Pediatric Head Trauma

Introduction

Evaluation and treatment

Quick guide for Head Injury

Prevention

Introduction

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 pediatri 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.

Evaluation and treatment

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.

  • The physical exam should cover vitals (hyper/hypotension, tachy/bradycardia, abnormal respirations), HEENT- head (scalp lacerations, obvious fracture, hematoma, fontanelle); eyes (visual acuity, visual fields, papilledma, doll's eyes, sunsetting,and pupillary reactivity); neck (C spine precautions and airway); and a complete neuro exam.

  • Retinal hemorrhages are extremely uncommon in small children, and their presence should raise your suspicions of child abuse.

  • You should have a low threshold in ordering a head CT on a child with a head injury. All children with head injuries who have an alteration of consciousness, persistent headache and vomiting, skull fracture, or seizures should have a CT scan. The results of the CT scan and the clinical information can be used to determine if the child should be admitted, discharged, or evaluated with other diagnostic studies.

  • Children with mild head injury and a normal neurologic exam can be sent home (provided child abuse is not suspected).

  • Children with a normal head CT but persistent nausea and vomiting should be admitted by the primary care physician for hydration until they are able to tolerate an oral diet.

  • Children with an abnormal head CT or neurologic exam should be referred to neurosurgery for consultation.

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).

Quick guide for Head Injury in Children

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.

Reviewed by CDR Wendy Bailey, MC, USN, Pediatric Specialty Leader, Department of Pediatrics, Naval Medical Center San Diego, San Diego, CA. Revised by CDR Robert Heim, MC, USN, Neurosurgery Specialty Leader and Staff Neurosurgeon, National Naval Medical Center, Bethesda, MD (1999).

Preface  ·  Administrative Section  ·  Clinical Section

The General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C., 20372-5300

This web version of The General Medical Officer Manual, NAVMEDPUB 5134 is provided by The Brookside Associates Medical Education Division.  It contains original contents from the official US Navy version, but has been reformatted for web access and includes advertising and links that were not present in the original version. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense. All material in this version is unclassified. This formatting © 2006 Medical Education Division, Brookside Associates, Ltd. All rights reserved.

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