SYMPOSIUM: ACCIDENTS AND POISONING
The management of
traumatic brain injury
Holly Roy
Peter Richards
Abstract
Paediatric head injury is an important clinical problem. Essential man-
agement begins with initial resuscitation supporting the airway,
breathing and circulatory systems with cervical spine stabilization.
Neurological assessment should include evaluation of the Glasgow
Coma Score and pupil reactivity. Further imaging, admission for
observation and neurosurgical referral may be indicated. This article
is aimed at the general paediatrician and emergency department
physician. We discuss the epidemiology, pathophysiology and general
principles of paediatric head injury management from the time of injury
through to discharge from hospital.
Keywords Glasgow Coma Scale; head injury; intracranial pressure;
neurosurgery
Introduction
Most childhood head injuries are minor, but severe head injuries
can be devastating for patient and family. Childhood incidence
peaks at around 15 years in both sexes but it is more common in
males of all ages. Causes include falls, road traffic collisions,
sport, firearms, deliberate assault and, specific to paediatrics,
‘non accidental injury’ which is the cause of injury in 25e30% of
children under the age of 2 years who are hospitalized after head
trauma. According to the NICE head injury guidelines (2014), 1.4
million people attend emergency departments in England and
Wales annually with a head injury, of which between 33% and
50% are children.
Head injury pathophysiology
The damage in head injury occurs in two phases. Primary, or
‘impact injury’, is the neurological damage sustained at the time
of injury and is a direct result of forces applied to the cranium at
the moment of trauma. The effects of primary injury include
diffuse axonal injury (DAI), skull fractures, brain parenchymal
contusions and lacerations. Secondary injury describes the
neurological damage that develops over the minutes, hours and
days following the initial insult. Doctors have the potential to
intervene to prevent secondary injury but have little control over
primary injury which can only be improved by avoiding or
lessening the accident.
Holly Roy BA BM BCh MRCS is a Senior House Officer in the
Department of Neurosurgery, Derriford Hospital, Plymouth, UK.
Conflict of interest: none declared.
Peter Richards MBBS FRCS FRCPCH is a Consultant in the Department
of Neurosurgery, Oxford University Hospital, Headley Way, Oxford,
UK. Conflict of interest: none declared.
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Causes of secondary injury interlink and include hypoxia,
ischaemia and raised intracranial pressure (ICP). For this reason,
hypoxia and hypovolaemia should be corrected urgently
following head injury, as these can be major determinants of
neurological outcome. Management of raised ICP is usually
carried out on a specialist neuro-intensive care ward and may
involve neurosurgery to evacuate a mass lesion.
Initial assessment and management of the severe
paediatric head injury
Optimal head injury care is streamlined with management of
other injuries in accordance with Advanced Trauma Life Support
(ATLS) principles. The primary survey and initial history should
be succinct and directed at resuscitation along with injury
severity stratification; assessing whether the patient can be dis-
charged immediately, or requires a further period of observation
and investigation, or direct referral to specialist services.
National Institute of Clinical Excellence (NICE) guidelines
state that all patients presenting with head injury should have an
initial assessment within 15 minutes of presentation, the focus of
which should be establishing whether or not the patient is at high
risk for clinically important brain or cervical spine injury. A
clinician with training in safeguarding should be involved in the
initial assessment of a child admitted to the emergency depart-
ment following a head injury and any concerns should be
documented and local protocols followed.
Structured approach to a child with head injury e ABCDER
It is important to be thorough and structured in the approach to a
child with traumatic head injury. Following an ABCDER
approach is vital to optimize outcomes. The initial approach is
separated into the primary (see Box 1) and secondary surveys.
Radiological investigations
A patient over the age of 10 years presenting with a significant
injury history should have a ‘trauma series’ carried out, which
includes X-rays of the cervical spine, chest, pelvis and any long
bones in which a fracture is suspected.
To reduce the radiation exposure children <10 years may
have more limited views undertaken but require particular im-
aging to exclude cervical spine injuries. Children <10 with GCS
8 or strong clinical suspicion of cervical spine injury should
have CT imaging of the cervical spine within one hour of pre-
sentation or when they are sufficiently stable for transfer to the
CT scanner.
