Pediatric Head Trauma


Article Author:
Micelle Haydel


Article Editor:
Wajeeha Saeed


Editors In Chief:
Chaddie Doerr


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
1/23/2019 11:01:46 AM

Introduction

Blunt traumatic brain injury (TBI) is a disruption in the normal function of the brain caused by a mechanical impact to the head. TBI ranges from mild to severe and/or fatal. TBI can be conceptualized as a primary event occurring at the moment of impact, followed by secondary damage due to edema and elevated intracranial pressure. Early identification and management of traumatic brain injury are crucial in halting the progression of the primary insult and preventing or reducing secondary brain injury. TBI is typically classified as mild, moderate or severe, based on the Glasgow coma scale (GCS). Patients with a GCS of 14 to 15 are considered to have mild TBI, while patients with a GCS of 9 to 13 have moderate TBI, and those with a GCS of 3 to 8 have severe TBI. Initial symptoms of moderate-severe TBI in children are similar to adults, but the ultimate functional impact in children who survive TBI becomes more apparent as the child ages and faces increased challenges in processing information, reasoning, and impaired judgment.

Etiology

The most common cause of TBI in children are falls and sports/recreation-related injuries. Falls (striking the head) are more common in very young children because of their under-developed ambulatory skills combined with disproportionately large heads, a shifted center of gravity, and immature neck muscles. Less common, but more severe etiologies of TBI include non-accidental trauma and motor vehicle-related injuries including pedestrians struck by a vehicle.

Epidemiology

Each year, pediatric TBI results in over 500,000 emergency department visits and about 60,000 hospitalizations in the United States.[1] Fatal TBI in children is primarily caused by non-accidental trauma and motor vehicle-related injuries (including pedestrians struck by a vehicle). Falls and sports/recreation-related TBI rarely lead to fatal injuries but can cause post-concussive symptoms in up to 30% of patients. Falls are more common in children in the 0 to 4 year age group, while sports and recreation-related injuries are more common in the 5 to 14 year age group. Across all age groups, males are more likely to present with TBI.

Pathophysiology

Most patients with moderate-to-severe TBI have a combination of intracranial injuries. Diffuse axonal injury (DAI) is thought to be present to some degree in the majority of patients with moderate-to-severe TBI. DAI is typically caused by a rapid rotational or deceleration force that causes stretching and tearing of neurons, leading to focal areas of hemorrhage and edema that are not always detected on initial CT scan. Subarachnoid hemorrhage (SAH) due to tearing of pial vessels is considered a marker of severity, present in almost half of pediatric patients with severe TBI. Subdural and epidural hematomas are the most frequent type of mass lesion identified in TBI. Cerebral contusions occur in about one-third of patients with moderate-to-severe TBI, caused by a direct impact or acceleration-deceleration forces that cause the brain to strike the frontal or temporal regions of the skull.  Intracerebral bleeding or hematoma, caused by coalescence of contusions or a tear in a parenchymal vessel, occurs in up to one-third of patients with moderate-to-severe TBI.

History and Physical

The initial resuscitation should proceed in a step-wise fashion to identify all injuries, as well as optimize cerebral perfusion by maintaining hemodynamic stabilization and oxygenation. The initial survey should also include a brief, focused neurological examination with attention to the GCS, pupillary examination, and motor function.

The pediatric GCS is similar to the adult GCS, but the main difference is in the verbal response in which the pediatric GCS assigns a normal verbal score of 5 for babbling, cooing, or smiling appropriately, while subtracting 1 point if crying but consolable, subtracting 2 points for inconsolable crying, subtracting 3 points for moaning or grunting, and subtracting 4 points for no verbal response.

After addressing any airway or circulatory deficits, a thorough head-to-toe physical examination must be performed with vigilance for occult injuries and careful attention to detect any of the following warning signs:

  • Inspection for cranial nerve deficits, periorbital or postauricular ecchymoses, cerebrospinal fluid (CSF) rhinorrhea or otorrhea, hemotympanum (signs of base of skull fracture)
  • Fundoscopic examination for retinal hemorrhage (potential sign of abuse in children) and papilledema (sign of increased intracranial pressure [ICP])
  • Palpation of the scalp for hematoma, crepitance, laceration, and bony deformity (markers of skull fractures). In infants fullness of the fontanelle can be a marker of intracranial hematoma or elevated ICP
  • Auscultation for carotid bruits, painful Horner syndrome or facial/neck hyperesthesia  (markers of carotid or vertebral dissection)
  • Evaluation for cervical spine tenderness, paresthesias, incontinence, extremity weakness, priapism (signs of spinal cord injury)
  • Extremities: Motor and sensory examination (for signs of spinal cord injury)

Evaluation

Non-contrast cranial computed tomography (CT) is the imaging modality of choice for patients with TBI and an abnormal GCS. CT findings associated with a poor outcome in TBI include midline shift, subarachnoid hemorrhage into the verticals, and compression of the basal cisterns. MRI may be indicated when the clinical picture remains unclear after a CT to identify more subtle lesions. Several clinical decision guidelines[2] have been validated and can be applied to determine which children with a normal or near normal GCS can safely avoid CT.

Treatment / Management

Airway adjuncts are indicated in patients not able to maintain an open airway, or not able to maintain greater than 90% oxygen saturation with supplementary oxygen. Oxygenation parameters should be monitored using continuous pulse oximetry with a target of greater than 90% oxygen saturation. Ventilation should be monitored with continuous capnography with an end-tidal CO2 target of 35 to 40 mm Hg. Placement of a definitive airway is recommended in the patient with a GCS of less than 9.  

