- Carefully rule out mild head injury in the context of other facial or scalp injuries.
- Suspect nonaccidental trauma in infants and toddlers, especially when the history is not consistent either with the child's developmental milestones or with the physical findings.
- Have a lower threshold for imaging younger children (<2 years old) because they are at greater risk of asymptomatic intracranial injury.
- Do not hesitate to observe the child for a few hours, especially if there is any discomfort on the part of the physician or the caregiver(s).
- Evaluate concussed athletes carefully: They are very motivated to hide their symptoms so that they can return to play. The player may not have had any loss of consciousness, but may still have sustained a significant concussion.
- Discharge instructions and counseling are critical, especially as to reasons to return to the emergency department, return to play criteria, and the possible duration of concussive symptoms.
Unintentional, blunt traumatic brain injury (TBI) is the leading cause of death and disability in the under-20 age group. There are 7440 deaths, 642 000 emergency department (ED) visits, and 65 000 hospitalizations annually because of TBI.1 The majority (84%) of these head injuries is classified as mild traumatic brain injury (MTBI). Unfortunately, there is significant variability in how investigators define MTBI; they also disagree over whether any lasting effects may result (Tables 15–1 and 15–2).
Table 15-1. Definition of MTBI by the American Academy of Pediatrics |Favorite Table|Download (.pdf)
Table 15-1. Definition of MTBI by the American Academy of Pediatrics
Normal mental status on initial examination.
No abnormal or focal neurologic findings.
No physical evidence of skull fracture.
LOC of <1 min.
May have had a seizure immediately after injury.
May have vomited after injury.
May exhibit other signs and symptoms, e.g., headache or lethargy.
Known or suspected cervical spine injury;
Suspected intentional head trauma; and
History of bleeding diathesis or neurologic disorders.
Table 15-2. Definition of MTBI by American Congress of Rehabilitation Medicine |Favorite Table|Download (.pdf)
Table 15-2. Definition of MTBI by American Congress of Rehabilitation Medicine
Any loss of memory for events immediately before or after the injury.
Any alteration in mental state at the time of the injury.
Focal neurologic deficits that may or may not have resolved.
Exclusion criteria include:
LOC >30 min;
GCS score <13 after 30 min; and
Posttraumatic amnesia >24 h.
Concussion is included in the spectrum of MTBI. Physicians have long regarded concussion to be a benign condition, but its role in long-term brain damage is being investigated and argued. The American Congress of Rehabilitation Medicine has a slightly different definition, based on the belief that the trauma has induced a physiologic disruption of brain function with possible prolonged or permanent sequelae. The inclusion criteria comprise at least one of the following.
The infant's head has a disproportionately large size and weight relative to the rest ...