Blunt head injury in kids is one of the commonest presentations that we see in ED. In my experience, the rate of serious brain injury is low, and yet we often are unsure as to who to admit, who to scan or who to send home after review. There are a heap of myths and strongly held beliefs about signs and symptoms that “mean” brain injury and often result in a CT head.
Well there have been a few decision-making rules used over the years, but in 2009 the folks at PECARN followed 42,000+ kids to get the lowdown on what factors are useful, what is not and how to avoid irradiating kids. The rules they developed actually predict risk down to levels where the risk of cancer-death from CT is lower than the risk of clinically significant brain-injury.
So what are the rules? What factors should you look at when assessing kids with a bump on the noggin?
- Age – either < 2 years or older than 2
- GCS 14 or less
- Other altered mental status
- Scalp haematoma (not frontal ) or palpable fracture
- LOC > 5 secs
- Severe mechanism: Motor vehicle crash with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by a motorized vehicle; falls of more than 0.9m/3ft; head struck by a high-impact object
Check out the calculator for risk at MD Calc for Paeds Head injury the algorithm is below:
Basically you can use this algorithm to put kids into one of 3 groups – those you send home, those you watch and the ones you need to scan. If you are in a place with no CT, then you have a number at least – you can say: “this kid has a x% risk of significant brain injury” and base your subsequent management / transfer decision on this. I think that this algorithm should be on the wall of my ED, this is good data and allows us to reassure parents with a great degree of certainty.