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The statement that children are not small adults particularly
applies when considering the developing nervous system. The nervous
system is constantly changing throughout childhood. Thus the way
trauma to the developing nervous system affects the child depends
on where along the neuraxis the trauma occurs, at what age and developmental
stage, and the mechanism of the trauma. These specifics are important
to consider in the context of the most frequent causes of trauma,
the implications, and the outcomes. Trauma usually results in acute deterioration
in neurologic function but late sequelae or delayed effects must
also be anticipated. In this section, discussion will focus on the most
commonly encountered scenarios of trauma to the nervous system in
pediatrics. This includes accidental traumatic brain injury, inflicted
neurotrauma, spinal cord injury, and associated injury to adjacent
tissues, such as bone in skull fractures and blood vessels in hemorrhage.
The acute management of these injuries is further discussed in Chapter 104. Trauma to the brachial plexus during delivery will be briefly
discussed.
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Under normal circumstances, the skull protects the brain from
minor trauma by cushioning the sensitive contents from external
blows. The surrounding cerebrospinal fluid (CSF) assists in reducing
any force by providing a fluid layer in which the brain may “float.” However,
with more severe trauma, the differential rate of movement of the
skull, brain, CSF, and blood vessels causes acute injury to the
contents. Traumatic brain injury results from the sudden acceleration
or deceleration of the brain relative to the skull or from penetrating
injury. The degree of injury manifests along a spectrum from mild
functional impairment without obvious visible injury (either on
physical examination or neuroimaging) to severe, generalized, or focal/multifocal
injury.
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Head injury is one of the most common neurologic disorders in
pediatrics. Millions of children and adolescents suffer an injury
to the head each year but most do not seek medical attention or
are seen by a primary physician well after the event. Thus, the
incidence and characteristics of these head injuries are not fully
known. Of those who seek care in a hospital-based setting, each year,
approximately 475,000 traumatic brain injuries (TBIs) occur in children
ages 0 to 14 years.1 More than 90% of
these (435,000) present to emergency rooms for immediate care, 37,000
are hospitalized, and 2685 are fatal. The rate of TBI-related emergency room
(ER) visits, hospitalizations and deaths is greater than 50% more
common in boys than girls ages 0 to 14. Across all ages in children
and adolescents, TBI is more common in males than in females. Falls
are the most common cause of TBI from ages 0 to 14, accounting for
39% of all TBIs in that age range. After age 14, motor vehicle
accidents become the most common cause, followed by assaults and
falls. Most fall-related TBIs are evaluated in the emergency room
and more than 90% of patients are released to their home. However,
after age 4 years, motor vehicle ...