In addition to the routine trauma scans, children who have
suffered traumatic head injury may need a CT head scan to
indicate whether or not there is intracranial pathology which
requires treatment. Indications for an immediate CT head (within
1 hour), according to NICE guidelines are:
 Suspicion of non-accidental injury
 Post-traumatic seizure with no history of epilepsy
 On initial ED assessment, GCS of <14 or for children <1
year, paediatric GCS of <15
 At 2 hours after injury, GCS <15
 Suspected open or depressed skull fracture or tense
fontanelle
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 SYMPOSIUM: ACCIDENTS AND POISONING

The primary survey appropriate analgesia and anti-emetics should be therefore provided,
A ‘look, listen, feel’ approach should be continued throughout the avoiding morphine and other sedating agents to maintain an optimal
primary survey. conscious level. For similar reasons, the bladder should be decom-
pressed with a urinary catheter, the stomach with a naso-gastric tube
Airway and cervical spine if necessary and fractures should be splinted.
Look: is the cervical spine stable? If not sure stabilize it until stability
is proven radiologically. Is there cyanosis? Does the patient have an Box 1
obviously reduced conscious level? (If the GCS is <8, an anaesthetist
 Any sign of basal skull fracture (e.g. haemotympanum,
should be called to help intubate).
‘panda’ eyes, leakage of cerebrospinal fluid from the ear or
Listen: is there gurgling or stridor? Check for sources of airway
nose, Battle’s sign)
obstruction and use suction. If a chin lift improves breathing a naso-
 Focal neurological deficit
or oropharyngeal may be of use.
 For children <1 year, presence of bruise, swelling or
laceration of more than 5 cm on the head
Breathing
A provisional CT report should be made available within one
Look: is the patient tachypnoeic? Is there accessory muscle use or
hour of the scan being performed. For children with none of the
unequal chest expansion? Observe the rate and depth of respirations.
above risk factors but more than one of the risk factors listed
Inspect for flail segments.
below, a CT within an hour of admission is also indicated:
Listen: for breath sounds and heart sounds.
 Loss of consciousness for >5 minutes
Feel: feel for expansion, subcutaneous emphysema and check the
 Abnormal drowsiness
trachea is midline.
 Three or more episodes of vomiting
Manage: breathing with high flow oxygen via a face mask and
 Dangerous mechanism of injury (high-speed road traffic
reservoir bag and pulse oximetry. Address reversible causes of
accident as pedestrian, cyclist or vehicle occupant, fall
breathing problems, e.g. pneumothorax, haemothorax or flail
from a height of greater than 3 m, high-speed injury from
segment.
projectile or other object)
 Amnesia (antegrade or retrograde) lasting more than 5
Circulation
minutes
Look: is there skin pallor or evidence of external haemorrhage?
If a child presenting with a head injury has none of the in-
Feel: assess the rate and quality of the pulse, and take a blood
dications on the first list above, but one on the second list, they
pressure. Feel the extremities, checking temperature and capillary
should be observed for 4 hours. If, over the period of observation
refill (which should be <2 seconds).
they develop any of the features below, they should have a CT scan:
Manage: Obtain vascular access (using the intra-osseous route if
 GCS less than 15
necessary) and give fluid resuscitation if required (10 ml/kg in
 Further vomiting
trauma). If the patient’s circulation does not respond appropriately,
 A further episode of abnormal drowsiness
consider occult blood loss requiring immediate attention.
The NICE guidelines also state that if none of the above fea-
The aim at this stage should be to have the patient pink, warm and
tures develop during the period of observation, it is up to the
stable. Only at this stage consider neurological investigation.

