What are the implications of a paediatric (pediatric) head injury?

From the Guidelines

When a child experiences a head knock, healthcare professionals should use validated clinical decision rules, such as the Pediatric Emergency Care Applied Research Network (PECARN) decision rules, to identify those at low risk for intracranial injury (ICI) and do not require a head CT, as recommended by the Centers for Disease Control and Prevention guideline 1.

Key Considerations

• The PECARN decision rules consider factors such as age younger than 2 years, vomiting, loss of consciousness, severe mechanism of injury, severe or worsening headache, amnesia, nonfrontal scalp hematoma, Glasgow Coma Scale score less than 15, and clinical suspicion for skull fracture to assess the risk for more serious injury 1.
• Children with concerning symptoms, such as loss of consciousness, repeated vomiting, severe headache, seizures, unusual drowsiness, confusion, slurred speech, or unequal pupils, require immediate medical attention.
• For mild bumps without concerning symptoms, applying a cold compress for 20 minutes to reduce swelling and giving age-appropriate acetaminophen (paracetamol) for pain may be considered.
• It is essential to monitor the child closely for 24-48 hours for signs of concussion or more serious injury and ensure they rest both physically and cognitively.
• If symptoms worsen or persist beyond 24-48 hours, a medical evaluation is necessary, and children should not return to sports or physical activities until completely symptom-free and cleared by a healthcare provider to prevent second impact syndrome 1.

Management

• The primary goal is to identify children at high risk for ICI who may require a head CT and those at low risk who do not need imaging, using validated clinical decision rules like PECARN 1.
• Close monitoring and prompt medical attention for concerning symptoms are crucial in managing paediatric head knocks.
• The use of acetaminophen for pain management and cold compresses for swelling reduction should be guided by the child's age and weight, with dosages not exceeding recommended limits.
• Cognitive and physical rest are vital components of concussion management, and return to activities should be gradual and supervised by a healthcare provider 1.

From the Research

Paediatrics Head Knock

• Traumatic brain injury (TBI) can lead to coagulopathy, a condition characterized by bleeding and clotting disorders 2, 3.
• Coagulopathy is a common sequela of TBI, and consumptive coagulopathy and secondary hyperfibrinolysis are associated with hypercoagulability 2.
• The risk of developing intracranial bleeding is significantly higher for patients on antiplatelet drugs, whereas the risk of anticoagulated patients overlapped with that of the general population 4.
• Patients with a Glasgow Coma Scale (GCS) score of 15 on long-term anticoagulation therapy seem to be at no higher risk for intracranial hemorrhage than are nonanticoagulated patients 4.
• However, patients with a GCS score of 15 on antiplatelet therapy seem to be more prone to developing intracranial bleeding than are the general population, with a trend to be more at risk when it comes to second-generation drugs 4.
• The benefit of systematic head CT for mild traumatic brain injury in patients under antithrombotic therapy is limited, with a low frequency and severity of intracranial hemorrhages detected 5.
• Coagulopathy can be used as an early predictor of mortality after penetrating traumatic brain injury, with patients who died being more coagulopathic 6.

Diagnosis and Treatment

• Coagulation and fibrinolytic parameters such as fibrinogen and D-dimer should be measured routinely to predict and prevent the development of coagulopathy and its negative outcomes 2.
• Tranexamic acid is the only evidence-based treatment for traumatic brain injury with coagulopathy, but its use should be considered on a patient-by-patient basis 2.
• The management of mild traumatic brain injury patients under antithrombotic therapy may not require systematic head CT scans, but rather a more individualized approach 5.

Complications and Outcomes

• Traumatic brain injury-induced coagulopathy is a common and well-recognized risk for poor clinical outcomes, including increased risk of bleeding and clotting disorders 3.
• Coagulopathy can lead to persistent and delayed intracranial hemorrhage and systemic bleeding, resulting in poor prognosis and increased mortality 3, 6.