-
DOI: 10.1542/pir.33-9-3982012;33;398Pediatrics in Review
Jeff E. Schunk and Sara A. SchutzmanPediatric Head Injury
http://pedsinreview.aappublications.org/content/33/9/398located
on the World Wide Web at:
The online version of this article, along with updated
information and services, is
Pediatrics. All rights reserved. Print ISSN: 0191-9601.
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2012 by
the American Academy of published, and trademarked by the American
Academy of Pediatrics, 141 Northwest Pointpublication, it has been
published continuously since 1979. Pediatrics in Review is owned,
Pediatrics in Review is the official journal of the American
Academy of Pediatrics. A monthly
at UNIV OF CHICAGO on May 24,
2013http://pedsinreview.aappublications.org/Downloaded from
-
Pediatric Head InjuryJeff E. Schunk, MD,* Sara
A. Schutzman, MD
Author Disclosure
Drs Schunk and
Schutzman have
disclosed no financial
relationships relevant
to this article. This
commentary does not
contain a discussion of
an unapproved/
investigative use of
a commercial product/
device.
Educational Gap
Recent studies have provided updated guidelines for the
diagnosis of head injury and the
management of patients who experience concussions. A
multidisciplinary panel has re-
cently issued new guidelines for return to play after head
injury.
Objectives After reading this article, readers should be able
to:
1. Understand the anatomy and pathophysiology relevant to
pediatric head injuries.
2. Take an appropriate history, perform an appropriate physical
examination, and decide
what imaging, if any, is warranted in the case of a child with a
head injury.
3. Know the characteristics of the various types of intracranial
injuries.
4. Understand the proper management of both minor and severe
head injuries in
children.
IntroductionPediatric head injury is extremely common. Although
the vast majority of children withhead trauma have minor injuries,
a small number, even among well-appearing children, willhave more
serious injuries with the potential for deterioration and signicant
sequelae. Theclinician is challenged to discern which few among the
many injured are at high risk forintracranial complications.
Clinical symptoms are neither completely sensitive nor specicfor
signicant injury: vomiting may be associated with intracranial
injury (ICI), but mostchildren who experience vomiting do not have
a complication. Computed tomography(CT) accurately identies ICIs
requiring intervention, but also identies minor lesions withunclear
clinical importance (ie, not requiring intervention) and exposes
developing brainsto ionizing radiation with the associated
risks.
Although clinical decision rules determine which children are at
highest risk and providea useful clinical framework, they may not
necessarily direct care. Additionally, in this era of
reliance on imaging, it is important to remember what
theclinical examination tells us regarding brain function,
infor-mation that may or may not correlate with the structural
in-formation provided on head CT.
The purpose of this discussion is to review important as-pects
of pediatric head trauma. Sections on epidemiology,mechanisms of
injury, and the pathophysiology of specicinjuries will provide a
backdrop for the discussion of clinicalassessment and indications
for imaging and admission. Whatfollows is a discussion of
concussion, postconcussion syn-drome, and return-to-play
recommendations.
EpidemiologyChildhood head injuries account formore than 600,000
emer-gency department (ED) visits per year and presumably a
larger
Abbreviations
BSF: basilar skull fractureCSF: cerebrospinal uidCT: computed
tomographyEDH: epidural hemorrhageGCS: Glasgow Coma ScaleICI:
intracranial injuryICP: intracranial pressurePECARN: Pediatric
Emergency Care Applied Research
NetworkSAH: subarachnoid hemorrhageSDH: subdural hemorrhageTBI:
traumatic brain injury
*Professor, Division of Pediatric Emergency Medicine, Department
of Pediatrics, University of Utah School of Medicine, Primary
Childrens Medical Center, Salt Lake City, UT.Assistant
Professor, Department of Pediatrics, Harvard Medical School, Senior
Associate Physician in Medicine, Division of
Emergency Medicine, Department of Medicine, Childrens Hospital
Boston, Boston, MA.
Article neurologic disorders
398 Pediatrics in Review Vol.33 No.9 September 2012
at UNIV OF CHICAGO on May 24,
2013http://pedsinreview.aappublications.org/Downloaded from
-
number of visits and calls to primary care providers.Most
pediatric head injuries are minor, including scalpand face
contusions, abrasions, and lacerations that donot raise concern for
signicant underlying pathology;however, trauma is the leading cause
of death in chil-dren older than 1 year, and among trauma
patients,head injury is the leading cause of death and
disability.Pediatric head traumarelated deaths in the UnitedStates
are in excess of 3,000 per year.
Although children exhibit almost limitless creativitywith regard
to sustaining injury, most pediatric headtrauma results from falls,
motor vehicle collisions, autoversus pedestrian incidents,
bicycle-related injuries, andsports. Younger children suffer more
falls and are moreoften the victims of child abuse, whereas motor
vehiclecrashes and sports-related mechanisms play a greater rolein
older children. This discussion focuses on blunt headtrauma rather
than penetrating trauma (eg, gunshotwound) because penetrating
injury is much less commonand unlikely to present to the primary
care clinician.
