Transcript Pediatric Head Trauma

10 yr old F, riding on the shoulders of
another child
 Held onto top of doorframe, then both
children fell
 Pt landed on a wooden floor
 No LOC, no emesis, no jerking or seizurelike activity, no visible injuries, but parents
concerned because patient “just not
acting right”
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No medical conditions
 No daily medications
 NKDA
 No surgeries in the past
 No history of head injury in the past
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Pt seen on
stretcher,
trying to get
off of bed,
combative
with
medical
personnel,
no C-collar
in place.
A – pt maintaining own airway
 B – pt breathing without assistance, pulse
oximetry > 97% RA, lungs CTA bilaterally
without wheezes/rales/rhonchi
 C – cap refill < 2 seconds, strong distal
pulses, nl S1, S2, no murmurs, NSR on
monitor
 D – GCS 14; PERRLA, brisk
 E – No other signs of trauma
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Eye Opening
› 4 Spontaneously
› 3 To voice
› 2 To pain
› 1 No response
Verbal Response
› 5 Appropriate words,
spontaneous cooing
› 4 Inappropriate words
› 3 Cries
› 2 Incomprehensible
sounds, grunts
› 1 No response
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Motor Response
› 6 Obeys
› 5 Localizes pain
› 4 Flexion withdrawal
› 3 Flexion abnormal
(decorticate posturing)
› 2 Extension
(decerebrate posturing)
› 1 No response
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Head
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› Scalp lacerations
› Hematomas
 Cephalohematoma
 Subgaleal hematoma
› Skull fractures
 Linear
 Basilar
 Depressed
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Nose
› CSF rhinorrhea
Ears
› Battle sign
› Hemotypanum
› CSF otorrhea
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Eyes
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Pupil size, reactivity
EOM
Nystagmus
Raccoon eyes
Patient who has both raccoon eyes and the Battle sign after blunt trauma to the
head.
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Alert, combative,
yelling for mother
Uncooperative with
examination, vital
sign measurements
Pt fell asleep when
not being touched
No visible injuries
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EMV 14
Unable to assess
cervical spine
tenderness so ccollar placed
Decision made to
obtain head CT
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There are more than half a million pediatric head
CT scans ordered annually in the United States and
rates of neuroimaging for head trauma have
doubled over the past decade. However, most
children who undergo CT have minor TBI and a
negative CT scan.
With radiation attributable cancer risk estimated to
be as high as 1/2000 in CT exposed children; riskbenefit analyses should be taken into
consideration before CT scan of any child with TBI.
A great deal of variation in practice exists
with respect to neuroimaging after
pediatric head trauma.
 The American Academy of Pediatrics
recommends observation of the child with
minor closed head injury without LOC and
either observation or CT scan for those with
LOC
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A
Decision Rule for Identifying Children
at Low Risk for Brain Injuries After Blunt
Head Trauma, ANNALS OF
EMERGENCY MEDICINE 42:4 OCTOBER
2003
Type of Injury
No.
(% of Children)
 Cerebral contusion/hemorrhage 50 (51.0)
 Subdural hematoma 31 (31.6)
 Subarachnoid hemorrhage 24 (24.5)
 Cerebral edema 17 (17.3)
 Epidural hematoma 16 (16.3)
 *A total of 98 enrolled children had traumatic brain
injury identified on CT scan; a combination of injuries
was found in 41 of these 98 patients. Note that an
isolated skull fracture was not considered a traumatic
brain injury.
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Results: Two thousand forty-three children were enrolled,
1,271 (62%) underwent CT, 98 (7.7%; 95% confidence interval
[CI] 6.3% to 9.3%) had traumatic brain injuries on CT scan, and
105 (5.1%; 95% CI 4.2% to 6.2%) had traumatic brain injuries
requiring acute intervention. Abnormal mental status, clinical
signs of skull fracture, history of vomiting, scalp hematoma
(in children ≤2 years of age), or headache identified 97/98
(99%; 95% CI 94% to 100%) of those with traumatic brain
injuries on CT scan and 105/105 (100%; 95% CI 97% to 100%)
of those with traumatic brain injuries requiring acute
intervention. Of the 304 (24%) children undergoing CT who
had none of these predictors, only 1 (0.3%; 95% CI 0% to 1.8%)
had traumatic brain injury on CT, and that patient was
discharged from the ED without complications.