Disability
Only after stabilization of airway, breathing and circulation, should
Child >2 and adult Glasgow Coma Score (maximum
the neurological status be investigated. Assessment of neurological
score 15)
status in the trauma setting requires an assessment of the Glasgow Eyes Verbal Motor
Coma Score (GCS), pupils and limb movement. GCS should be
assessed and documented in terms of its ‘E’, ‘V’ and ‘M’ component, 1 Does not No verbal response No motor response
using the paediatric scale in pre-verbal children (see Tables 1 and 2). open eyes
Pupil diameter (in mm) and reactivity should also be documented. If 2 Opens eyes in Incomprehensible Decerebrate response
the GCS is less than eight or the patient appears to be unable to response to sounds (extensor posturing)
maintain their airway, and this issue has not been addressed at an painful stimuli
earlier stage, an anesthetist must be available for urgent intubation. 3 Opens eyes in Inappropriate Decorticate response
response to voice words (abnormal flexion
Exposure to pain)
The patient should be fully exposed and a full survey for other in- 4 Opens eyes Confused speech Withdraws/flexes in
juries performed. This will include a log roll, where the spine can be spontaneously response to painful
palpated and a rectal examination performed to assess anal stimuli
sphincter tone if spinal injury suspected. Temperature should be 5 e Oriented speech Localises painful stimuli
checked, and warming blankets provided to maintain the core tem- 6 e e Obeys commands
perature if necessary. Pain can increase intracranial pressure, and
Table 1

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 SYMPOSIUM: ACCIDENTS AND POISONING

 Persistent nausea and vomiting following the head injury

Infant Glasgow Coma Score (maximum score 15)  Persistent headache
Eyes Verbal Motor  Poor concentration and high distractibility
 Post traumatic seizures
1 Does not open No verbal response No motor response  Loss of consciousness (immediate/delayed)
eyes  Post-traumatic amnesia (difficult to assess in pre-verbal
2 Opens eyes in Inconsolable, Decerebrate response children)
response to agitated (extensor posturing)
painful stimuli Past medical history
3 Opens eyes in Inconsistently Decorticate response As much knowledge about the patient’s past medical history,
response inconsolable, moaning (abnormal flexion intercurrent illnesses, tetanus vaccination status and drug ther-
to voice to pain) apy should be obtained. If the child is taking any anticoagulant
4 Opens eyes Cries but consolable, Withdraws from pain medications it is important to take a decision with the relevant
spontaneously inappropriate teams about whether these need to be stopped or reversed. It is
interactions also important to check that the child is not on the child pro-
5 e Smiles, orients to Withdraws from touch tection register.
sounds, follows objects,
interacts Examination
6 e e Moves spontaneously
or purposefully It is helpful to think of the examination as having a general
element, looking at the patient as a whole as well as a specific
Table 2 neurological focus:

clinician to decide whether a period of longer indication is war-
ranted. For children with none of the above indications for a CT
scan but who are on warfarin, a CT scan of the head within 8
hours of the injury is indicated, again with a provisional radi-
ology report required within 1 hour of the scan.
Full history and neurological examination
After the initial process of resuscitation and stabilization has
been carried out, a full history and detailed neurological exami-
nation should be performed.
History
Timing of injury
Information about injury timing is significant as since significant
delays to treatment can increase the effects of secondary injury.
The ambulance report should document a GCS score at the scene
which should be documented in the clinical notes.
General
The cervical spine should have been cleared radiologically by
this point and the trauma review is a good time to check or re-
confirm that it has been done. Examine the patient for evi-
dence of a base of skull fracture. Signs of a base of skull fracture
include CSF otorrhoea/rhinorrhea, periorbital ecchymoses (‘ra-
coon eyes’), mastoid ecchymosis (‘Battle’s sign’), bleeding from
one or both ears or new deafness. Suspicion of a base of skull
fracture necessitates a CT scan and neurosurgical referral.
Assess the patient for maxillo-facial trauma, through palpa-
tion of the facial bones and examination of eye movements. New
diplopia or strabismus may be an indicator of an orbital fracture
with tethering of the orbital muscles. If there is any suspicion of
fractured facial bones, organize specific imaging and contact the
maxillo-facial surgeons and ophthalmologists.
Examine the scalp for lacerations, haematomas and fractures.
Wash out and close lacerations unless there is an underlying
skull fracture, which will require discussion with neurosurgery.
Extensive lacerations, especially those involving the face or eyes,
may need a plastic surgery involvement.

Mechanism of injury Neurology

In particular, it is important to find out: (a) whether the injury
was a high-energy injury, (b) whether the trauma was blunt or
penetrating, and (c) the main site that sustained the forces. Even
in paediatric cases it is important to find out whether alcohol or
drugs were involved.
