What is the management of pediatric head injury patients at risk of intracranial complications?

From the Guidelines

Children with head injuries at risk of serious intracranial pathology should be monitored for at least 24 hours, with immediate CT imaging and stabilization following the ABCDE approach, as recommended by recent guidelines 1. The management of pediatric head injury patients at risk of intracranial complications requires a systematic approach, with particular attention to maintaining adequate oxygenation and preventing secondary brain injury.

Key Considerations

• Children with moderate to severe head injuries (Glasgow Coma Scale <13), focal neurological deficits, seizures, persistent vomiting, or concerning mechanism of injury should undergo immediate CT imaging of the brain 1.
• Initial stabilization follows the ABCDE approach with particular attention to maintaining adequate oxygenation (target SpO2 >95%) and preventing secondary brain injury by avoiding hypotension and maintaining cerebral perfusion pressure.
• Elevated intracranial pressure should be managed with head elevation to 30 degrees, maintaining midline head position, and ensuring adequate sedation and analgesia.
• Hyperosmolar therapy with 3% hypertonic saline (3-5 mL/kg over 10-20 minutes) or mannitol (0.25-1 g/kg IV) may be necessary for signs of increased intracranial pressure.
• Seizure prophylaxis with levetiracetam (20-40 mg/kg/day divided twice daily) or fosphenytoin (loading dose 15-20 mg PE/kg) should be considered for patients with moderate to severe traumatic brain injury.
• Temperature control is essential, with antipyretics for fever and avoidance of hyperthermia.
• Serial neurological assessments using age-appropriate scales are crucial for detecting deterioration.
• Neurosurgical consultation should be obtained early for patients with intracranial hemorrhage, depressed skull fractures, or progressive neurological decline, as managing severe TBI children in a paediatric trauma centre or in an adult trauma centre with paediatric expertise is associated with reduced morbidity and mortality 1.

Monitoring and Observation

• Children under 2 years old are at higher risk for intracranial complications and should be closely monitored, as the incidence of raised ICP was found high and a strong association existed between cerebral perfusion pressure and neurological outcome 1.
• The risk of clinically significant intracranial injury in children under 2 years old is estimated at approximately 4.4% 1.
• CT imaging has the advantage of rapid acquisition and excellent sensitivity for acute intracranial hemorrhage and fractures, making it a recommended imaging modality for high-risk patients 1.

From the FDA Drug Label

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From the Research

Management of Pediatric Head Injury Patients

The management of pediatric head injury patients at risk of intracranial complications involves careful assessment and monitoring.

• Patients with mild traumatic brain injury (mTBI) are at risk of developing traumatic intracranial hemorrhage (tICH) 2.
• The risk of delayed intracranial hemorrhage in anticoagulated patients with mild traumatic brain injury is low, with a pooled estimate of 0.60% (95% CI 0-1.2%) 3.
• In pediatric patients with acute acquired comitant esotropia, there is a small but nontrivial risk of serious intracranial pathology, with 1 patient (0.9%) found to have a cerebellar medulloblastoma 4.

Risk Factors for Traumatic Intracranial Hemorrhage

Several risk factors have been identified for traumatic intracranial hemorrhage in mild traumatic brain injury patients, including:

• Signs of a skull base fracture (OR 11.71,95% CI 5.51-24.86) 2
• GCS < 15 (OR 4.69,95% CI 2.76-7.98) 2
• Loss of consciousness (OR 2.57,95% CI 1.83-3.61) 2
• Post-traumatic amnesia (OR 2.13,95% CI 1.27-3.57) 2
• Post-traumatic vomiting (OR 2.04,95% CI 1.11-3.76) 2
• Antiplatelet therapy (OR 1.54,95% CI 1.10-2.15) 2
• Male sex (OR 1.28,95% CI 1.11-1.49) 2

Use of Anticoagulation Agents

The use of anticoagulation agents after traumatic intracranial hemorrhage may lead to progression of hemorrhage, but the benefits may outweigh the risks in certain situations 5.

• The risk of immediate and delayed intracranial hemorrhages from initiating anticoagulant therapy in intracranial injury must be weighed against the morbidity of delaying treatment 5.
• The use of direct oral anticoagulants (DOACs) after mild traumatic brain injury is associated with a low risk of delayed traumatic intracranial hemorrhage, with 20 instances of delayed tICH reported in 1375 subjects 6.