Head Trauma

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Chapter 56 Head Trauma

Sara A. Schutzman, MD

GENERAL

1 How common and important is head trauma in children?

Head trauma accounts for approximately 650,000 emergency department (ED) visits and 50,000 hospitalizations per year. Traumatic brain injury is the most common cause of death and disability in childhood.

Palchak MJ, Holmes JF, Vance CW, et al: A decision rule for identifying children at low risk for brain injuries after blunt head trauma. Ann Emerg Med 42:492–506, 2003.

2 What kinds of head injuries commonly present to the ED?

Head trauma includes injuries to the scalp, skull, and intracranial contents. Although most injuries are minor, there is a wide spectrum ranging from simple contusion to lethal brain injury. Lacerations and contusions are common scalp injuries. Injuries to the cranial vault result in skull fractures, and intracranial injuries include concussion, cerebral contusion, hematoma (epidural, subdural, subarachnoid, and intracerebral), and acute brain swelling. Most head injuries result from blunt head trauma, but penetrating injuries rarely occur and are caused by bullets, teeth (e.g., dog bites), or other sharp objects (e.g., dart, pellet, pencil).

3 How is head trauma severity defined?

There is no standard definition for minor head trauma, which accounts for about 80% of injuries evaluated. Many definitions of minor head trauma have been based on the Glasgow Coma Scale (GCS) score; however, there has been no consistency, with various sources, including children with GCS scores of 13–15, 14–15, or 15. The American Academy of Pediatrics defined children with minor head injury as those who have normal mental status at the initial examination, normal neurologic examination, and no physical evidence of skull fracture. Moderate head trauma is typically defined as a GCS score of 9–12, and severe head trauma as a GCS score of 3–8.

Committee on Quality Improvement, American Academy of Pediatrics: The management of minor closed head injury in children. Pediatrics 104:1407–1415, 1999.

Schutzman S, Greenes D: State of the art: pediatric minor head trauma. Ann Emerg Med 37:65–74, 2001.

4 How many children evaluated for minor head trauma have intracranial injuries?

Approximately 3–7% of children with minor head injury have an intracranial injury noted on computed tomography (CT). Approximately 0.5–1.5% require surgical intervention. Overall, about 50% of intracranial injuries occur in kids with a GCS score of 15.

Schutzman S, Greenes D: State of the art: Pediatric minor head trauma. Ann Emerg Med 37:65–74, 2001.

5 Name the ways in which infants differ from older children with regard to head trauma

Children younger than 1–2 years of age differ in several ways that make a low threshold for head imaging prudent:

image Clinical assessment is more difficult.

image Intracranial injury is frequently asymptomatic.

image Skull fractures and intracranial injuries may result from relatively minor trauma.

image Inflicted injury occurs more often.

Schutzman SA, Barnes P, Duhaime AC, et al: Evaluation and management of children younger than two years of age with apparently minor head trauma: Proposed guidelines. Pediatrics 107:983–993, 2001.

6 How common is abuse in infants and young children with head trauma?

Although most head trauma is accidental, up to 10% of children brought to the ED with traumatic injury are victims of intentional injury, and abusive head trauma is the most common cause of traumatic death in children. Because these children are preverbal and abusive caretakers are rarely forthcoming, the clinician must have a heightened sense of awareness to diagnose nonaccidental trauma. This is important to guide appropriate therapy and to prevent further trauma.

Jenny C, Hymel KP, Ritzen A, et al: Analysis of missed cases of abusive head trauma. JAMA 281:621–626, 1999.

Ludwig S: Child abuse. In Fleisher G, Ludwig S, Henretig FM (eds). Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 1761–1801.

SKULL FRACTURES

7 Why are skull fractures important?

Skull fractures are important because they are predictors of intracranial injury (the presence of a skull fracture increases the likelihood of an intracranial injury by approximately twentyfold). In addition, fractures themselves occasionally lead to complications and may be important evidence of child abuse.

Quayle KS, Jaffe DM, Kuppermann N, et al: Diagnostic testing for acute head injury in children: When are head computed tomography and skull radiographs indicated? Pediatrics 99:E11, 1997.

8 Describe the different types of skull fractures

Skull fractures are described in terms of location and characteristics. They may occur in the frontal, parietal, occipital, and temporal bones of the skullcap (calvarium). The skull base consists of portions of the temporal and occipital bones, along with the maxillary, sphenoid, and palatine bones. Fractures in this area are referred to as basilar skull fractures.

Fractures may be linear, depressed (if the inner table of the skull is displaced by more than the thickness of the entire bone), or diastatic (traumatic separation of the cranial bones at one or more suture sites). Compound fractures communicate with lacerations, and comminuted fractures are those with several fragments.

