Neurology

Head Trauma Evaluation in Children

 

Introduction

Head trauma is a very common occurrence in pediatric practice. The pediatrician must know how to evaluate a patient with a history of head trauma and also play a role in advising parents how to prevent significant intracranial injury. 

 

Common Etiologies

  1. Automobile accidents- may be prevented with use of carseats and seatbelts
  2. Bicycle injuries- encourage use of bike helmets
  3. Pedestrian-car accidents
  4. Falls- greater than 15 feet associated with increased morbidity and mortality
  5. Non-accidental trauma i.e. child abuse
  6. Skating
  7. Missiles

 

Epidemiology

  1. Greater in boys than girls
  2. Less than 5 years of age account for about half the presentations to ERs. May represent greater apprehension by parents in this age group
  3. Vast majority have no significant sequelae
  4. Approximately 100,000 hospital admissions per year in the United States
  5. Most common injury in children associated with death

 

Important Clinical Features

  1. Mechanism of injury, height of fall, speed of missile.
  2. Was their loss of consciousness. Greater than 5 minutes often associated with major injury. LOC may be difficult to assess in young child and need to ask if the child cried immediately or was there apnea or pallor. 
  3. Amnesia?
  4. Are there any neurologic deficits, seizures, or cortical blindness?
  5. Commonly the child will be initially lethargic, nauseous, vomit a few times, and have a headache. The child often wants to sleep. These symptoms often last less than 5 hours. 
  6. Previous history of head trauma? Any bleeding disorders? 
  7. Basilar skull fracture may be suspected if Battle sign is present, there are raccoon eyes, blood behind the tympanic membrane, and leaking CSF from nose and ears. 
  8. Vital signs changes may indicate increased intracranial pressure
  9. Do a careful neurologic exam

Indications for Radiographic Evaluation - There are no definite guidelines. It is important to consider the general low incidence of positive findings, radiation exposure, need for sedation, and high cost of getting CT scan in all cases of head injury. Lowest risk for abnormal findings on CT scan is an isolated head injury with normal neurologic exam

  1. Presence of cephalahematoma
  2. Prolonged LOC
  3. Penetrating wound
  4. Palpable skull defect or depressed skull fracture.
  5. Focal neurologic signs
  6. Unequal pupils
  7. Signs of basilar skull fracture
  8. Signs and symptoms of increased intracranial pressure
  9. < 1 year of age because of possible abuse.
  10. Fall from height greater than 15 feet
  11. Injuries 

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When to Admit

  1. Deterioration of level of consciousness
  2. Prolonged confusion
  3. Excessive vomiting
  4. Questionable mechanism of injury or unwitnessed trauma
  5. Focal neurologic signs
  6. Seizure
  7. Skull fracture

In general, children who are alert and awake, acting normally, and have a normal neurologic examination, may be observed for about 4 hours, and if there is no deterioration in status, do not need a radiographic examination nor hospitalization. But, there are no clinical studies producing data at this time to verify this point of view. 

 

Discharge Instructions

  1. Parents should be told specifically of what to look for after they get home that warrants a return to the ER or phoning the doctor. 
  2. Explain that the child may continue to have headache and vomit. Also, you may allow the child to sleep but you may want to intermittently awake to judge alertness. 
  3. May maintain on clear liquids for a short period of time
  4. Make phone contact with patient in few hours even if they are doing okay.

Study in Lancet 2009 regarding indications for CT scans to detect significant traumatic brain injuries.  Chances of abnormal scan very low if:
      Glasgow score of 15 and  < 2 years old
           Normal mental status
           No scalp hematoma except frontal
           No LOC > 5 seconds
           Mild or moderate mechanism of injury
           No palpable skull fracture
           Normal behavior according to the parents
   
       Glasgow score and > 2 years old
            Normal mental status
            No LOC
            No Vomiting
            Mild or modeerate mechanism of injury
            No clinical signs of basilar skull fracture
           No severe headache

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References

  1. Beattie T.F. Minor Head Trauma. Archives of Disease of Childhood. 1997
  2. Roddy S.P. et al. Minimal Head Trauma in Children Revisited: Is Routine Hospitalization Required? Pediatrics. 1998
  3. Academy of Pediatrics  The Management of Minor Closed Head Injury in Children Dec 1999
  4. Coombs J. and Davis R.  Synopsis of the AAP Practice Paramete on the Management of Minor Closed Head Injury in Children.  Pediatrics in Review December 2000
  5. Gedeit R. Head Injury.  Pediatrics in Review April 2001
  6. Palchak M. et al. Does an Isolated History of Loss of Consciousness or Amnesia Predict Brain Injuries in Children After Blunt Head Trauma. Pediatrics June 2004
  7. Atabaki S. Pediatric Head Injuries.  Pediatrics in Review June 2007
  8. Meehan W. Bachur R. Sport-Related Concussion.  Pediatrics Jan 2009
  9.  Kupperman N. et al.  Identification of children at very low risk of clinically important brain injuries after head trauma: a prospective cohort study.  Lancet 2009
  10. Schunk J. and Schutzman S.  Head Injuries.  Pediatrics in Review 2012

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