Clinical response to injury
There are certain features of a patient’s response to injury that
act as clinical indicators of the severity of injury and are useful
determinants of the necessity for a CT scan and/or prolonged in-
hospital neurological observation. In the history, a note should
be made about whether the patient experienced any of the
following:
Carefully and repeatedly assess the GCS. If the cranial sutures
have not yet fused, palpate the fontanelle e a tense fontanelle is
suggestive of raised ICP.
Assess the upper and lower limbs for tone, power, reflexes,
co-ordination and sensation as far as possible given the re-
strictions of age and conscious level. Lack of symmetry is a cause
for concern and could signify a mass lesion affecting the hemi-
sphere contralateral to the side of the abnormality. Assess gait
and balance if possible.
The cranial nerves should be examined, assessing visual
acuity, direct and consensual pupil response to light and eye
movements. Fundoscopy should always be attempted, even if
difficult especially in an infant. Papilloedema is an important

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 SYMPOSIUM: ACCIDENTS AND POISONING
sign of raised ICP, although rarely develops rapidly after injury,
and retinal haemorrhages may suggest non-accidental injury.
Dilating drops should, however, be avoided as this will preclude
subsequent monitoring of the pupillary response to light. The
examination should continue, depending on age, looking at facial
movements and sensation, hearing, palatal and tongue move-
ments. Any focal deficit should lead to further investigation.
Cranial nerve deficits may indicate base of skull fractures, limb
deficits may indicate cerebral dysfunction or spinal injury. They
should be considered along with the GCS
Decision rules
Following resuscitation, history and clinical examination, there
are three possible clinical outcomes:
1. Discharge
2. Admission for further observation
3. Referral for specialist neurosurgical care for patients with
evidence of significant neurological injury
1. Discharge
Most paediatric head injuries are minor and are discharged
home by emergency medicine departments. If the patient has
reached and maintained a normal level of consciousness for a
reasonable period of time, there are no indications for longer
periods of observation as discussed above, and there are no
outstanding concerns about the clinical or social well-being of
the child relating to the head injury, it is reasonable to plan for
discharge. The caregivers should be given a verbal and written
description of ‘red flags’ such as reduced level of consciousness,
seizures, new neurological deficits, ongoing nausea/vomiting or
persistent headache, that should lead them to re-present to
medical services. Caregivers should be made aware that even
minor head injuries can result in short neurological and neu-
ropsychological sequelae, including memory and cognitive
problems, sensitivity to bright lights or loud noises, irritability,
and post-traumatic stress reactions, and occasionally these can
become long term problems. The written discharge information
should contain contact details for services which deal with head
injury rehabilitation and support in the community should
caregivers need to access such services. Caregivers should also
be given appropriate advice about return to school and sporting
activities in keeping with the degree of injury sustained. If a
child has been knocked out, even transiently, it is prudent to
advise avoiding contact sports for 6 weeks after the injury.
Finally, details of support organisations should be provided to
the family, as well as details about who to contact if persistent
or delayed symptoms occur. A discharge letter should be sent to
the GP within 48 hours of the patient’s discharge, and a copy
sent to the health visitor or school nurse as appropriate for the
patient’s age.
2. Admission for further observation
Some children will require admission for further observation
without immediate transfer to the neuroscience unit. In-
dications for admission include CT abnormalities, ongoing
headache or nausea, failure to return to GCS 15 after imaging,
signs of meningism or suspicion of NAI. It is generally prefer-
able to adopt a cautious approach, and if in doubt admit. The
NICE guidelines recognize the special challenges associated
with observations in children, and the need for nurses trained
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in paediatric care to be involved. Normally, while the GCS is
under 15, observations should be carried out every 30 minutes
and should include pulse, blood pressure, pupil size and reac-
tivity, temperature, oxygen saturations, limb movements and
GCS. When GCS 15 has been reached, half hourly observations
should be maintained for 2 hours, but then reduced to hourly
for 2 hours, and then 2-hourly observations until the neuro-
logical concern has resolved. Any deterioration in the GCS (a
drop in one point for >30 minutes or any drop of two points in
the motor score or three points in the eye or verbal score)
should be followed by resumption of observations every 30
minutes and should also trigger re-assessment by the super-
vising doctor and consideration of the need to repeat the CT
scan. Just because a CT scan was normal on admission doesn’t
mean an intracranial haematoma cannot develop over a few
hours.
