Sometimes coincidence leads to a change in practice.
While minor head trauma is frequently seen in the emergency department, in a 3-week period in 2010, three walk-in pediatric head injury patients with skull fractures/bleeds presented to our small community hospital ED.
Each was triaged as a level 3, and in one case there was a significant delay in care. For reference, level 1 are critical and/or dying patients; level 5 patients require no resources or special needs.
A root cause analysis led to the decision to designate all pediatric head injuries a level 2 for prompt evaluation.
Case No. 1 was a 2-month-old female whose caregiver fell while holding her. The baby was crying but consolable with no loss of consciousness (LOC). She vomited initially and once again in the ED. There was a moderate left parietal hematoma, no obvious distress, VS 97.8-160-46. With the ED extremely busy, a delay in care occurred. CT showed a nondepressed linear parietal skull fracture with a questionable subarachnoid hemorrhage and a scalp hematoma. The child was airlifted to the pediatric trauma center.
Case No. 2 was a 3-year-old female who fell and hit her head but had no LOC. Her physician evaluated her promptly; she was "OK". One week later, her parents brought her back to the ED with a large left scalp hematoma and increase in daily naps from one, to two or three. She was running around the waiting room, oriented with a headache but no nausea or vomiting; VS 98.3-103-20, BP 88/40, O2 sat 98 percent RA. CT showed a non-depressed linear temporal/parietal skull fracture with subdural hematoma. Very stable, she was sent to the pediatric trauma center via ambulance. Her Hispanic, non-English-speaking parents were commended for bringing the child back to the ED. Nurses must ensure all caregivers understand head injury after-care instructions, including when to return, and especially when there is a language barrier.
Case No. 3 was a 2-month-old female who fell out of a bed, falling two feet and hitting her head on a metal swing arm of the crib. She cried immediately with no LOC or open wound. There was a right posterior scalp hematoma, VS 97.4-127-28. CT showed nondisplaced right parietal skull fracture with a tiny epidural hematoma and 2.7 cm scalp hematoma. The patient was transferred to the pediatric trauma center by helicopter.
What the Literature Told Us
Head injury is the main cause of death in children older than 1 year, with 50,000 children suffering permanent disability each year, most from closed head injury.1
Although severe head trauma is emphasized, identifying intracranial injury in patients with minor head trauma prevents serious mortality and morbidity. The American Academy of Pediatrics defines minor head trauma in children as normal mental exam on initial exam, no abnormal or focal findings on neurological exam, and no physical evidence of skull fracture.2
The younger the child, the greater that risk: children under 2 have a higher risk of skull fracture due to thinner bones, and fractures may occur in short falls under 3-4 feet. They are more difficult to assess and are at higher risk for intracranial lesions which may occur with a minor mechanism of injury.
Children may have a normal exam but risk if higher if there is a skull fracture. Most skull fractures have a scalp hematoma.
Parietal skull fractures are most common (60-70 percent), followed by occipital, frontal and temporal fractures. Linear fractures are the most common type (60-90 percent), trailed by depressed and basilar fractures. More than 90 percent of linear fractures have hematomas or soft tissue swelling that may not be there initially. Larger hematomas or temporal/parietal hematomas are more likely to indicate fracture.
History may include seizure, altered mental status, persistent vomiting, and amnesia. Physical exam includes focal neural deficits, altered mental status or signs of skull fracture. Larger hematomas have greater risk, with frontal hematomas low risk.1 Loss of consciousness may not be a significant sign. In one study intracranial injury was found in 2.5 percent of patients with LOC, compared to 4.7 percent of patients with NO LOC - not what you would expect!3
The American Academy of Pediatrics provides specific recommendations for head CTs determined by age and risk.2 Not every patient needs a head CT. Risk versus benefit must be weighed. If the suspicion is high, the benefit outweighs the risk. CT pros are the CT shows traumatic brain injury (TBI), prevents mortality, relieves parents of worry and expedites disposition.1
CT cons include radiation exposure to the head (CT = 300 - 500 chest X-rays), with a higher lifetime risk for radiation-related cancer (1 in 2000 for infants, 1 in 5000 for children).1 Cost, sedation and its associated risks, along with the need to transport the child out of the ER are also cons.
Impact on Care
Comparing our cases to the literature, each case had the most common fracture type: linear (60-90 percent). Each had a scalp hematoma found in 90 percent of linear fractures.
Cases No. 1 and No. 3 were 2 months old: younger child, thinner bones. These two cases also had relatively short falls of less than 3-4 feet as well as parietal skull fractures (60-70 percent of all fractures).
Case No. 2 had a parietal- temporal fracture; temporal fractures occur in frequency after parietal, frontal and occipital. None of the patients had a loss of consciousness, and only one had any vomiting. It was interesting that three different types of bleeds were present: epidural (arterial); subarachnoid (venous); and subdural (acute or chronic, may occur over days and weeks).
What could have been changed in all of these cases?
In each case, the triage nurse asked for a CT, but especially in the young child, provider evaluation prior to CT weighs risk versus benefit as well as possible need for sedation. Triaging these patients as level 2 would have ensured earlier provider evaluation and intervention.
How has this impacted our care?
It has made us more aware that children with head contusions are more at risk for skull fractures and bleeds. We look more closely for subtle concussion signs. Initially, we assigned all pediatric head injuries as level 2; this was later fine-tuned to designate only children under age 2. The risk of serious potential damage cannot be dismissed.
Be suspicious. Look at age related factors such as falls, abuse, bicycle/motor vehicle/pedestrian accidents, aggressive behavior and sports.4 An accurate history is essential. Do the injuries match the story?
Evaluate the patient. The pediatric Glasgow Coma Scale is a viable resource. Concussion symptoms may be subtle and difficult to evaluate. Discharge education and its understanding by family/caregivers are crucial. Clearly define when to bring the patient back to the ED. Make family aware they may call if questions.
Head injury prevention via education and enforcement of infant seat/seatbelt/helmet use, fall prevention, sports safety and child abuse/shaken baby syndrome can reduce the amount and severity of injuries. Nurses in all arenas have many opportunities to teach and support pediatric minor head injury prevention.
Glenda Heyser is an emergency department nurse from Gettysburg, PA.