RCH Clinical Practice Guideline Head injury

VFPMS Guideline: Forensic investigation of head injury

Key points

• Scalp swelling and/or bruising of the head and/or neck in young infants can be associated with underlying bone and intracranial injury. Consider radiological investigations to search for signs of head and spine injury when signs of head and neck trauma are detected.
  • Admission to ICU should be considered when an infant or child with a head injury has experienced an altered conscious state (particularly after suspected shaking) because of the high risk of further neurological deterioration caused by progressive brain swelling
• In infancy and early childhood, skull fractures are common.
  • Skull fractures commonly result from accidental falls and impacts but can also be caused by inflicted trauma.
  • The most common location and type of skull fracture is a unilateral single linear parietal skull fracture.
  • Single linear parietal skull fractures are the most common type of skull fracture attributed to accidents and are also the most common type of skull fracture attributed to abuse.  
    
• Symptoms of intracranial injury are often subtle and can easily be missed.
• Signs of intracranial injury are often subtle and can easily be missed
• Urgent CT brain scan is the investigation of choice when concerns exist about significant and/or potentially life-threatening intracranial injury.
• The risks associated with radiological investigations must be balanced against the risks associated with failing to detect physical abuse and/or failing to determine the extent of injury.

Clinical Advice

The following information should be obtained about the presenting symptoms and signs. Ask about.

• Timing and detailed information about mechanism of injury (for example, information about impacting surface and objects, position of child when first observed after traumatic event)
• Circumstances surrounding the injury (Who was present? Who heard or saw what? What was happening prior to the event and what happened in the minutes to hours after?)
• Symptoms and signs of injury (including suspected brain and spine injury). Ask about alterations to breathing (including apnoea and gasping), seizures and abnormal posturing, movements, colour change, eye changes, changes to conscious state – GCS if possible, vomiting)
• Resuscitative efforts (including cardiac massage technique) and response

The following information should be obtained about the past medical history. Ask about.

• Birth and immediate perinatal period. (Instrumental birth? Any birth-trauma injury? Was Vitamin K given IM? Cephalhaematoma or scalp swelling? Feeding and behaviour during newborn period, admission to SCN and if so, for what reason?)
• Surgeries and bleeding history (see VFPMS CPG on bruising)
• Medical conditions and treatment (include therapies)
• Accidents
• Medication
• Developmental milestones and current developmental skills

The following information should be obtained about the family history. Ask about.

• Consanguinity
• Inherited neurodevelopmental disorders / genetic conditions
• 3 generation genogram regarding fractures and dislocations, bleeding disorders
• Seizures & epilepsy
• Deafness, dental enamel deficiencies, skin findings compatible with ectodermal dysplasia, Ehlers Danlos

The following information should be obtained about the social history. Ask about.

• Prior engagement with Child Protection and/or police. Protective and Family Violence orders
• Child-care arrangements (and recent child carers’ contacts with the child)
• Violence in the home (safety)
• Parental alcohol and drug use (past and recent)
• Parental mental illness and treatment
• Parenting experience, skills and capacity

Examination tips

Thoroughly examine and palpate the scalp, look in all orifices of the head (ears, nose, mouth) and examine the conjunctivae.

Look behind the ears and elevate the head to examine the neck.

Investigations are unlikely to be required when

• The accident/ traumatic event has been witnessed by multiple observers (for example a motor vehicle collision) and there are no concerns about child abuse.
• There is a low probability of child abuse (determination based on clinical findings).
• A). In infants with skull fractures, the following features may be seen in association with a low probability of a diagnosis of abuse.
  • The skull fracture is a single linear parietal skull fracture with no diastasis
  • The mechanism of injury is entirely compatible with the child’s developmental skills
  • The history of mechanism of injury (anamnesis) does not change over time.
  • The findings are entirely compatible with the alleged mechanism of injury.
  • There has been no respiratory compromise (no apnoea, hypopnea or altered breathing pattern)
  • There has been no alteration in, or loss of, consciousness
  • No seizures have been reported
  • Examination top-to-toe and in orifices reveals no injuries suspicious for abuse

• Consultation with VFPMS is recommended when infants with skull fractures do not also have these features.
• Consultation with VFPMS is recommended when clinical and radiological findings are of skull fracture in combination with intracranial injury.

• B). In older children (for example > 3 years old) who have a mild-moderate head injury and who do not need admission to hospital, consideration should be given to guidelines regarding a period of observation and radiological investigations (for example, RCH Clinical Practice Guidelines) https://www.rch.org.au/clinicalguide/guideline_index/Head_injury/ and the Emergency Medicine algorithm Babl, FE, et al. Australian and New Zealand guideline for mild to moderate head injuries in children. Emerg Med Australas. 2021. 33(2), 214-231. 

Consider investigations when

Concerns exist about physical abuse of infants and young children (for example an infant’s examination reveals unexplained bruises or fractures) and head injury is considered reasonably possible.

When concerns exist about inflicted head injury, particularly cranio-spinal injury resulting from shaking, the following investigations should be considered:

• CT head, particularly in unwell infants when intracranial injury is suspected (symptoms such as vomiting, seizures, apnoea, altered conscious state) and when a skull fracture is suspected
• MRI head and whole spine
• Eye (including retinal) examination by an ophthalmologist, particularly for children aged < 12 months
• Investigations for occult bone injury (as for fracture CPG - blood tests, skeletal survey)
• Investigations for bruising (as for bruising CPG) when scalp swelling and/or head and neck bruising are present.
• Consider more than 1^st line investigations for coagulation disorders when intracranial haemorrhage is present, particularly in infants and young children.
• Urine metabolic screen and consider serum organic acids. Check results of Guthrie screen. Consider other metabolic tests (such as free and total carnitine, B12, folate, copper, caeruloplasmin) and consultation with genetic/metabolic specialists when clinical scenario suggests possible metabolic/genetic condition/s.