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Conclusion: Important factors for identifying children at low
risk for traumatic brain injuries after blunt head trauma
included the absence of: abnormal mental status, clinical
signs of skull fracture, a history of vomiting, scalp hematoma
(in children ≤2 years of age), and headache.
Results similar in 2005 article in Pediatrics.
 Found significant ICI is unlikely in a child
who does not exhibit at least 1 of the highrisk criteria
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Evidence of significant skull fx
Altered level of alertness
Neuro deficit
Persistent vomiting
Scalp hematoma
Abnl behavior
coagulopathy
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Did the child cry immediately after injury? (No crying may indicate loss of
consciousness.)
Is there a "goose egg" or scalp hematoma present? (Young children who have
parietal hematomas are more likely to have an underlying skull fracture.)
Was there bleeding or fluid draining from the nose or ears? (A "yes" answer may
indicate the presence of a basilar skull fracture.)
Was the fall greater than 3 feet? (A "yes" answer indicates increased risk of skull
fracture in infants.)
How old is the child? (Infants are at increased risk for skull fracture and intracranial
injury.)
Has the child had a recent head injury? (A second head injury to a now
symptomatic child may result in increased morbidity.)
Examination of the child is warranted if an answer to any of these questions
confirms a risk for significant head injury. If answers to the questions do not
indicate a risk for a significant head injury, the parents should be counseled to
supervise the child closely up to 24 hours after the time of injury and to contact
the physician if there is any change in the child's mental status or any seizures,
persistent or increasing headache, or protracted vomiting (more than two to
three episodes).
Head CT normal
 Pt still combative when
aroused, still refusing
food and drink
 Diagnosed with
concussion
 Decision made to
admit to hospital for
observation
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Pathophysiologic process resulting in the
self-limited impairment of neurologic
function that has an associated set of
clinical symptoms
 Symptoms usually acute in onset, result
of functional rather than structural
disturbances
 Estimated that up to 25% of pts with
minor head trauma develop a
concussion
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Headache
Dizziness
Depression
Confusion
Nausea/vomiting
Sensitivity to light or
noise
Anxiety
Poor memory
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Lethargy
Slow response to
questions
Decreased energy
Irritability
Blurred or double
vision
Poor concentration
Poor balance
Insomnia
Severity
Symptoms
Management
Grade 1 (Mild)
No LOC, ringing,
headache, dizziness, or
memory loss
Observation
May not return to
competition until
symptom-free upon
exertion
Grade 2 (Moderate) LOC <5 min or PTA >30
min
Grade 3 (Severe)
Observation
May not return to
competition for 1 wk
after symptom-free
upon exertion
LOC >5 min or PTA >24 h Admit
Refer for neurocognitive
testing prior to
resumption of contact
sports
LOC=loss of consciousness; PTA=posttraumatic amnesia
Car seats
 Proper helmet use
 Never allowing infants to be
unsupervised on tables/beds/etc.
 Keep side rails up on cribs, lowering
mattress when child pulls to stand
 Gate to stairways
 Forbid trampolines
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A Decision Rule for Identifying Children at Low Risk for Brain Injuries
After Blunt Head Trauma, ANNALS OF EMERGENCY MEDICINE 42:4
OCTOBER 2003
Pediatric Minor Closed Head Injury, Pediatr Clin N Am 53 (2006) 1 –
26
Prehospital Evaluation and Management of Traumatic Brain Injury in
Children, Clin Ped Emerg Med 7:94-104
Pediatric Head Injury, Peds in Review, Pediatr. Rev., Jun 2007; 28: 215
- 224.
CLINICAL PRACTICE GUIDELINES PEDIATRICS Vol. 104 No. 6
December 1999, pp. 1407-1415 AMERICAN ACADEMY OF
PEDIATRICS: The Management of Minor Closed Head Injury in
Children Committee on Quality Improvement, American Academy
of Pediatrics
Pediatric Advisor 2006
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Thanks to Dr. Craig Carter
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