What are the guidelines for managing traumatic brain injury (TBI) in pediatric patients?

From the Guidelines

Management of head injuries in children requires prompt assessment and appropriate intervention based on injury severity, with the goal of minimizing morbidity, mortality, and improving quality of life. For mild head injuries (Glasgow Coma Scale 13-15), close observation at home is typically sufficient with acetaminophen (10-15 mg/kg every 4-6 hours) or ibuprofen (5-10 mg/kg every 6-8 hours) for pain relief, as recommended by the Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children 1. Parents should monitor for concerning symptoms like persistent vomiting, worsening headache, confusion, seizures, or difficulty waking the child, which warrant immediate medical attention.

Some key points to consider in the management of head injuries in children include:

• The use of clinical decision rules, such as the Pediatric Emergency Care Applied Research Network (PECARN) criteria, to determine the need for neuroimaging in children with minor head trauma 1
• The importance of maintaining adequate oxygenation (SpO2 >95%) and age-appropriate blood pressure to prevent secondary injury from hypoxia and hypotension 1
• The need for post-concussion management, including physical and cognitive rest for 24-48 hours followed by gradual return to activities, with full return to sports only after complete symptom resolution and medical clearance, typically following a 5-step return-to-play protocol over at least 5-7 days 1

In terms of specific interventions, the use of hyperosmolar therapy with 3% hypertonic saline (3-5 ml/kg) or mannitol (0.25-1 g/kg) may be needed for increased intracranial pressure, as recommended by the French Guidelines for the management of severe traumatic brain injury 1. Additionally, intracranial pressure monitoring may be required for severe injuries, with treatment goals of maintaining pressure below 20 mmHg.

Overall, the management of head injuries in children requires a comprehensive approach that takes into account the severity of the injury, the need for prompt medical attention, and the importance of preventing secondary injury and promoting optimal recovery. By following the recommendations outlined above, healthcare providers can help minimize morbidity, mortality, and improve quality of life for children with head injuries.

From the Research

Head Injury Management in Children

• Head injury is the most common cause of injury-related death and permanent disability in children, with minor head trauma being common in childhood and not requiring medical treatment 2.
• Emergency department clinicians should be aware of signs and symptoms indicating severe traumatic brain injury to triage for urgent intervention 2, 3.
• Assessment, investigation, and early management of head injury are essential to reduce the potential risk of disability or death 3.

Severity Assessment and Management

• The Glasgow Coma Scale (GCS) is used to assess the severity of brain injury, with severe head injury potentially leading to secondary brain damage from cerebral ischaemia 4, 5.
• Interventions such as antibiotics, anticonvulsants, corticosteroids, hyperventilation, hypothermia, and mannitol may be used to reduce complications of moderate to severe head injury 4, 5.
• The use of prophylactic anticonvulsants, such as phenytoin and carbamazepine, may be recommended to prevent early post-traumatic seizures (PTS) in high-risk patients during the first week following head injury 6.

Triage and Discharge

• Clinicians should know when children can be sent home with reassurance and information, and when they require admission or transfer to a neurosurgical unit 2.
• After-care following head injury is important, with advice on signs and symptoms of severe head injury and the importance of computed tomography outlined 3.