Pediatric emergency medicine trisk 910
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Infants with intracranial injuries may have limited neurologic
findings and appear asymptomatic.
Clinical assessment of infants may be challenging.
Index of suspicion for nonaccidental trauma should be low.
Goal of Treatment
The primary goal in the evaluation of any patient who has sustained a blunt
head injury is to determine the severity of the injury and identify ciTBI. As
with all trauma evaluations, the initial goal of treatment is immediate
stabilization.
Current Evidence. Neurotrauma is one of the most common reasons for
ED evaluation with more than 800,000 annual visits by children. ED visits
for younger children up to 4 years of age have increased significantly in the
past several years. Common mechanisms of injury include falls, being
unintentionally struck by or against an object, motor vehicle collisions
either as a passenger or pedestrian struck by, bicycle accidents, sportsrelated, assaults, and nonaccidental trauma. A detailed description of
anatomy, pathophysiology, and causes of increased intracranial pressure
(ICP) is included in Chapter 41 Injury: Head .
Briefly, the spectrum of traumatic brain injury (TBI) patterns range from
minor head injury, concussion, skull fracture, pneumocephalus, intracranial
hematoma, cerebral edema, diffuse axonal injury (DAI), cerebral herniation
to death. Cerebral hematomas may be extra-axial, occurring in the epidural
or subdural space or intra-axial, occurring within the parenchyma of the
brain. Most recent studies have separated intracranial injury from ciTBI.
The definition of ciTBI includes the presence of a depressed skull fracture
necessitating surgical elevation, neurosurgical intervention including, but
not limited to, invasive ICP monitoring, ventriculostomy, hematoma
evacuation and/or decompressive craniectomy, endotracheal intubation for
more than 24 hours, hospital admission for 48 hours or more, and death.
Utilizing this definition, the overall incidence of ciTBI ranges from 0.02%
to 4.4%.
TBI is the leading cause of acquired disability in children. Neurologic
and cognitive deficits are related to patient age at time of injury, severity of
injury, and degree of structural injury. Unique considerations should be
given to children with shunt-dependent hydrocephalus and bleeding
diatheses or platelet disorders, such as hemophilia.
Clinical Considerations (See Also Chapter 41 Injury: Head )
Clinical Recognition. The historical and physical features of TBI
encompass a wide spectrum of signs and symptoms. For a detailed review
of signs and symptoms, please review Chapter 41 . The presentation of
infants may be nonspecific and include poor feeding, vomiting, irritability, a
bulging anterior fontanelle, altered mental status defined as a Pediatric
Glasgow Coma Score of less than or equal to 14 ( Table 113.1 ), lethargy,
seizure and presence of scalp hematoma and/or depression. Typical
complaints in children include headache, progression of headache with
increasing severity, vomiting, confusion, altered mental status defined as a
Glasgow Coma Scale (GCS) of less than or equal to 14 ( Table 113.1 ),
seizure, lethargy, focal neurologic abnormality, obtundation, or signs of a
basilar skull fracture, such as Battle sign, periorbital ecchymosis
hemotympanum, and cerebral spinal fluid (CSF) otorrhea or rhinorrhea.
Signs of impending cerebral herniation include altered mental status,
pupillary changes, bradycardia, hypertension, and respiratory depression.
Recent clinical decision rules to assist in the determination for emergent
radiography have stratified ciTBI risk based on key historical and physical
examination features. The clinical decision rules are applied to two separate
patient populations, children less than 2 years of age and children 2 years of
age and greater. Children less than 2 years of age provide a unique
challenge to the clinician as they commonly present after minor trauma but
may be asymptomatic or clinical assessment may be difficult. Additionally,
the clinician must always have a low index of suspicion for nonaccidental
trauma, as the incidence of child abuse in this age group is high. Head
injury accounts for the highest mortality in nonaccidental or intentional
injury. For a detailed review of inflicted injuries, please refer to Chapter 87
Child Abuse/Assault .
The features that place children less than 2 years of age at higher risk of
ciTBI include altered mental status, especially if the parent is concerned the
child is acting abnormally, parietal, temporal, or occipital scalp hematoma,
loss of consciousness >5 seconds, evidence of depressed or basilar skull
fracture, bulging anterior fontanelle, persistent vomiting, posttraumatic
seizure, focal neurologic examination findings, or suspicion of
nonaccidental trauma. The features that place children 2 years of age and
greater at higher risk of ciTBI include altered mental status, evidence of
depressed or basilar skull fracture, posttraumatic seizure, prolonged loss of
consciousness, worsening severe headache, and focal neurologic
examination findings. See Table 113.2 . Emergent neuroimaging should be
performed for any child with one or more of these features.
Just as certain features dictate the use of radiographic imaging, the
absence of these features should allow the clinician to spare the patient
unnecessary radiation exposure. Children less than the age of 2 who have a
normal mental status with normal behavior, lack a scalp hematoma or have
a frontal scalp hematoma, without evidence of skull fracture and a normal
neurologic examination should not undergo radiographic imaging; nor
should older children who have a normal mental status, no loss of
consciousness, no vomiting, no severe headache, without evidence of a
skull fracture, and a normal neurologic examination.
The diagnostically challenging patient population are the children in the
intermediate-risk category. These are the children who may have isolated
features indicative of ciTBI with resolution or improvement of symptoms
and a normal neurologic examination. Observation for 4 to 6 hours after the
injury may offer an alternative to emergent neuroimaging.
TABLE 113.1
GLASGOW COMA SCALE AND PEDIATRIC GLASGOW COMA
SCALE