3. Referral for specialist neurosurgical care
Reasons to discuss a patient with the neurosurgical team
include abnormal imaging findings and/or an abnormal clinical
picture. Imaging findings that warrant referral include evidence
of a new mass lesion, including subdural extradural or intra-
cerebral haematoma, contusional injury, intraventricular or
subarachnoid blood and base of skull or depressed skull frac-
tures. Clinical findings which should prompt referral include a
GCS 8 following resuscitation, ongoing confusion persisting
for more than 4 hours, a drop in GCS during a period of
observation (particularly if this is attributable to a reduction in
the motor score) and progressive focal neurological deficits.
Additional indications for specialist referral include known or
suspected penetrating injury, a seizure without full recovery or
a CSF leak.
If a patient is to be transferred to the neurosurgical unit, it is
essential that the transfer is carefully planned, and it is important
that there is a means by which clinicians on the transfer team are
able to communicate changes in the patient’s status with the
base hospital and also the neurosurgical unit during the transfer.
A patient should not be transferred if there are any concerns
about cardiovascular instability. A doctor with appropriate
knowledge of head injury management and paediatric resusci-
tation with a suitably trained assistant should accompany the
patient during the transfer. Pre-transfer intubation is mandatory
if the GCS is 8 or if there are other signs that the airway is
Making a neurosurgical referral
Essential information:
Patient name, age, date of birth
History including mechanism and time of injury
Initial GCS and GCS at time of referral
Resuscitation and management to date including other injuries
Past medical history, medications and allergies
Scan findings with images linked across to the neurosurgical centre if
possible - this should not delay the decision making process,
especially if an intracranial haematoma is identified.
Box 2
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 SYMPOSIUM: ACCIDENTS AND POISONING
Specialist neurosurgical care
Three of the main areas of care performed by the specialist neuro-
surgical unit are management of raised intracranial pressure (either
medically or surgically), management of fractures and management
of intracranial mass lesions.
Medical Management of raised intracranial pressure (ICP)
Most severely injured patients now have ICP measured using mini-
mally invasive transducers. Some centres also monitor brain paren-
chymal chemistry and cerebral blood flow. Raised ICP can develop
following traumatic brain injury for a number of reasons including
intraparenchymal swelling due to cerebral oedema secondary to
axonal injury or a space occupying mass lesion as a result of hae-
morrhage. The Monro-Kellie principle states that within the fixed
cranium, the intracranial volume is composed of blood, brain pa-
renchyma and CSF. Under normal circumstances, alterations in
intracranial blood or CSF volume can provide an auto-regulatory
mechanism to maintain a constant ICP, however, following head
injury, these compensatory mechanisms may be inadequate to pre-
vent ICP spikes and up to 75% of children with severe head injury will
experience raised ICP. Techniques employed to control ICP medically
include sedation and muscle paralysis, ventilation to normocarbia,
mild hypothermia, seizure control, maintenance of a 30 head up tilt
and osmotic manipulation. ICP management is usually managed in
conjunction with blood pressure to maintain an adequate cerebral
perfusion pressure.
Surgical Management of raised intracranial pressure (ICP)
Large intracranial blood clots causing cerebral compression would
usually be removed by craniotomy unless the patient was too un-
stable for surgery, or brain stem function had been lost and a deci-
sion made that treatment would be futile. A surgeon and anaesthetist
experienced in managing children should perform such procedures,
unless the patient is deteriorating so rapidly that waiting for a pae-
diatric surgical team would be detrimental. In the infant great care
must be taken to minimize avoidable blood loss and the volume of
the intracranial clot itself must be taken into consideration when
assessing the circulating volume.
Surgical procedures that can support medical management of raised
intracranial pressure include placement of an external ventricular
drain to reduce the contribution of CSF to the intracranial volume. As
a last resort treatment, a decompressive craniectomy can be per-
formed to allow room for the brain to expand outside the confines of
the bony skull. Although this is a controversial technique, there is
some weak evidence to support its use in children, in cases of
intractable raised ICP.
