Assessment and management of pediatric head injuries
Aim: To understand the assessment, management and outcome of head injuries in pediatric trauma patients
Objectives:
Knowledge objectives:
The trainee should have acquired the following knowledge:

Epidemiology and etiology of head injuries in children

Understand the role for prevention of head injuries as the single most important aspect of head injury care, including counseling regarding helmet use

Understanding of common associated injuries in the head-injured child and the impact of these injuries on the assessment and management of the pediatric trauma patient

Understanding of normal intracranial anatomy and physiology

Understanding of normal and abnormal intracranial pressure including the Monroe-Kellie
Doctrine

Understanding of cerebral perfusion pressure and cerebral blood flow in pediatric patients

Appreciate the role of open sutures in infants and young children in traumatic brain injury

Know the difference between primary and secondary brain injury, and the role of preventing secondary brain injury

Understanding of the presentation and patterns of injury in the child abuse victim with a head injury

Clinical assessment of a pediatric patient with a head injury including examination principles during the primary and secondary survey

A thorough understanding of Glasgow Coma Score (GCS) measurement and pediatric differences

Understanding of the association of shock in the head injured child and the relationship to age, the presence of skull sutures and associated injuries

Classification of pediatric head injuries according to mechanism of injury (blunt vs. penetrating)

Classification of pediatric head injuries according to severity of injury (mild GCS 14-15, moderate GCS 9-13 and severe GCS 3-8)

Classification of pediatric head injuries according to morphology, including o fractures, o presence or absence of CSF leak, o nerve palsy, o focal injuries (epidural, subdural or intracerebral hematoma) or o diffuse injuries (concussion, multiple contusions, hypoxemic/ischemic injury)

Knowledge of basal skull fractures including clinical signs, assessment, and the indications for antibiotics

Indications for CT scan in the head-injured child

Pediatric Head Injury Discharge Instructions with an understanding of the principles of activity precautions after concussion

Knowledge of concussion, post-concussion, and second impact syndromes

Know the Canadian Pediatric Society guidelines for return to sports/ play after concussion

Indications for neurosurgical consultation in the head injured child

Indications for hospital admission and/or monitoring of the head injured child

Indications for Intensive Care consultation and admission in the head injured child


Initial management principles of the head injured child

Understand the indications and role of the following to prevent secondary brain injury: o Judicious fluid management, o Inotropes o Intubation and ventilation strategies, o Hypertonic saline, o Sedation and paralysis, o Mannitol, and o Anticonvulsants

Know the indications for intracranial pressure monitoring

Understanding of the indications for surgical intervention in the head injured child

Prognosis and outcome for head injuries in pediatric patients

Understanding and recognition of the Second Impact Syndrome

Understanding of the Diagnosis and Clinical Assessment of Brain Death in the traumatized child

Understanding of the indications and process for Organ Donation in the traumatized child declared brain dead

Understanding the large role that injury prevention plays in reducing patient / family suffering and burdens
Skill objectives:

Demonstrate assessment and diagnostic skills in determining the type and extent of head injury

Demonstrate a knowledge of the Glasgow Coma Scale and its modification for the non-verbal pediatric patient

Demonstrate ability to review CT scan of the head in a pediatric trauma patient

Recognition of major intracranial bleeding (epidural, subdural, subarachnoid, intracerebral), and the need to obtain immediate neurosurgical opinion

Recognition of patterns of brain injury in child abuse


Demonstration of helmet removal in the traumatized child with cervical spine protection
Perform adequate resuscitation in a severely head injured child

Demonstrate the ability to manage the airway definitively with appropriate neuroprotection

Recognition of orbital floor fracture with optic nerve injury as a potential reason for unilateral dilated pupil
 Knowledge of “AVPU” score as a quick and gross assessment of neurological status