Tia Dickson, RN, BSN

Primary Children's Hospital

Head injuries in children are very common. They account for roughly 500,000 pediatric emergency department visits per year in the US. Most often these are children with minor head injuries, but during the winter months it isn't uncommon to see an upswing in head injuries. Children have a large head in proportion to their body. It has been said "kids are lawn darts;" they lead with their head and most pediatric patients involved in trauma are at risk for head injury.

Abrasion: Involves the top layer of skin.

Contusion: The skin is intact but a hematoma (bruise) forms under the skin like a "goose egg."

Laceration: The skin is torn. The scalp is riddled with blood vessels and a patient can bleed to death if the laceration is large and pressure is not applied to stop the bleed. Scalp injuries may be concerning if the child is younger, if the hematoma is found in a non-frontal location, or if it is very large or associated with a severe injury mechanism.

Linear: A crack in the bone

Comminuted: The bone is shattered

Depressed: A bone fragment goes inward toward the brain tissue

Basilar Skull Fracture: A linear fracture at the base of the skull

The signs and symptoms develop over several hours and these signs tend to be less common in children.

• Battle Sign (Mastoid Echymosis)
• Racoon Eyes (Periorbital Echymosis)
• CSF leak from nose or ears
  
• Special transport considerations–no NGs

Traumatic brain injury (TBI) is one of the leading causes of acquired disability and death in infants and children. Falls and motor vehicle collisions are common unintentional causes, whereas abuse in infants and young children and assaults in adolescents are unfortunate inflicted causes of TBI. Management of these injuries focuses on limiting the progression of the primary brain injury and minimizing secondary brain injury(ies). The quality of prehospital care is a major determinant of long-term outcome for these patients.

Concussion: Diffuse injury of the brain tissue that alters mental status with or without loss of consciousness. These tend to be mild but can become complicated especially when the patient has multiple concussions.

• Short and long term signs and symptoms in small children include headache, vomiting, inconsolability, restlessness/irritability, seizures, dizziness or confusion, change in personality, change in sleep pattern, changes in eating, lack of interest in favorite toys.

• Utah House Bill 204 “Protection of Athletes with Head Injuries” went into effect in May 2011. Any child suspected of sustaining a concussion must be immediately removed from sports. The athlete must obtain a written, signed statement from a trained healthcare provider that clears them before they can resume participation in the sport.

Contusion: Small, specific area of bleeding in the brain tissue.

• Coup-contrecoup: damage to the brain on the opposite side of impact (the brain bounces around in the skull).
  

Diffuse Axonal Injury: The axon of the nerves tear. This injury has a poor prognosis.

Hematomas: Bleeding in brain

• Epidural Hematoma: A bleed between the dura and the skull. This is usually an arterial bleed and the patient may decline rapidly. Signs and symptoms including waxing and waning (periods of alertness alternating with loss of consciousness).
• Subdural Hematoma: Bleeding between the dura and the arachnoid due to a tear in the bridging veins. Because it's usually venous, symptoms can be slow and progress over hours or even days.
• Subarachnoid Hemorrhage: Bleeding in the subarachnoid space, like an aneurysm and patients will often describe it as "the worst headache of my life."
• Intracerebral Hemorrhage: Bleeding directly into brain tissue generally has a poor prognosis.

These things qualify as severe mechanism of injury for the pediatric patient:

• MVC with ejection, death, or rollover
• Pedestrian or bicyclist without helmet struck by a vehicle
• Fall > 3 feet if < 2 years and > 5 feet if > 2 years
• Head struck by high impact object
  

Signs the injury may be more serious (high risk hematoma):

• Young age (especially < 6 months)
• Size of the injury (especially > 3 cm)
• Boggy and non-frontal location on the skull increases risk of ICI (intracranial injury) on CT

ABCs: Prevent hypoxia and hypotension!

C-spine: Establish cervical spinal motion restriction. There are many changes being made to agency immobilization policies in this state but good c-spine stabilization is especially important in pediatric trauma care. Due to their relatively large head and weaker neck muscles and ligaments, spinal cord injury is a real risk in ALL those with a head injury.

Transport: “Severe pediatric traumatic brain injury outcomes improve when patients are treated at an appropriate facility. Children with severe traumatic brain injuries have an eight times greater risk of death when treated at a non-tertiary hospital. Current guidelines recommend pediatric patients with mild TBI (GCS 13-15) be treated at a local ED, with a moderate TBI (GCS 9-12) at a trauma center, and with severe TBI (GCS less than 9) at a pediatric trauma center or adult trauma center with pediatric severe TBI qualifications."

Neurologic and cognitive evaluation

• Check pupils: Non-reactive or unequal pupils are a big red flag (but late) sign.

• Minimal sedation: Constant reassessment of the neurological status of your patient is important. Treat pain but provide minimal sedation so you do not mask deterioration.
• Get a baseline pediatric Glasgow Coma Score and know what is baseline and what is abnormal for age.

The Glasgow Coma Scale (GCS) is used to describe the general level of consciousness in patients with traumatic brain injury (TBI) and to define broad categories of head injury. The GCS is divided into three categories, eye opening (E), motor response (M), and verbal response (V). The score is determined by the sum of the score in each of the three categories, with a maximum score of 15 and a minimum score of three.

