Pediatric Head Trauma

Department of the Navy
Bureau of Medicine and Surgery

Head injury is a very common occurrence in childhood. The three most common mechanisms of injury in decreasing order are falls, motor vehicle accidents, and bicycle accidents. This notwithstanding, one should always have a high index of suspicion for non-accidental trauma (child abuse), especially in nonverbal children. The risk of death from head injury in children is extremely low if the patient is not comatose at the time of admission. This is assuming the early detection of intracranial masses or cerebral swelling and subsequent appropriate therapy. The GMO is extremely important in this early detection.

Prevention interventions

As a "front line" care provider, the GMO should take every opportunity to discuss the prevention of head injuries with every pediatric patient and their parents. Key points to discuss include the use and wearing of protective gear at all times, such as helmets for cycling or roller blading, and seat belts while in a car.

Most patients with mild head injury can be safely sent home. Severely injured children clearly will need hospitalization and intensive care. The proper disposition of the remaining patients may not be so obvious; many patients may be observed for 6 hours and sent home, while others with mild presenting symptoms may worsen and develop increased intracranial pressure (ICP). Outlined below is a management strategy to help identify high-risk patients.

The initial assessment of a child with head trauma involves the ABC's and assessment of mental status (use the Glasgow Coma Scale (GCS), modified for developmental age). A focused history follows with attention to the mechanism and severity of injury, loss of consciousness, seizure activity, and the possibility of child abuse.

Signs of increased ICP may be subtle, and can include slowly decreasing GCS scores, or persistent or worsening central nervous system (CNS) irritability. More obvious signs include changes in vitals, especially Cushing's Triad (hypertension, bradycardia, respiratory changes), temperature instability; posturing (decerebrate, decorticate): bulging fontanelle or split sutures; papilledema (late finding), and pupillary abnormalities. Should any of these things occur while the patient is in your care, you need to take action while awaiting transport to another facility. Immediate management involves controlled intubation if needed, neutral head position (better venous return) with head of bed at 30 degrees, hyperventilation (pC02 30-35, pO2 >100), fluid resuscitation (patients with cord injury and extracranial sources of bleeding may require very large amounts of fluid), A-line, mannitol 0.25-1 gram/kg , and anticonvulsants (Ativan 0.1-0.2 mg/kg and Dilantin 10-20 mg/kg).

Children with the following history or clinical findings need neurosurgical consultation:

• Skull fractures

• Linear non-depressed skull fracture ( case by case basis).

• Open, depressed, or penetrating skull fracture.

• Basilar skull fracture (raccoon eyes, Battle sign, hemotympanum, CSF drainage).

• Abnormal CT.

• Abnormal neuro exam.

• Depressed or decreasing level of consciousness.

• Signs of ICP (see above).

• History of severe force.

• History of seizure.

• Persistent signs of CNS irritability (vomiting, irritability, headache, drowsiness, agitation, amnesia) for greater than 6 hours.

• Loss of consciousness.