Pediatric head trauma occurs commonly with most being minor; however, seemingly low-risk presentations may have intracranial injuries, and thus it is important to maintain a high index of suspicion. The Glasgow Coma Scale (GCS) quantifies neurologic findings and allows uniformity in description and communication among team members involved in taking care of the patient. A GCS score of 14 to 15 is categorized as mild head injury; a GCS score of 9 to 13 as moderate head injury and GCS score less than 9 as severe head injury.
Figure 20.1 ▪ Penetrating Head Injury.
(A) This infant was stabbed in the head with a butter knife during a domestic dispute between his mother and angry father. He suffered no neurologic deficits after the knife was removed by neurosurgery in the operating room. (B) A lateral projection of the skull demonstrates the butter knife imbedded within the occipital-parietal region of the skull. (Photo/legend contributors: Mark Silverberg, MD/John Amodio, MD.)
Emergency Department Treatment and Disposition
Stabilize airway with cervical spine immobilization, breathing and circulation as indicated followed by evaluations for disability and exposure. Moderate hyperventilation, if signs of impending herniation, and fluid resuscitation, if evidence of hypotension, are critical.
Treat any seizures with a benzodiazepine or fosphenytoin, and consider using the latter prophylactically, if intracranial hemorrhage is present. Obtain laboratory tests including CBC type and cross-match, electrolytes, and coagulation profile in patients with serious head injuries. Consider obtaining ethanol level and toxicologic screen in adolescents. Order C-spine imaging in all patients with midline neck pain or neurologic deficits, and in all unconscious patients. Obtain a head CT scan (without contrast) if loss of consciousness, GCS score <13, penetrating injury, a high-risk mechanism of injury, clinical signs of basilar or depressed skull fracture, a posttraumatic seizure, a large scalp hematoma (especially parietal/temporal), repetitive vomiting, prolonged lethargy, amnesia, past history of bleeding diathesis (eg, hemophilia), significant past medical history (eg, shunts) or suspected abusive head injury. Leave any penetrating foreign bodies of the head in place for operative removal; consult neurosurgery emergently for such cases and for any abnormalities seen on the head CT scan.
Figure 20.2 ▪ Penetrating Head Injury.
An axial slice from a noncontrast head CT shows a penetrating gunshot wound with fracture of the frontal and parietal bones, and large hemorrhagic contusion along the tract of the bullet. High-density bullet fragments are also noted in the frontal region of the brain. (Photo/legend contributors: Mark Silverberg, MD/John Amodio, MD.)
Admit patients with abnormal CT findings, witnessed loss or change of consciousness, penetrating injuries, focal or abnormal neurologic examination, abusive injuries, evidence of depressed or basilar skull fracture, other significant associated injuries, persistent symptoms (even with a normal CT scan), amnesia, or an unreliable caretaker at home. Refer to the American Academy of Pediatrics guidelines for minor head injury for patients aged <2 years, and for patients aged 2 to 20 years. Discharge other patients with written instructions that are clear to the caretaker, including the directive to return to the emergency department (ED) immediately if the patient develops any of the following: (1) excessive sleepiness or difficulty in awakening; (2) confusion or abnormal behavior; (3) progressive headache; (4) progressive vomiting or nausea; (5) abnormal gait; (6) ataxia; (7) unequal pupils, double vision, or any visual disturbance; (8) convulsions; and (9) bleeding or watery drainage from the nose or ear.
Diffuse brain injury (concussion or diffuse axonal injury) is the most common type of head injury.
Prevent secondary brain injury in patients presenting with head trauma or multiple trauma.