9 Since CT is available, are skull films ever indicated?

CT is the imaging modality of choice to evaluate for acute injury since skull radiography gives no direct information about intracranial injuries (ICI). Rarely, skull radiography may be considered in:

image Alert, asymptomatic infants with scalp hematomas: These infants are at risk for harboring occult ICIs, and skull fractures are one of the best predictors for ICI. Skull radiography offers the advantage of requiring no sedation and having significantly less radiation. The practitioner or radiologist should be proficient at reading skull radiographs (if ordered) since they may be challenging to interpret. CT should be performed if a fracture is identified.

image Possible nonaccidental injury: Skull radiography sometimes detects fractures missed by CT, and are indicated (as part of a skeletal survey) for the evaluation of possible abuse.

image Suspicion of possible depressed fracture, penetrating trauma, or foreign body.

Chung S, Schamban N, Wypij, et al: Skull radiograph interpretation of children less than age two: How good are pediatric emergency physicians? Ann Emerg Med 43:718–722, 2004.

10 Name the most important complications of basilar skull fractures

image Intracranial injury: 10–40% of patients with basilar skull fracture have an associated ICI, and about 20% of alert children with basilar skull fractures and a normal neurologic status have an ICI.

image Cerebrospinal fluid (CSF) leak: An associated dural tear may lead to CSF leak through the nose or ear and occurs in approximately 15–30% of children with basilar skull fractures.

image Meningitis: Meningitis occurs in 0.7–5% of children with BSF (due to CSF leak and exposure to microorganisms); the rate is < 1% for children with GCS score > 13 and no ICI.

image Cranial nerve impairment: This occurs in 1–23% of cases, with cranial nerves VI, VII, and VIII most commonly injured. The impairment may be transient or permanent.

image Hearing loss: This occurs in up to half of patients with basilar skull fracture; it can be conductive (from hemotympanum or otic canal disruption) or sensorineural.

Kadish HA, Schunk JE: Pediatric basilar skull fracture: Do children with normal neurologic findings and no intracranial injury require hospitalization? Ann Emerg Med 26:37–41, 1995.

KEY POINTS: HEAD INJURIES IN CHILDREN YOUNGER THAN 2 YEARS OF AGE

1 Children younger than age 2 differ from older children in significant ways that make a lower threshold for imaging prudent.

2 Up to 20–45% of infants with ICI have no signs or symptoms of brain injury (occult ICI).

3 Most infants with occult ICI have an associated skull fracture, which is usually associated with scalp hematoma (more concerning if larger, nonfrontal, and in younger child).

4 Clinicians should always be alert to the possibility of nonaccidental injury in this age group.

11 How are CSF leaks treated?

Most CSF leaks through dural tears resolve spontaneously without complications within 1 week, and are thus managed conservatively. Operative intervention may be needed for persistent leaks. Given the potential for developing meningitis with CSF leaks, there has been significant controversy regarding the use of prophylactic antibiotics. Current data do not indicate that routine use of prophylactic antibiotics significantly reduces the incidence of meningitis.

INTRACRANIAL INJURY

12 Define primary and secondary brain injury

Primary brain injury is the neural damage sustained at the time of trauma. Secondary brain injury is neuronal damage sustained after the initial traumatic event to cells not initially injured, and results from numerous causes including hypoxia, hypoperfusion, and metabolic derangements. Because many causes of secondary brain injury are potentially preventable, the clinician’s main goal is to monitor for and attempt to prevent these complications in order to limit further neuronal damage.

13 What is a concussion? How are concussions graded?

A concussion is defined as head trauma–induced alteration in mental status that may or may not involve loss of consciousness. The American Academy of Neurology has defined three grades of concussion, summarized by the Centers for Disease Control and Prevention as follows:

image Grade 1 concussion: Transient confusion, no loss of consciousness, and duration of mental status abnormalities < 15 minutes

image Grade 2 concussion: Transient confusion, no loss of consciousness, and a duration of mental status abnormalities > 15 minutes

image Grade 3 concussion: Concussion involving loss of consciousness, either brief (seconds) or prolonged (minutes or longer)

Centers for Disease Control and Prevention: Sports-related recurrent brain injuries—United States. MMWR Morb Mortal Wkly Rep 46:224–227, 1997.

14 What is the second impact syndrome?

The second impact syndrome, a very rare event, is acute, usually fatal, brain swelling that occurs when a second concussion is sustained before complete recovery from a previous concussion. The pathophysiology of the second impact syndrome is not well understood; the initial blow may be associated with alteration in cerebral blood flow and failure of normal autoregulation, making the second impact so much more devastating, with resulting brain swelling and increased intracranial pressure.