The GCS is often used to help define the severity of TBI.

• A score of 14 makes a patient 50% more likely to need a CT scan.
• Scores between 13 and 15 are considered mildly impaired but are expected to make a full recovery.
• Patients with scores between nine and 12 for more than 30 minutes will often have physical and cognitive impairments.
• Scores consistently between three and eight are associated with poor neurological outcomes.
• A score of less than eight = intubate.

Tips for evaluating the pediatric GSC

• Parents are your resource for baseline status and for calming the patient.
• Use age appropriate communication, get down on the child’s level.
• Don’t guess with GCS, use a scoring card and know in which areas they are missing points.
• If you are on the fence in one area, use the best score.
• When in doubt use AVPU but in TBI, the hospital will value a GCS above the AVPU.

Manage increased intracranial pressure:

• Ensure adequate blood pressure: Patients with a head injury can have high intracranial pressure and need higher blood pressure to maintain cerebral perfusion pressure. Preventing hypotension and hypoxia in the field can REALLY impact patient outcome.
• Consider 3% NS or mannitol: Helps to decrease intracranial pressure.
• Elevate head of bed
• Keep patient calm: Sedate intubated patients.

End Tidal Goal pCO2 is 35-40: Too high and the patient has vasodilation of cerebral vessels increasing pressure in brain; too low and you get vasoconstriction reducing the amount of blood flow to brain/ischemia.

References

1. 2009, Dewall, J. MD, NREMT-P, Severe Pediatric Traumatic Brain Injury, EMS World

https://emedicine.medscape.com/article/2058902-overview

https://www.youtube.com/watch?v=w1vk49NAuR4

Mayo Clinic Brochure

We are pleased to announce that EVERY EMS agency in Utah now has a designated Pediatric Emergency Care Coordinator (PECC)! Utah EMS is AMAZING!

There's an exciting new resource for follow-up from Primary Children's

Primary Children's hospital heard you! In my years with EMSC I have heard one request over and over . . . "We need better follow up on the patients we transport to Primary Children's." See below for who you can contact to get direct follow up and case reviews (both in person and virtual).

The long-awaited approval of COVID-19 vaccines for 5-11 year olds has arrived! Please help support and promote vaccination for children ages 5 through 11 so we can protect as many children and families as possible from COVID-19.

“Many people think children don’t get COVID-19 or get only very mild cases. That’s a myth,” says Andrew Pavia, MD, director of hospital epidemiology at Primary Children’s Hospital. Children are at risk for contracting COVID-19 and some can get seriously ill. Even if a child doesn’t get severely ill, they could face long-term health consequences or pass the virus to others. The best way to protect children against COVID-19, including the Delta variant—in school, in sports, with their friends—is by getting them vaccinated.

Primary Children’s Hospital’s Community Pharmacy and the Shot Spot walk-in clinics are offering the vaccine. Access Intermountain pediatric vaccine locations here.
You can find other vaccine locations at vaccines.gov.

Rumor Control

1. The vaccines can give you myocarditis. What is the risk of getting myocarditis from the vaccine? If you are a woman your risk is infinitesimal. Males 16-29 yrs old are at the highest risk and currently they are seeing 70 to 80 cases per million (1 in 300,000 vaccines) and most cases of myocarditis have had a mild course with full recovery. Male or female, you have a much higher risk of getting myocarditis from COVID-19.

2. I've had COVID, I have natural immunity so I'm good. “The most compelling reason to be vaccinated after having COVID-19 is that while infection-acquired and vaccine-acquired immunity are both natural and important, both wane over time,” says Intermountain infectious diseases specialist Brandon Webb, MD. “Vaccination after previous infection results in very high antibody levels that are long lasting and cover many variants.” Why vaccinate after Covid

What is Omicron?
Omicron (B.1.1.529) is a new variant of SARS-CoV-2, the virus that causes COVID-19. Omicron was first detected in the United States on December 1, 2021, and first detected in Utah on December 3 in a traveler who had returned from South Africa. Right now though, Delta is still the dominant variant in the U.S. and Utah and represents more than 99% of circulating strains.

“Vaccination is really important,” adds Dr. Webb. “Early data from South Africa suggests that severe omicron cases are clustering very heavily in the unvaccinated population. This is very important epidemiologically, because South Africa had extremely high rates of natural infection during their beta and delta variant surges. This suggests that prior infection may not be as effective as vaccination against omicron, and highlights the importance of getting vaccinated or boosted now in order to prepare for the arrival of omicron."

Caseloads and vaccination rates among Utah's school-aged children

coronavirus.utah.gov/case-counts/

Covid-19 Trackers

Johns Hopkins Global tracker (desktop)

Johns Hopkins Global tracker (mobile)

Utah Department of Health

Do you have a question for our EMSC Medical Director, Hilary Hewes, MD, PCH, ER Attending Physician about this newsletter topic or anything related to pediatrics? Shoot an email to the following address tdickson@utah.gov.

Pediatric Education for the Prehospital Provider

Register online at www.peppsite.com. Look up classes in Utah and find the one that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($18.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at erikandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

The Emergency Medical Services for Children (EMSC) Program aims to ensure that emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure that the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, no matter where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth