SAQ 397 – Paediatrics – head injury with extradural haemorrhage

Paediatrics – head injury with extradural haemorrhage.

a. Urgent CT indications

• Altered GCS, including GCS less than 14 or declining GCS.
• Focal neurological deficit.
• Signs of skull fracture, including depressed, open, or basal skull fracture.
• Seizure.
• Concern for non-accidental injury.
• Other significant or progressive symptoms.

b. CT features

• Acute left parietal extradural haemorrhage, greater than 2 cm by greater than 8 cm.
• Midline shift greater than 1 cm.
• Effacement of the left lateral ventricle.
• Sulcal effacement.
• Loss of grey-white differentiation.

c. Pharmacological ICP treatment

• Mannitol 0.25-0.5 g/kg IV over 20-30 minutes.
• Alternatively, hypertonic saline 3% sodium chloride 3 mL/kg IV over 10-20 minutes, with 1-5 mL/kg/dose acceptable.

d. Other ICP strategies

• Actively manage or prevent seizures.
• Provide adequate sedation and paralysis.
• Target low-normal CO2; short-term hypocapnia may be used only as a bridge in critical deterioration.
• Elevate the head 20-30 degrees.
• Avoid restriction of venous return.
• Avoid hypoxia, hypotension, and hyperthermia.

e. Parent discussion

• She is critically unwell.
• Prognosis is guarded.
• Treatment given so far.
• Expected treatment at the receiving centre.
• Time frame and method of transfer.
• Where parents should go and how to get there.
• Supports available at referring and receiving sites and during parent transport.