Although the approach to head injury should considerthe
potential for serious injury in all cases, some mecha-nisms can be
regarded as relatively trivial and unlikely tobe associated with
serious injury. These injuries includelow-velocity self-propelled
contact into stationary objects(eg, the toddler runs into the door
frame) and falls fromstanding or sitting height or lower. However,
the pres-ence of any symptoms of head trauma despite the historyof
an apparently benign mechanism would no longerqualify the head
injury as trivial.
Rarely, minor mechanisms may create more serious in-jury in the
presence of undiagnosed intracranial pathol-ogy (eg, hemorrhage
into a brain tumor). The clinicianalso must be alert to more
dangerous mechanisms thatcould be concealed, either because the
child choosesnot to disclose or because the injury was inicted.
General PathophysiologyBrain injury results from the blow to the
head and the in-terplay of brain parenchyma, the brains coverings,
thebrains housing structure (the cranial vault), and the vas-cular
supply. It is useful to consider the relevant anatomicstructures as
layers from outside to inside.
The scalp consists of ve layers of soft tissue thatcover the
skull. Common injuries to the skin and subcu-taneous tissue (the
outer two layers) include lacerations,abrasions, and freely mobile
contusions. Beneath lies thestrong galea aponeurotica that also
connects musculartissue on the front and back of the skull.
Underneathare the loosely applied areoloar tissue layer and thenthe
pericranium.
Hemorrhages may occur in the subgaleal region fromdirect blows
or as a result of bleeding from a fracture.Cephalohematomas are
hematomas caused by bleedingbeneath the periosteum, a condition
well known to thosewho care for newborn infants.
The skull can be divided into the calvarium or bonyskullcap and
the skull base. The skullcap is composed ofthe frontal, parietal,
occipital, and temporal bones. Thebase of the skull is made up of
the sphenoid, palatine,and maxillary bones and portions of the
temporal andoccipital bones. Injury to the calvarium results from
di-rect forces, and fractures commonly are linear.
Less commonly, skull fractures may be depressed (in-truded by
more than the thickness of the bone), commi-nuted (consisting of
multiple fragments), diastatic (widelysplit), or open
(communicating with a laceration). Fracturesinvolving the skull
base, known as basilar skull fractures(BSFs), are more complicated
because of adjacent anatomicstructures (eg, cranial nerves,
sinuses), their association withICI, and the risk they pose for
meningitis.
Within the skull are the intracranial contents, consist-ing of
the brain and its covering membranes (the menin-ges), blood, and
cerebrospinal uid (CSF). The meningesplay an important role in the
genesis of serious ICI. Theoutermost meningeal layer, the dura
mater, is attachedtightly to the inner aspect of the skull. The
epidural spaceis a potential space between the dura and the skull.
Menin-geal arteries course between two layers of the dura and
maybecomemore grooved into the skull as the skull matures, sothat a
skull fracture may injure these vessels and causebleeding into the
epidural space. Meningeal arteries are par-ticularly vulnerable to
injury because they run beneath thethinnest part of the skull.
Channels exist within the dura forvenous drainage and these dural
sinuses also may be lacer-ated. Blood collecting in the epidural
space is referred to asan epidural hematoma or epidural hemorrhage
(EDH).
Beneath the dura lies the arachnoid mater, a thin tissuelayer
coursing close to the brain but not following thebrain sulci. This
membrane separates the CSF-containingsubarachnoid space beneath it
from the subdural space.Within the subdural space lie the bridging
veins that re-turn blood from the brain to the dural sinuses.
Thesebridging veins are susceptible to shearing forces whenthere is
rapid acceleration or deceleration that movesthe brain within the
skull. A hematoma in this space istermed a subdural hemorrhage
(SDH).
The third, innermost meningeal layer is termed the piamater and
adheres to the underlying brain, coursing overall gyri and sulci.
This layer contains many small vesselsthat can be injured from
direct blow or shear forces, re-sulting in a subarachnoid
hemorrhage (SAH).
neurologic disorders head injury
Pediatrics in Review Vol.33 No.9 September 2012 399
at UNIV OF CHICAGO on May 24,
2013http://pedsinreview.aappublications.org/Downloaded from
-
Beneath themeninges lies the brain parenchyma, a semi-solid
tissue that is not afxed to the skull and can movefreely within it.
The CSF that bathes the brain and the spi-nal cord provides some
degree of cushioning for the brain.
It is useful to discuss brain injury as having two phases.The
primary injury is mechanical damage sustained im-mediately at the
time of trauma from direct impact (eg,brain impacts the inner
aspect of the skull or a skull frag-ment moves into the brain) or
from shear forces when thegray matter and white matter move at
different speedsduring deceleration or acceleration.
