Head trauma in the child

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Head trauma in the child


Cranial-brain injury resulting from a traumatic event

Head trauma in the child

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Main causes of head trauma

< 5 years (particularly <2 years): accidental falls and abuse > 5 years: sports and road accidents Most of the child’s head injuries are minor and have no consequences; however, it is extremely important to identify those traumas that pose a risk of death or disabling sequele.

Head trauma in the child

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Triage methodology

On the door assessment: • ABC sequence • Glasgow Coma Scale/pGCS (if < 1 year) • A(lert) V(erbal) P(ain) U(nresponsive) • Gross neurological deficits

Head trauma in the child

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GLASGOW COMA SCALE (GSC) FOR MORE DETAILED ASSESSMENT OF NEUROLOGICAL STATUS, MODIFIED FOR PEDIATRIC AGE EYE OPENING Score 4 3 2

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Age > 1 year Spontaneous In command To pain No response

Age < 1 year Spontaneous To noise To pain No response

BEST MOTOR RESPONSE Score 6 5 4 3 2

1

Age > 1 year Obeys Localizes the pain Flexes/retracts from pain Decorticated flexure Brainless extension No response

Age < 1 year Normal spontaneous Localizes the pain Flexes/retracts from pain Decorticated flexure Brainless extension No response

BEST VERBAL RESPONSE Score 5 4 3 2

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Head trauma in the child

Age > 5 years

Age 2-5 years

Age 0-23 years

Oriented, converse Disoriented, converse Disconnected words Incomprehensible sounds No response

Appropriate words/phrases Inappropriate words Persistent crying/yelling Incomprehensible sounds No response

Vocals/laughs Cries/is inconsolable Persistent crying/yelling Incomprehensible sounds/agitated No response

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Head trauma in the child

CODE

GCS

PUPILS

1

≤9

anisocoria

2

10-13

miosis/mydriasis

3

14

normal

4

14

normal

5

15

normal

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Triage methodology

Data collection (patient/companion): • Trauma modality and elapsed time • Symptoms following the trauma (including possible amnesia) • Possible pathologies or taking drugs predisposing to bleeding (thrombocytopenia, hemophilia, taking aspirin or anticoagulants, etc.) • Previous NCH interventions

Head trauma in the child

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Triage methodology

Vital parameters collection: • • • • • •

Blood pressure Heart rate Respiratory frequency Body temperature SpO2% Pain (FLACC/VAS)

Head trauma in the child

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Triage methodology

During the physical examination, evaluate: • • • • • •

Skull depressions Penetrating or bleeding wounds Floating swellings Oto- or rhinorrhea Periorbital or retroauricular ecchymosis Stability of the dentition and facial bones

Head trauma in the child

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Head trauma in the child ON THE DOOR ASSESSMENT • ABC, AVPU, GCS • Presence of neurological deficits

CODE 1 Emergency

• • • • •

YES

Loss of consciousness ≥ 30 sec Drowsiness Difficulty waking up and/or speaking Motor and/or sensory deficits Anisocoria or non-reactive pupils

• • • • •

Pulsating bleeding from the scalp Oto-rhinorrhea Coagulation deficit DVP presence GCS ≤ 9

CODE 2 Urgency

NO

SHOCK ROOM

• • • • • • • •

Reported loss of consciousness <30 sec. • • Vomit ≥ 4 episodes • Inconsolable crying • Irritability • Severe headache • Amnesia • Visual impairments • Dizziness

N.B: if the Triage nurse suspects cervical trauma, he/she will apply a rigid cervical collar. Head trauma in the child

NO

Recent seizure Retroauricular or periorbital bruising Multiple wounds/lacerations Severe depressions in the cranial case Age < 6 months Inappropriate history Greater dynamics GCS 10-13

15 minutes have passed and the patient still has not accessed the treatment area?

YES • Direct observation with constant condition monitoring • Revaluation of Vital Parameters • GCS, AVPU, Pain revaluation • Associated signs and symptoms 10


Head trauma in the child NO

Deferrable urgency CODE 3

YES

• • • • •

Headache Slight irritability Vomit < 4 episodes Localized wounds/lacerations GCS 14

Minor urgency CODE 4

NO

60 minutes have passed and the patient still has not accessed the treatment area?

• Repetition of parts or all of the assessment steps as judged by the Triage nurse or the patient/carer • Vital parameters revaluation • GCS, AVPU, Pain revaluation • Associated signs and symptoms

• • • •

Minor head injury without loss of consciousness Absence of vomiting episodes Sensory intact Non neurological deficits “Minor” wounds 120 minutes have passed and the patient still has not accessed the treatment area?

Patient access to the examination room

Head trauma in the child

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PEDIATRIC TRIAGE OF TRAINING TRAUMA TRIAGE CODE

1

2

3

4

5

Vital parameters

from code 1

from code 2

from code 3

from code 4

from code 5

Characteristics of the main symptom/sign

Reported prolonged loss of consciousness ≥30 sec. Drowsiness. Difficulty waking up and/or speaking. Motor and/or sensory deficits. Anisocoria or non-reactive pupils. Pulsating bleeding from the scalp. Oto Rhinoliquorhea.

