Pediatric emergency medicine trisk 0820 0820
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drainage of CSF into paranasal sinuses and rhinorrhea. Anterior venous sinus
drainage may cause blood leakage into the periorbital tissues (raccoon eyes).
Given the location of basilar skull fractures, associated cranial nerve palsies may
occur. There is a high incidence of associated TBI in children with basilar skull
fracture, even in those with a Glasgow Coma Scale (GCS) score of 15 and normal
neurologic examination results. Of note, not all basilar skull fractures are evident
on computed tomography (CT); however, a patient with classic clinical signs
should be considered to have this fracture even without demonstrable fracture on
CT.
Traumatic Brain Injury
Insults to intracranial contents include functional derangements without
demonstrable lesions on CT scan (concussion, posttraumatic seizures) as well as
structural changes such as hemorrhage (cerebral contusion, epidural hematoma
[EDH], subdural hematoma [SDH], subarachnoid hemorrhage, and intracerebral
hemorrhage), and cerebral edema. Depending on the proximity of imaging to the
injury event, some structural changes (such as diffuse axonal injury) may not be
initially evident on CT scan though such lesions would likely be apparent on
Magnetic Resonance Imaging (MRI). MRI also demonstrates greater sensitivity
in detecting microhemorrhages though the clinical significance of these lesions is
controversial. Rarely, penetrating brain injuries occur in children. TBIs may also
be classified as focal (e.g., contusions, hematomas, lacerations) or diffuse (e.g.,
diffuse axonal injury with cerebral edema). Focal injuries are usually apparent on
the initial CT scan, even if clinically asymptomatic. Diffuse injuries, in contrast,
may not demonstrate striking abnormalities on early CT imaging, even if the
patient manifests significant alteration in neurologic function.
Since some small intracranial abnormalities noted on advanced imaging are of
unclear significance (those that require neither clinical intervention nor prolonged
hospitalization), clinically important traumatic brain injury (ciTBI) has been
defined as brain injury that causes death or requires neurosurgical intervention,
intubation, or hospital admission for at least two nights.
Concussion
Concussion is typically a minor brain injury characterized by posttraumatic
alteration in mental status that may or may not involve loss of consciousness
(LOC). No consistent associated pathologic lesion has been identified on
neuroimaging. The child may have a depressed level of consciousness, pallor,
vomiting, amnesia, and confusion. The clinical picture often normalizes within