Evans R: Concussion and mild traumatic brain injury. In Rose BD (ed): Waltham, MA, UpToDate, 2006.

15 What imaging modality is recommended for acute injuries?

CT identifies essentially all significant ICI requiring intervention.

16 If CT identifies major complications, why not image all children with head injuries?

CT carries disadvantages, including exposure to ionizing radiation and the possible requirement for pharmacologic sedation, as well as additional health care costs. Therefore, CT ideally should be used selectively.

Brenner DJ, Elliston CD, Hall EJ, et al: Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR 176: 289–296, 2001.

17 Which children are at high risk for intracranial injuries and should undergo CT?

Evidence indicates that children with a GCS score < 15, abnormal neurologic examination, evidence of skull fracture, or seizure should undergo CT. Additional criteria for infants include irritability, bulging fontanel, or suspected abuse.

Dunning J, Batchelor J, Stratford-Smith P, et al: A meta-analysis of variables that predict significant intracranial injury in minor head trauma. Arch Dis Child 89:653–659, 2004.

Palchak MJ, Holmes JF, Vance CW, et al: A decision rule for identifying children at low risk for brain injuries after blunt head trauma. Ann Emerg Med 42:492–506, 2003.

Quayle KS, Jaffe DM, Kuppermann N, et al: Diagnostic testing for acute head injury in children: When are head computed tomography and skull radiographs indicated? Pediatrics 99:E11, 1997.

18 What are the indications for imaging in those who are alert with a nonfocal neurologic examination and no signs of skull fracture?

To date, studies have not found consistent signs or symptoms that are completely sensitive for identifying ICI in this group. Headache, vomiting, and loss of consciousness have been variably significant as predictors. CT should be considered for children with these symptoms, and the longer the duration and the more intense the symptoms, the more strongly the clinician should consider imaging, especially if more than one symptom is present. For children with mild symptoms, careful observation in the ED or at home may be an alternative approach, with reevaluation and CT for persistent or worsening symptoms.

Dunning J, Batchelor J, Stratford-Smith P, et al: A meta-analysis of variables that predict significant intracranial injury in minor head trauma. Arch Dis Child 89:653–659, 2004.

Palchak MJ, Holmes JF, Vance CW, et al: A decision rule for identifying children at low risk for brain injuries after blunt head trauma. Ann Emerg Med 42:492–506, 2003.

19 Are there additional factors to consider for alert, nonfocal children younger than 1–2 years old?

Symptoms in these children can be subtle, so in addition to vomiting, headache, and loss of consciousness, possible signs of ICI include a history of lethargy or irritability (now resolved), and caretakers’ concern about the child’s behavior. Additionally, these children may have “occult intracranial injuries” (i.e., injuries with no signs of brain injury). Since most occult injuries have an associated skull fracture, which is typically associated with scalp swelling, a scalp hematoma in these young patients is of concern. Hematomas of greatest concern are those that are larger in size, nonfrontal in location, and present in younger children. The youngest infants (particularly those younger than 2–3 months of age) may have no signs or symptoms with ICI; therefore, a very low threshold for imaging (unless very trivial trauma) is prudent.

Greenes DS, Schutzman SA: Clinical indicators of intracranial injury in head-injured infants. Pediatrics 104:861–867, 1999.

Greenes DS, Schutzman SA: Clinical significance of scalp abnormalities in head-injured infants. Pediatr Emerg Care 17:88–92, 2001.

Palchak MJ, Holmes JF, Vance CW, et al: A decision rule for identifying children at low risk for brain injuries after blunt head trauma. Ann Emerg Med 42:492–506, 2003.

Schutzman SA, Barnes P, Duhaime AC, et al: Evaluation and management of children younger than two years of age with apparently minor head trauma: Proposed guidelines. Pediatrics 107:983–993, 2001.

20 What is the cerebral perfusion pressure (CPP)?

CPP is the difference between the mean arterial pressure (MAP) and the intracranial pressure (ICP) (CPP = MAP − ICP). Therefore, significant decreases in mean arterial pressure or significant increases in ICP can lead to inadequate CPP, with resultant cerebral ischemia and secondary brain injury.

21 How does increased ICP occur?

After infancy (when the cranial sutures fuse), the cranial vault becomes stiff and poorly compliant. The normal intracranial contents include brain, blood, and CSF. Because intracranial volume is fixed, any increase in the volume of one of the components (e.g., cerebral edema, expanding epidural hematoma) must be accompanied by a proportional decrease of the others; otherwise, ICP will increase.

KEY POINTS: INTRACRANIAL INJURY

1 Most head injury is minor; most children with minor head injury don’t have ICI, but about 5% do; and about 50% of ICIs occur in children with minor head trauma.

