Severe Head Injury

Head trauma is considered severe in a child with a Glasgow Coma Scale (GCS) score of ≤ 8. These children often have intracranial injury identified on neuroimaging and all have suffered traumatic brain injury (TBI). Injury is the leading cause of death in children >1 year of age, and TBI is the most significant cause of death and disability across all ages.¹

• Children have larger head-to-body size ratios (higher incidence of head trauma), thinner cranial bones (increased risk of skull fractures), and unfused sutures (better initial tolerance of increased intracranial pressure).
• Pediatric brains have increased water content and decreased myelination making children more susceptible to shear injuries (e.g., diffuse axonal injury) and cerebral swelling.
• Consider abusive head trauma in infants and young children (see TREKK Recommendations for Suspected Child Abuse).

• Stabilize children with severe head trauma as per Advanced Trauma Life Support (ATLS) principles.
• Consider unique differences in childhood anatomy/physiology (see TREKK Recommendations for Multisystem Trauma).
• Apply spinal motion restriction when indicated.
• Once need for advanced trauma care is identified, refer and organize transport early after stabilization to optimize outcomes.
• Use the modified GCS for Infants and Children to assess and document neurological status in preverbal children. Alternatively, use the AVPU Scale (Alert, Voice, Pain, Unresponsive). A child who is responsive only to pain/unresponsive has a GCS of ≤ 8.
• Assume multisystem injury in all children presenting with significant head trauma due to mechanism of injury and smaller size/unique anatomy.
• Manage airway of children with severe TBI prior to transport.
• Recognize intracranial hypertension and cerebral herniation by:

1. 1. Progressive obtundation
   2. Unilateral pupillary dilatation
   3. Cushing’s triad (hypertension, bradycardia, abnormal respiration)

• Do not proceed with CT imaging prior to transport to Pediatric Trauma Centre unless recommended by transport/accepting physician. CT imaging is not required for diagnosis and should NOT delay transport.

• The main goal of treatment of TBI is to prevent secondary brain injury by maintaining cerebral perfusion while minimizing increased intracranial pressure.
  • Cerebral Perfusion Pressure (CPP) = Mean Arterial Pressure (MAP) – Intracranial Pressure (ICP)
• Neuroprotective measures with expedient transfer are critical to optimizing outcome.
• Avoid hypoxia and hypotension with effective airway and hemodynamic support. These 2 factors contribute most to secondary brain injury.
• Aim for euthermia and normocapnia (ETCO₂ 35-40). Hyperventilation is reserved for herniation. Inadvertent hyperventilation with ETCO₂ < 30 contributes to cerebral ischemia.
  • “Non-value added time” in pediatric TBI has been shown to worsen outcomes. Streamline resuscitation as much as possible and transfer early for definitive care.

• This includes EMERGENT reduction of intracranial pressure:

1. 1. Hyperventilation to pupillary response, reversal of Cushing’s Triad, and/or ETCO₂ of 30-35.
   2. Raise head of bed to 30o and loosen cervical collar or provide manual in-line stabilization.
   3. Hyperosmolar agents (3% NaCl and/or mannitol, see dosing table below).
   4. Airway protection with Drug Assisted Intubation while spinal motion restriction is maintained.
   5. Neurosurgical intervention for hematoma evacuation or decompressive craniectomy.

• Use a standardized streamlined approach with agents delivered in rapid succession.
• Ensure volume resuscitation, when indicated, is initiated prior to induction to prevent hypotension.

Thank you to the following content experts who led the development of this resource:

Suzanne Beno MD, FRCPC, DABP, Medical Co-Director, Trauma Program, The Hospital for Sick Children Associate Professor of Paediatrics, University of Toronto

Joe Nemeth MD, CCFP, EM, FCFP, McGill University Emergency Medicine Physician/Trauma Team Leader, MUHC, Montreal General Hospital Montreal Children’s Hospital, Director – Trauma Fellowship for the Emergency Medicine Physician Associate Professor Dept. of Emergency Medicine-Dept. of Pediatrics

Thank you to Danica Irwin, BSc. Phm, Pharmacist, Children’s Hospital of Eastern Ontario, for her medication review and to the TREKK Editorial Committee who provided editorial support and expertise in the development of this resource. Thank you as well to the following people who coordinated and oversaw the development process:

Mateja Carevic, BA, MA
TREKK Knowledge Broker University of Manitoba

Mary Anne Nurmi, BA, MSc
TREKK Knowledge Broker University of Manitoba

Mona Jabbour, MD, MEd
TREKK Co-Director; Interim Chair/Chief, Department of Pediatrics; Associate Professor, Pediatrics and Emergency Medicine, University of Ottawa Children’s Hospital of Eastern Ontario

Sarah Reid, MD
TREKK Editorial Lead; Clinical Investigator, CHEO Research; Institute Physician, Division of Emergency Medicine, CHEO ; Assistant Professor and Director, Emergency Department Outreach, University of Ottawa 

(as cited in the Severe Head Injury Bottom Line Recommendations):

1. Ajdari A, Boyle LN, Kannan N et al. Examining Emergency Department Treatment Processes in Severe Pediatric Traumatic Brain Injury. J Health Qual. 2017 Nov/Dec;39(6):334-344.
2. Kochanek, P, Tasker, RC, Carney, N, et al. Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines. Pediatr Crit Care Med. 2019 Mar;20(3S):S1-S82.
3. Lumba-Brown A, Totten A, Kochanek PM. Emergency Department Implementation of the Brain Trauma Foundation’s Pediatric Severe Brain Injury Guideline Recommendations. Pediatr Emerg Care. 2020 Apr;36(4):e239-e241.

For a complete list of the evidence that informed the creation of the Severe Head Injury Bottom Line Recommendations see the Evidence Repository here.

The purpose of this document is to provide healthcare professionals with key facts and recommendations for the diagnosis and treatment of community acquired pneumonia in children in the emergency department. The TREKK Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. THIS DOCUMENT IS SUBJECT TO FULL DISCLAIMER HERE: trekk.ca/terms-of-use