Management of skull fractures
Fractures can be classified as open or closed, and involving the vault
or the base of the skull. Open fractures need debridement of the
wound edges and suitable antibiotic prophylaxis prescribed because
the broken tissues have provided an entry route for bacteria into the
normally protected brain and CSF spaces. Depressed skull fractures
may need operating to repair the dura if there is a substantial CSF
leak or to decompress cranial nerves if there is a progressive deficit,
but if they are closed and not in a prominent area cosmetically there
may not be any need to operate on them. Infants with depressed
skull fractures, as can occur with forceps delivery, usually remould
themselves by skull growth and don’t usually require surgery.
Box 3
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under impending threat (excessive bleeding into the mouth or
the presence of unstable facial fractures, progressive deteriora-
tion in the GCS, loss of laryngeal reflexes, irregular respirations,
inability to maintain oxygen saturation above 13 kPa, or a rising
pCO2 above 6 kPa, spontaneous hyperventilation causing pCO2
to drop below 4 kPa, or seizures). Intubation should be accom-
panied by muscle relaxants, short acting sedation and analgesia.
The target pO2 is normally >13 kPa and the target pCO2 between
4.5 and 5.0 kPa.
In ideal circumstances transfer should be carried out by a
Paediatric Retrieval Team. However, in a patient deteriorating
due to an expanding intracranial mass the risk of delay in
assembling and transporting the retrieval team must be balanced
against the risk of transport by a less experienced transport team
and individual case decisions made.
The receiving neurosurgical team will expect certain pieces of
information and access to CT images before accepting the
referral. A recommended referral framework is described in Box
2. For information about some of the specialist head injury
management that takes place in the neurosurgical department,
see Box 3.
It is important to communicate the reasons for transfer to the
patient’s family and carers, and also to allow them to have as
much access to the patient as is reasonable and possible.
Rehabilitation and outcome
Whether the head injured child is discharged from the neuro-
science unit, from an observation ward or directly from the
emergency department, a number of rehabilitation steps should
be considered.
In an ideal world all head injured children should be referred
for a neuropsychological review after discharge. Cognitive defi-
cits can occur even with minor head injuries; the sooner these
are identified and educational adjustments made where neces-
sary the better. If undetected, such problems can result in long-
term hindrances to the child’s educational and social progress.
However, if facilities are not available for such close neuropsy-
chological involvement at the least schools should be informed of
the head injury so appropriate observation and support can be
offered.
Follow up clinical review and imaging should be decided on
an individual case basis.
The majority of children will not require long-term anti-
convulsant medication, although rapid short term seizure control
in the severely injured child is mandatory. If, however, post-
traumatic seizures develop they should be controlled with anti-
convulsant medication.
Conclusions
Management of paediatric head injuries requires a rapid and
thorough system of assessment and treatment. Medical staff
should be alert to any deterioration in neurological status and be
quick to re-evaluate with further imaging if necessary. Involve-
ment of neurosurgical teams is required for significant head in-
juries, including those associated with depressed, open or base of
skull fractures, raised intracranial pressure, or intracerebral pa-
thology. Careful discharge and follow-up is important, including
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 SYMPOSIUM: ACCIDENTS AND POISONING
addressing concerns about child protection and ensuring that
post-discharge neuropsychological difficulties are addressed,
even in apparently minor head injuries. A
FURTHER READING
1 NICE head injury guideline (CG176 2014).
2 Rogers Textbook of Paediatric Intensive Care (Nichols DG).
3 Pediatric Neurosurgery (Choux M, Di Rocco C & Walker ML).
4 Management of Severe Traumatic Brain Injury: Evidence, Tricks
€nde, P.-O.; Juul, N.; Kock-Jensen,
and Pitfalls. (Sundstrøm, T.; Gra
C.; Romner, B.; Wester, K. (Eds.)).
5 Neurosurgery for Basic Surgical Trainees 2nd Ed (Liebenberg WA &
Johnson RD).
6 Handbook of Neurosurgery (Greenberg MS).
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Practice points
C Cervical spine stabilization with management of airway,
breathing and circulation are the essential first steps in
head injury management.
C A CT head scan is the investigation of choice for head injury
assessment.
C Indications for neurosurgical referral include an intracere-
bral mass lesion, reduced conscious level or a new focal
neurological deficit.
C Follow up after head injury is important and should include
neuropsychological input.
C Suspicion of non-accidental injury should be taken seriously
and lead to involvement of child protection services.
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