Evaluation and Management of Moderate to Severe Pediatric Head Trauma
Anand Swaminathan, MD, MPH; Phil Levy, MD; Eric Legome, MD
Abstract
A case of pediatric head trauma is presented with a detailed discussion of current concepts in evaluation and treatment. Management of the moderate to severe head-injured child is reviewed, and best practices for emergency department treatment are discussed.
Background: Pediatric head trauma is a common and potentially devastating injury. Thorough knowledge of the clinical evaluation and treatment will assist the emergency physician in providing optimal care.
Discussion: Using a case-based scenario, the initial management strategies along with rationale evidence-based treatments are reviewed.
Conclusions: Computed tomography scan is the diagnostic test of choice for the moderate to severe head-injured pediatric patient. Several unique scales to describe and prognosticate the head injury are discussed, although currently, the Glasgow Coma Scale is still the most commonly accepted one. Similar to the adult patient, avoidance of hypotension and hypoxia are key to decreasing mortality. Etomidate and succinylcholine remain the choice of medications for intubation. Hyperventilation should be avoided.
A case of pediatric head trauma is presented with a detailed discussion of current concepts in evaluation and treatment. Management of the moderate to severe head-injured child is reviewed, and best practices for emergency department treatment are discussed.
Background: Pediatric head trauma is a common and potentially devastating injury. Thorough knowledge of the clinical evaluation and treatment will assist the emergency physician in providing optimal care.
Discussion: Using a case-based scenario, the initial management strategies along with rationale evidence-based treatments are reviewed.
Conclusions: Computed tomography scan is the diagnostic test of choice for the moderate to severe head-injured pediatric patient. Several unique scales to describe and prognosticate the head injury are discussed, although currently, the Glasgow Coma Scale is still the most commonly accepted one. Similar to the adult patient, avoidance of hypotension and hypoxia are key to decreasing mortality. Etomidate and succinylcholine remain the choice of medications for intubation. Hyperventilation should be avoided.
Case Presentation
A 35-day-old ex-premature 35-week boy was brought in by Emergency Medical Services (EMS) after a witnessed fall out of a baby carrier down 15 carpeted steps. The parents stated that the child continued breathing, but was otherwise unresponsive to voice or pain for 30 s, and then began to cry inconsolably. They denied witnessing vomiting or seizure-like activity after the fall. EMS secured the patient in his baby carrier and transported the child to the Emergency Department (ED). En route, the patient was crying, with episodes of decreased responsiveness. On ED arrival, vital signs revealed a blood pressure of 51/24 mm Hg, a heart rate of 171 beats/min, respiratory rate of 44 breaths/min, and an oxygen saturation of 100% on room air. On primary survey, the airway appeared patent. Breathing was normal and breath sounds were equal bilaterally. The child was pink in color with strong brachial and femoral pulses bilaterally. He opened his eyes to painful stimuli but not spontaneously, and would move all four extremities equally without any specific response to pain. The patient made no vocal response. The initial pediatric Glasgow Coma Scale (GCS) was 6.
Immediately upon arrival, intravenous access was established, the patient was placed on a monitor, and blow-by oxygen was delivered. The patient's neck was also immobilized. Secondary survey revealed a large hematoma over the left frontoparietal region without any evidence of laceration. The anterior fontanelle was open and flat and there were no palpable skull fractures. Pupils were 5 mm bilaterally and reactive to light. The chest, abdomen, and extremity examinations were unremarkable. A bedside FAST (focused assessment with sonography in trauma) examination revealed no evidence of free intra-peritoneal fluid or pericardial effusion
After the secondary survey was completed, the patient had recurrent, intermittent apneic episodes lasting 56 s each. Bag-valve-mask ventilation was initiated and intubation was attempted. Intubation was complicated by emesis and desaturation, but eventually the airway was secured. Because the blood pressure after intubation was 45/23 mm Hg, a 60-cc bolus of normal saline was administered, with a resultant increase in blood pressure to 57/35 mm Hg.
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A 35-day-old ex-premature 35-week boy was brought in by Emergency Medical Services (EMS) after a witnessed fall out of a baby carrier down 15 carpeted steps. The parents stated that the child continued breathing, but was otherwise unresponsive to voice or pain for 30 s, and then began to cry inconsolably. They denied witnessing vomiting or seizure-like activity after the fall. EMS secured the patient in his baby carrier and transported the child to the Emergency Department (ED). En route, the patient was crying, with episodes of decreased responsiveness. On ED arrival, vital signs revealed a blood pressure of 51/24 mm Hg, a heart rate of 171 beats/min, respiratory rate of 44 breaths/min, and an oxygen saturation of 100% on room air. On primary survey, the airway appeared patent. Breathing was normal and breath sounds were equal bilaterally. The child was pink in color with strong brachial and femoral pulses bilaterally. He opened his eyes to painful stimuli but not spontaneously, and would move all four extremities equally without any specific response to pain. The patient made no vocal response. The initial pediatric Glasgow Coma Scale (GCS) was 6.
Immediately upon arrival, intravenous access was established, the patient was placed on a monitor, and blow-by oxygen was delivered. The patient's neck was also immobilized. Secondary survey revealed a large hematoma over the left frontoparietal region without any evidence of laceration. The anterior fontanelle was open and flat and there were no palpable skull fractures. Pupils were 5 mm bilaterally and reactive to light. The chest, abdomen, and extremity examinations were unremarkable. A bedside FAST (focused assessment with sonography in trauma) examination revealed no evidence of free intra-peritoneal fluid or pericardial effusion
After the secondary survey was completed, the patient had recurrent, intermittent apneic episodes lasting 56 s each. Bag-valve-mask ventilation was initiated and intubation was attempted. Intubation was complicated by emesis and desaturation, but eventually the airway was secured. Because the blood pressure after intubation was 45/23 mm Hg, a 60-cc bolus of normal saline was administered, with a resultant increase in blood pressure to 57/35 mm Hg.
DOWNLOAD PDF COMPLETE HERE
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