Reported loss of consciousness <30 sec. Vomiting ≥4 episodes. Inconsolable crying, irritability. Dizziness. Recent seizure. Retroauricular or periorbital bruising. Multiple wounds/lacerations, severe skull case depressions.

Headache, mild irritability. Vomiting <4 episodes. Localized wounds/lacerations.

Minor head injury, without loss of consciousness or vomiting. Sensory intact, no neurological deficits. «Minor» wounds.

Associated symptoms/signs

Coagulation disorders (thrombocytopenia, hemophilia); V-P derivation

Age <6 months. Inappropriate story. Greater dynamics.

Specific scores

GCS

GCS Pain

GCS Pain

GCS Pain

Head trauma in the child

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TRIAGE PROCEDURES Activities Consulting activity

Pain therapy Revaluation

Other

Head trauma in the child

1

2

3

4

5

Venous access, blood tests

from code 4

from code 5

Exceeded the 60 minute wait according to protocol According to local protocol Direct or videomediated observation with constant condition monitoring.

Repetition of part or all of the evaluation phases on the decision of the triagist, at the request of the patient, once the maximum recommended waiting time has elapsed.

See associated symptom tabs

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Head trauma in the child Clinical cases

Head trauma in the child

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Clinical case 1

• 8 month old patient • Conducted in PS due to falling from bed (about 50 cm high) which occurred one hour before arrival • The mother reports that she was present not directly witnessing the dynamics while hearing the baby’s cry • No loss of consciousness reported • One episode of vomiting

Head trauma in the child

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Clinical case 1

• • • • • • •

Good general conditions Alert and responsive pGCS 15 AVPU=A Absence of swelling of the scalp Isochoric pupils, isocyclic cells that react normally to the light stimulus Absence of strength deficit

Head trauma in the child

Vital parameters: • • • • • •

PA 91/54 FC 130 FR 30 TC 36.4 SpO2 100% in AA FLACC 1

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Clinical case 1 PEDIATRIC TRIAGE OF TRAINING TRAUMA TRIAGE CODE

1

2

3

4

5

Vital parameters

from code 1

from code 2

from code 3

from code 4

from code 5

Characteristics of the main symptom/sign

Reported prolonged loss of consciousness ≥30 sec. Drowsiness. Difficulty waking up and/or speaking. Motor and/or sensory deficits. Anisocoria or non-reactive pupils. Pulsating bleeding from the scalp. Oto Rhinoliquorhea.

Reported loss of consciousness <30 sec. Vomiting ≥4 episodes. Inconsolable crying, irritability. Dizziness. Recent seizure. Retroauricular or periorbital bruising. Multiple wounds/lacerations, severe skull case depressions.

Headache, mild irritability. Vomiting <4 episodes. Localized wounds/lacerations.

Minor head injury, without loss of consciousness or vomiting. Sensory intact, no neurological deficits. «Minor» wounds.

Associated symptoms/signs

Coagulation disorders (thrombocytopenia, hemophilia); V-P derivation

Age <6 months. Inappropriate story. Greater dynamics.

Specific scores

GCS

GCS Pain

GCS Pain

GCS Pain

Head trauma in the child

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Clinical case 2

• 9 year-old patient • Road accident (vehicle collision) • Rear passenger with protective equipment (seat belts) • Amnesia • One episode of vomiting 30 minutes after the trauma

Head trauma in the child

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Clinical case 2

• • • • •

Headache GCS 13 AVPU=V Scalp swelling Presence of tender swelling in the left zygomatic region and ipsilateral superior periorbital region Isochoric pupils, isocyclic cells that react normally to the light stimulus

Head trauma in the child

Vital parameters: • • • • • •

PA 118/69 FC 83 FR 22 TC 36 SpO2 100% in AA VAS 4

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Clinical case 2 PEDIATRIC TRIAGE OF TRAINING TRAUMA TRIAGE CODE

1

2

3

4

5

Vital parameters

from code 1

from code 2

from code 3

from code 4

from code 5

Characteristics of the main symptom/sign

Reported prolonged loss of consciousness ≥30 sec. Drowsiness. Difficulty waking up and/or speaking. Motor and/or sensory deficits. Anisocoria or non-reactive pupils. Pulsating bleeding from the scalp. Oto Rhinoliquorhea.

Reported loss of consciousness <30 sec. Vomiting ≥4 episodes. Inconsolable crying, irritability. Severe headache. Amnesia. Visual impairments. Dizziness. Recent seizure. Retroauricular or periorbital bruising. Multiple wounds/lacerations, severe skull case depressions.

Headache, mild irritability. Vomiting <4 episodes. Localized wounds/lacerations.

Minor head injury, without loss of consciousness or vomiting. Sensory intact, no neurological deficits. «Minor» wounds.

Associated symptoms/signs

Coagulation disorders (thrombocytopenia, hemophilia); V-P derivation

Age <6 months. Inappropriate story. Greater dynamics.

Specific scores

GCS

GCS Pain

GCS Pain

GCS Pain

Head trauma in the child

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