2 The clinician’s goal is to identify children with ICI in order to avoid further neuronal injury, while limiting unnecessary neuroimaging procedures.

3 No small group of signs or symptoms have been consistently sensitive for identifying all ICIs, but altered mental status, focal neurological examination, skull fracture, and seizure are predictors for increased risk of ICI.

4 Other signs and symptoms (including loss of consciousness, headache, vomiting) have been variably predictive for ICI.

5 All head-injured children who are discharged should be accompanied by a responsible adult who is given clear discharge instructions and able to return if concerning signs/symptoms of possible ICI develop.

22 What is the cerebral herniation syndrome?

The cranial cavity is separated by dural folds and bony prominences into the anterior, middle, and posterior fossa. Cerebral herniation occurs when increased ICP causes the brain parenchyma to shift into an anatomic area that it does not normally occupy.

Uncal herniation is the most common form, in which the uncus (inferomedial-most structure of the temporal lobe) slides through the tentorial notch, passing from the middle to the posterior fossa. Initial symptoms include headache and decreased level of consciousness, followed by ipsilateral pupillary dilatation and contralateral hemiplegia. Altered respirations, bradycardia, and systemic hypertension may ensue with decerebrate posturing or flaccid paresis; if the process continues unchecked, ultimately brain stem failure with respiratory arrest, cardiovascular collapse, and death occur.

23 Outline the ED treatment for increased ICP

image Manage the ABCs. This is essential to avoid hypoxia and hypercarbia, and to maintain adequate cerebral perfusion pressure.

image Avoid secondary brain injury from other metabolic causes, including hypoglycemia, hyperthermia, and seizures.

image Ensure appropriate positioning with elevation of the head of the bed 30 degrees, and the neck midline. This promotes venous drainage and can lead to a significant decrease of ICP.

image Perform emergent head CT to identify mass lesions that require surgical evacuation.

image Consider osmotic agents: Mannitol (dose of 0.5–1 gm/kg)/kg can be used to lower the ICP.

image Use sedation: Conscious patients who are paralyzed for intubation require sedation.

24 Isn’t hyperventilation used to treat elevated ICP?

Although hyperventilation had been a mainstay of emergency treatment for increased ICP, its use has become controversial. Carbon dioxide is one of the main determinants of cerebrovascular tone, with low levels producing vasoconstriction and decreased blood flow, thus lowering ICP. However, if cerebral blood flow diminishes too much, substrate delivery of oxygen and glucose is impaired and cerebral perfusion pressure may be inadequate, resulting in ischemic injury. Mild hyperventilation (PCO2 of 30–35) may be considered for periods of intercranial hypertension.

Skippen P, Seear M, Poskitt K, et al: Effect of hyperventilation on regional cerebral blood flow in head-injured children. Crit Care Med 25:1402–1409, 1997.

25 Are steroids indicated for treating increased ICP?

Steroids have not been shown to improve outcome for patients with head trauma; therefore, their use is not recommended.

DISPOSITION

26 Which children need to be admitted following acute head trauma?

Children with intracranial injuries or depressed or basilar skull fractures will usually require hospital admission. A neurosurgeon should be consulted regarding their management and disposition. Hospital admission should also be considered for patients with persistent neurologic deficits (despite normal CT scan), significant extracranial injuries, unremitting vomiting, or caretakers who are unreliable or unable to return if necessary. Any child with suspected nonaccidental trauma should also be considered for admission.

27 Why are discharge instructions important in patients with head trauma?

Even well-appearing children with head trauma who have no evidence of complications (either clinically or radiographically) have a small chance of subsequent deterioration. Therefore, it is mandatory that competent caretakers are available to observe the child at home. They should be educated about the signs and symptoms of complications of head trauma, and instructed to bring the child to medical care for reevaluation should concerning symptoms arise.

28 When can a child return to sports after a concussion?

Recommendations for the management of concussion in sports are designed to prevent second impact syndrome. They have been summarized as follows:

image Grade I concussion: No sports until the patient is asymptomatic. If a second grade I concussion occurs, no sports activity until the patient has been asymptomatic for 1 week.

image Grade II concussion: No sports until 1 week after symptoms resolve.

image Grade III concussion: No sports for 1–2 weeks after symptoms resolve, depending on the duration of loss of consciousness. For a second grade III concussion, no sports activity until the patient has been asymptomatic for 1 month. If intracranial pathology is detected on CT or magnetic resonance imaging, the athlete should not engage in any sports activity for remainder of the season and should be discouraged from future return to contact sports.

Centers for Disease Control and Prevention: Sports-related recurrent brain injuries—United States. MMWR Morb Mortal Wkly Rep 46:224–227, 1997.

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