Systemic hypotension negatively impacts the outcome in the setting of TBI, and current studies have demonstrated improved outcome in patients with a systolic BP = 120 mm Hg. Isotonic crystalloids should be used to prevent and correct hypotension; colloidal solutions have not been shown to improve outcomes.

Serial neurological examinations allow for early identification of patients with elevated intracranial pressure (ICP), and subsequent implementation of primary bedside interventions to improve venous outflow and reduce metabolic demands. Mortality in TBI is due to elevated ICP.

Initial bedside approaches to increased ICP include:

  1. Elevate the head of the bed to 30 degrees.
  2. Determine that the cervical collar is not impeding venous outflow.
  3. Appropriate analgesics and sedation: Pain and anxiousness can elevate the ICP.  Opiates and benzodiazepines are frequently used, and neuromuscular blockade may be required to prevent maneuvers that increase ICP such as coughing, straining and fighting against the ventilator.[3]
  4. Hyperventilation: Routine hyperventilation in TBI is not recommended, but in the setting of impending herniation, it remains one of the fastest, short-term methods to lower ICP.[4] 
  5. ICP monitoring may be considered in infants and children with severe TBI.[5]
  6. Osmotic agents: Hypertonic saline (3%) or mannitol are the common hyperosmolar agents used to reduce ICP.[4]
  7. Barbiturates: Patients with elevated ICP, refractory to other therapies, may benefit from barbiturates which are thought to decrease ICP by decreasing cerebral metabolic rate.[4]
  8. Decompressive hemicraniectomy: As part of a surgical procedure to evacuate hematoma, or as a primary treatment of refractory ICP, decompressive hemicraniectomy reduces ICP due to the removal of part of the skull.
  9. Hypothermia has not been shown to improve outcomes in children.[6]

Differential Diagnosis

A thorough head-to-toe physical examination must be performed with vigilance for occult injuries.

Prognosis

Nearly 90% of patients are discharged home from the emergency department after their head injury,[3] but about 1% of patients with a GCS of 14 to 15 have a clinically significant intracranial injury on CT,[7] and patients with severe TBI have mortality as high as 20%.

Enhancing Healthcare Team Outcomes

The management of pediatric head trauma is done by a multidisciplinary team that consists of an emergency department physician, neurologist, nurse practitioner, pediatrician, and a radiologist. Most children with mild head trauma are discharged. However, patients discharged after a head injury or concussion should be instructed to return to physical activities in a step-wise approach. The initial step is a period of physical and cognitive rest for no more than 2 to 3 days followed by scheduled increases in activities with close monitoring for recurrence of symptoms. Any recurrence of symptoms indicates the need for further limitation of activities. Recommendations for return-to-activities continue to change as new studies are published, and the CDC website is a helpful source for up-to-date guidelines.[8]


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Pediatric Head Trauma - Questions

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A 2-month-old child is dropped and hits her head. Which of the following is consistent with serious brain injury?



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Each year, pediatric traumatic brain injury (TBI) results in over 500,000 emergency department visits and over 60,000 hospitalizations in the United States. Which of the following is not a primary cause of fatal TBI in children?



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An 18-month-old child falls down a flight of stairs and is brought in for evaluation. She is opening her eyes and moving her extremities spontaneously and appropriately, but she has been crying inconsolably since the fall 1 hour ago. What is her pediatric Glasgow coma scale?



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A 12-year-old boy is in the emergency department after a motor vehicle collision. His initial Glasgow coma scale is 15, and his only complaint is a headache and several episodes of vomiting. CT of the head reveals a small epidural hematoma and several small cerebral contusions. Transfer to the local trauma center is arranged, and while awaiting transport, the nurse states that the patient's mental status has decreased. Examination of the patient and shows that he is becoming combative and his oxygen saturation is 90% on room air. Which of the following is not indicated?



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A 4-year-old child was an unrestrained passenger in a motor vehicle collision and sustained a femur fracture and a traumatic brain injury. Her Glasgow coma scale score is nine, and her head CT shows multiple contusions and small areas of subarachnoid hemorrhage. Her pupils are 4 mm dilated and reactive to light, and she is agitated. She is hemodynamically stable. All of the following should be initiated except which one?



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Pediatric Head Trauma - References

References

Chen C,Peng J,Sribnick EA,Zhu M,Xiang H, Trend of Age-Adjusted Rates of Pediatric Traumatic Brain Injury in U.S. Emergency Departments from 2006 to 2013. International journal of environmental research and public health. 2018 Jun 5     [PubMed]
Babl FE,Borland ML,Phillips N,Kochar A,Dalton S,McCaskill M,Cheek JA,Gilhotra Y,Furyk J,Neutze J,Lyttle MD,Bressan S,Donath S,Molesworth C,Jachno K,Ward B,Williams A,Baylis A,Crowe L,Oakley E,Dalziel SR, Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. Lancet (London, England). 2017 Jun 17     [PubMed]
Araki T,Yokota H,Morita A, Pediatric Traumatic Brain Injury: Characteristic Features, Diagnosis, and Management. Neurologia medico-chirurgica. 2017 Feb 15     [PubMed]
    [PubMed]
    [PubMed]
    [PubMed]
    [PubMed]
Choe MC,Gregory AJ,Haegerich TM, What Pediatricians Need to Know About the CDC Guideline on the Diagnosis and Management of mTBI. Frontiers in pediatrics. 2018     [PubMed]

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