2. Minor Head Injury

3. Case 1
One year old child was playing in a swing and accidentally fell. Since the fall about 2 hours back she has vomited twice .
There is no history of seizures or LOC. There is history of bleeding from nose which stopped on its own in a couple of minutes.
The family is well known to you , & bring the older sibling also to you.
The only significant finding is a bruise over the occipital area.
What would be your plan of action ?
In India,lots of CT scans are done as parents become panicky after the fall on head,or after seeing any outside bruise or Scalp Hematoma,but sometimes do not understand the seriousness if nothing obvious from externally but scientifically we feel it is urgent?

4. Classification of Head Injury
For AVPU and GCS
Refer
SOS- HOPE
APP
Severity
Mild : GCS score 13 ~ 15
Moderate : GCS score 9 ~12
Severe : GCS score 3 ~ 8
After Analysing Glassgow coma scale it is easier to analyse the severity of Head injury,early Radiology(CT scan ) if required, please note GCS scoring is different for < 5 year old compared to older children, please read minor head injury ( word document) for GCS scoring.

5. Importance of CT scan
Clinically important traumatic brain injury needs to be identified and scanned appropriately.
It is important to not subject patients to unnecessary scans as there is a small but definite increase in the incidence of leukemia & brain tumors in children subjected to radiation of CT ( 1in )
If necessary ,CT brain is important as we can interven immediately to have less morbidity and early recovery

6. Indications of CT scan in TBI
GCS < 14
Progressive headache
Worsening level of consciousness,
Definite Loss of Consciousness for more than few seconds,
Focal or abnormal neurological findings,
Seizure,
Persistent Vomiting
Penetrating skull injuries,
Signs of a basal or depressed skull fracture,
It is very important to see weather there is 1 single indication or multiple indication
Chances of intra cranial bleed is more if more than 1 symptom is present.
If 1 single episode of vomiting and no other symptoms , fall is less than 3 feet, child is conscious, then may be worth waiting

7. Do not perform CT scan in…
Low-risk patients should meet all of the following criteria
Normal mental status
No parietal, occipital or temporal scalp hematoma
No loss of consciousness >5 seconds
No evidence of skull fracture
Normal behavior according to the routine caregiver
No high-risk mechanism of injury
High Risk Mechanisms: fall >0.9 m [3 feet]; head struck by high impact object; motor vehicle collision with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by a motorized vehicle)
The risk for clinically important traumatic brain injury is less than 0.02 percent in these patients

8. Historical features that may suggest an increased risk of brain injury
Child younger than two years of age is not acting normally
Seizure, confusion, or loss of consciousness ( > 5 seconds )
Severe or worsening headache
Vomiting > 2 times after fall
High-risk mechanism, such as a fall from greater than 3 to 5 feet , significant motor vehicle collision, penetrating injury, inflicted injury, or unwitnessed fall
Pre-existing conditions that place the child at risk for intracranial hemorrhage, such as arterio-venous malformation or a bleeding disorder
Concerns about non accidental trauma
we follow standard guidelines then we can assure parents about its necessity can be explained
The probability of clinically important TBI ( ciTBI ) as determined by clinical findings is a key factor for identifying the optimal approach in individual patients. Patients at high risk for ciTBI should undergo prompt neuroimaging. Those at intermediate risk may undergo neuroimaging or observation with performance of imaging if persistent, worsening or new symptoms occur during observation. Infants and children at low risk for ciTBI should not undergo neuroimaging. Clinical decision rules can assist the clinician in determining the level of risk and need for neuroimaging but should not replace clinical judgment

9. Physical findings that may suggest an increased risk of brain injury
Scalp abnormalities, such as hematoma> 3cm in non frontal area , tenderness, or depression
In infants, bulging anterior fontanel
Abnormal mental status
Focal neurologic abnormality
Signs of basilar skull fracture
These signs can early detect raised IC pressure before the complications occur

10. Disposition
Perform neuroimaging in all patients with high risk signs or symptoms
Observe for 4-6 hours in all others.
Observation can be done at home by a compliant care giver or in the ER /Clinic
No role for X-ray of skull
Old concepts of X-ray skull does not help any way, High risk patients early hematoma, or intra-ventricular hemorrhage can save a life and prevent morbidity
While observation being done at home , please educate parents about what symptoms to observe and where to contact in case of emergency.