Pediatric emergency medicine trisk 915
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but this is not the current standard and there is no evidence supporting this
application.
Management. Unilateral, linear, nondepressed skull fractures without
underlying intracranial injury typically heal spontaneously and do not
necessitate immediate neurosurgical intervention. Recent evidence suggests
that an increasing number of patients are managed on an outpatient basis
with less than 1% of patients who returned after initial discharge from the
ED necessitated neurosurgical intervention. Patients with a nonfocal
neurologic examination who are asymptomatic may be discharged from the
ED if there is no concomitant intracranial injury, distracting traumatic
injury, nor a concern for nonaccidental trauma.
FIGURE 113.5 Basilar skull fracture. A: The arrow indicates a fracture of the left
temporal bone. The adjacent mastoid air cells are somewhat opacified. B: A small
extra-axial hematoma with associated pneumocephaly is seen (arrow ).
Neurosurgical consultation is mandated in patients with complicated,
basilar, open skull fractures or in fractures associated with underlying
intracranial injury. Diastatic fractures greater than 3 mm, burst fractures and
depressed skull fractures greater than 1 cm of depression are not likely to
heal without surgical reconstruction due to dural injury. Elective early
repair of dura and fracture fragments can prevent the late complication of a
growing skull fracture. Growing skull fractures are found months to years
after the initial injury and consist of craniocerebral erosion due to an
enlarging leptomeningeal cyst or vascular injury which leads to an
enlarging skull defect. The expanding defect may cause neurologic
deterioration over time.
Early- and late-onset posttraumatic seizures are increased in patients with
depressed skull fractures and retained bony fragments, as well as other
intracranial injuries as described above. The routine use of prophylactic
anticonvulsant medication is not recommended in patients with depressed
skull fractures.
Basilar skull fractures should be managed in conjunction with
neurosurgical consultation, but may necessitate otolaryngology consultation
as well. Despite the potential for involvement of the mastoid air cells or
paranasal sinuses, the risk of meningitis in basilar skull fractures is low.
There is no evidence to recommend the routine use of prophylactic
antibiotics in patients with basilar skull fractures with or without CSF
leakage. The risk of meningitis increased significantly in patients who had
persistent CSF leakage that did not resolve within 7 days. Neurosurgical
and otolaryngology intervention may be necessary in temporal bone
fractures associated with nerve palsies and persistent CSF leakage.
Interventions may include external CSF drainage to decrease intrathecal
pressure, operative repair of dural lacerations or of fistulas.
Additional evaluation and management of children with nonaccidental
head trauma are discussed separately. Please review Chapter 87 Child
Abuse/Assault .
Clinical Indications for Discharge. Unilateral, linear, nondepressed skull
fractures without underlying intracranial injury in patients who do not have
a distracting traumatic injury with a normal neurologic examination may be
discharged from the pediatric ED. If there is any apprehension regarding the
potential for nonaccidental trauma, social work consultation, as well as
neurosurgical or surgical consultation, should be obtained prior to
discharge.
Suggested Readings and Key References
Adelson PD, Wisniewski SR, Beca J, et al; Paediatric Traumatic Brain
Injury Consortium. Comparison of hypothermia and normothermia after
severe traumatic brain injury in children (cool kids): a phase 3,
randomized controlled trial. Lancet Neurol 2013;12(6):546–553.
Anderson V, Catroppa C, Morse S, et al. Recovery of intellectual ability
following traumatic brain injury in childhood: impact of injury severity
and age at injury. Pediatric Neurosurg 2000;32:282–290.
Babl FE, Borland ML, Phillips N, et al. Accuracy of PECARN, CATCH,
and CHALICE head injury decision rules in children: a prospective
cohort study. Lancet 2017;389(10087):2393–2402.
Bracken MB. Steroids for acute spinal cord injury. Cochrane Database Syst
Rev 2012;1:CD001046.
Bressan S, Marchetto L, Lyons TW, et al. A systematic review and metaanalysis of the management and outcomes of isolated skull fractures in
children. Ann Emerg Med 2018;71(6):714–724.e4.
Bressan S, Romanato S, Mion T, et al. Implementation of adapted PECARN
decision rule for children with minor head injury in the pediatric
emergency department. Acad Emerg Med 2012;19(7):801–807.
Centers for Disease Control and Prevention. Surveillance Report of
Traumatic Brain Injury-Related Emergency Department Visits,
Hospitalizations, and Deaths—United States, 2014 . Atlanta, GA: US
Department of Health and Human Services, CDC; 2019. Available at
HTTPS://www.cdc.gov/traumaticbraininjury . Accessed April 27, 2019.
Davis GA, Anderson V, Babl FE, et al. What is the difference in concussion
management in children as compared with adults? A systematic review.
Br J Sports Med 2017;51:949–957.
