS 9-12 severe = GCS 8 or less (SIGN)

Mild-Moderate Head Injury Support, information, advice and reassurance for child & family School/Nursery point of contact Ward review Out-patient (OP) clinic appointment; paediatric neurosurgery and/or paediatric neurorehabilitation

Moderate – Severe Head Injury A period of neuro assessment and rehabilitation Integrated Care Pathway Link with Education – point of contact ‘Wean’ off ward; day pass, overnight pass, weekend pass Regular ward reviews and OP appointments

FAQ Mood & Temperament Memory Fatigue – especially returning to school Sports

SIGN Guidelines Mild - Some evidence to show that some children will have moderate disability and this group would benefit from telephone/postal follow up Moderate/Severe – follow up is of benefit in terms of reducing behavioural changes, reducing anxiety and reducing reporting of symptoms

Case Studies

Case Study 1 11 year old girl Fell from monkey bars No loss of consciousness (LOC) Travelling to local emergency department (ED) became sleepy and incoherent CT showed a fracture extending through R mastoid and into the temporal bone, a small extradural (3mm) and a small pneumocephalus Transferred to Royal Hospital for Sick Children, (RHSC) Edinburgh and admitted into ward 7

Case Study 1 Cont: Post traumatic amnesia (PTA ≤24hrs) Continued with significant headaches and a further vomit Repeat scan showed no change In-patient for 4 days Remained neurological stable Discharge home with 6 week Neurosurgical follow up.

Case Study 1 Cont: Paediatric Neurology Nurse Specialist (PNNS) in frequent contact with Mum for support and information PNNS in contact with school about phased return and any difficulties which may be present

Case Study 2 3 year old boy Fell 2 stories onto concrete Sustained a severe head injury/traumatic brain injury Intubated in Emergency Department

Case Study 2 cont: CT scan showed right subdural collections, frontal lobe contusions and dramatic fracture from left parietal to right spheroid bone with injury to right orbital roof and adjacent muscles and proptosis (forward displacement of the eye) Transferred and admitted into intensive care unit (ITU)

Case Study 2 cont: On going problems with raised intracranial pressure Underwent bifrontal decompressive craniectomy (subsequent re-insertion of autologous frontal bone flap) Extubated and transferred to neuroscience unit (ward 7) for rehabilitation – 2/52 Multidisciplinary team discharge planning meeting 5/52 Discharged home – 6 weeks after initial injury

Case Study 2 cont: Attending ward reviews and outpatient appointments Health Visitor for information and advice Nursery School for information, advice and reassurance Transition meetings; nursery to primary Neuropsychology assessment Long term follow up

Service Development Promote Role Enhance referral system e.g. surgical ward admissions Information packs