I. INDICATIONS FOR ADMISSION TO A HOSPITAL WARD |
Children who have sustained a head injury should be admitted to hospital if any of the following risk factors apply:
Any indication for CT scan Suspicion of non accidental injury Significant medical comorbidity Difficulty making a full assessment Child not accompanied by a responsible adult Social circumstances considered unsuitable
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In injured children, especially the very young, the possibility of non-accidental injury must be considered:
When findings are not consistent with the explanation given If the history changes or If the child is known to be on the child protection register
In such cases a specialist paediatrician with the responsibility for child protection should be involved. Child protection procedures should be followed.
Primary and secondary care information systems should identify children on the child protection register and frequent attenders
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II. INDICATIONS FOR DISCHARGE FROM EMERGENCY ROOM (ER) |
Children can be discharged from ER for observation at home if fully conscious and no additional risk factors apply |
III. REFERRAL TO A NEUROSURGICAL UNIT |
Features suggesting that specialist neuroscience assessment, monitoring or management are appropriate include:
Persisting coma (GCS score 8/15 or less) after initial resuscitation Confusion which persists for more than four hours Deterioration in level of consciousness after admission (a sustained drop of one point on the motor or verbal subscales, or two points on the eye opening subscale of the GCS) Focal neurological signs A seizure without full recovery Compound depressed skull fracture Definite or suspected penetrating injury A CSF leak or other sign of a basal fracture.
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THE PROCESS OF TRANSFER TO A NEUROSURGICAL UNIT |
Transfer of a child to a specialist neurosurgical unit should be undertaken by staff experienced in the transfer of ill children. Consultation on the best method of transfer of an individual patient should be with referring healthcare professionals, transfer clinicians and the receiving neurosurgeon. It should take into account the clinical circumstances, skill of available staff, imaging, mode of transfer and timing issues. |
IV. DISCHARGE PLANNING AND ADVICE |
Before discharge from the ward a patient with a head injury must be assessed by an experienced doctor, who must establish that all the following criteria have been met:
Consciousness has recovered fully and is sustained at the pre-injury state The patient is eating and drinking normally and not vomiting Neurological symptoms/signs have either resolved, or are minor and resolving or are amenable to simple advice/treatment, (e.g. headache relieved by simple analgesia, or momentary positional vertigo due to vestibular disturbance) The patient is either mobile and self caring or returning to a safe environment with suitable social support The results of imaging and other investigations have been reviewed and no further investigation is required Extracranial injury has been excluded or treated. Clear written discharge instructions should be given to parents/caregiver. Staff should review this information with the parents/caregiver, clarifying any issues and ascertaining their understanding of the information
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V. FOLLOW UP |
Children suffering from moderate/severe head injury should be followed up by a specialist multidisciplinary team to assess rehabilitation needs. Parents should be given information and advice about the possible short/longer term difficulties that their child may have. The primary healthcare team, school health team and teachers should be notified of all children with a head injury regardless of severity. |