Secondary injury refers to ongoing derangement toneuronal cells
not initially injured during the traumaticevent. Ongoing injury
results from processes initiatedby the trauma, including hypoxia,
hypoperfusion (localor systemic shock), metabolic derangements (eg,
hypo-glycemia), expanding mass and increased pressure, andedema.
Because primary injury occurs at the momentof trauma, little can be
done to mitigate it other than pre-vention, so treatment during
trauma resuscitation focuseson preventing secondary injury.
When considering secondary injury, two additionalconcepts
warrant further discussion. The rst consider-ation relates to
pressure and volume within the cranialvault. After infancy, the
cranial vault is a relatively stiff,poorly compliant structure and
the intracranial volumeis relatively xed. From a simplistic
standpoint, the vaultcontains brain, blood, and CSF, and any
increase in thevolume of one component necessitates a relative
decreasein another.
If volume compensation does not occur, intracranialpressure
(ICP) will increase. With progressive increasesin ICP, the patient
will experience headache, vomiting,and depressed mental status,
then posturing, and ulti-mately vital sign deterioration.
Increasing ICP may leadto global ischemia through mechanisms
discussed later inthis section. Ultimately, increased ICP will lead
to brainherniation (abnormal movement of the brain across
skullstructures).
Herniation can occur at several different anatomic lo-cations
(Fig 1). When a mass lesion is one-sided andsupratentorial, uncal
herniation may occur. This type ofherniation involves movement of
the innermost part ofthe temporal lobe, the uncus, over the
tentorium, withresultant pressure on the midbrain and pressure on
thethird cranial nerve, impairing its parasympathetic bersand
leading to ipsilateral pupillary dilation.
Central herniation occurs when central brain struc-tures,
including the diencephalon and temporal lobes,move caudally through
the tentorium cerebelli. Cingu-late or subfalcine herniation occurs
when the cingulate
gyrus is pushed across the midline under the falx cereb-rial.
Although subfalcine herniation does not affect themidbrain
directly, it can affect blood ow and can prog-ress to central
herniation.
In tonsillar herniation, the cerebellar tonsils move downthrough
the foramen magnum with compression of thelower brainstem and upper
cervical spinal cord. Compressionof the brainstemmay result in
severe neurologic dysfunction,cardiovascular and respiratory
instability, and death.
The other important concept in considering second-ary injury
involves cerebral perfusion. Cerebral perfusionpressure is the
difference between the mean arterial bloodpressure and ICP. In
health, cerebral blood ow is main-tained despite variable blood
pressures by autoregulatorychanges in cerebral vascular resistance.
When severe inju-ries occur, this ability to autoregulate may be
impaired, sothat cerebral blood ow will be dependent on
cerebralperfusion pressure.
In the absence of appropriate autoregulation, cerebralperfusion
will diminish with elevated ICP or with sys-temic hypotension. In
either instance, resultant ischemia,neuronal death, and subsequent
edema all contribute tosecondary injury.
Figure 1. This figure depicts four types of brain herniation:
(1)cingulated (subfalcine), (2) central, (3) uncal
(transtentorial),and (4) tonsillar. (Figure is reproduced with
permission fromKaye AH. Head Injuries. In: Smith JA, Tjandra JJ,
Clunie GJ,Kaye AH, eds. Textbook of Surgery. 3rd ed. Oxford, UK:
Wiley-Blackwell; 2006:445453.)
neurologic disorders head injury
400 Pediatrics in Review Vol.33 No.9 September 2012
at UNIV OF CHICAGO on May 24,
2013http://pedsinreview.aappublications.org/Downloaded from
-
General Management ConsiderationsManagement focuses on
prevention of secondary injury,so initial attention is directed to
the ABCs of trauma re-suscitation, focusing on maintaining adequate
airway,breathing (ventilation and oxygenation), and
circulation(blood pressure and perfusion). Cervical spine
precautionsare taken when head injury is present because head
injurymay be associated with cervical spine injury. Oxygen is
ap-plied, ventilation is supported as necessary to
providenormocarbia (partial pressure of carbon dioxide at 3545 mm
Hg), and circulatory concerns are addressed.
Hyperventilation is no longer the standard of care, al-though
there is still a limited role for acutely lowering in-creased ICP
in the intensive care unit or operating room.Patients with Glasgow
Coma Scale (GCS)
-
with or without loss of consciousness. From a
practicalstandpoint, concussion often is used to refer to moreminor
head injury when the GCS is 14 to 15, the patienthas some symptoms
(eg, headache, dizziness, vomiting,amnesia, or confusion), there is
no evidence of a fracture,and there are no focal neurologic decits.
A more detaileddiscussion of concussion is below.
Skull FracturesThe main importance of skull fractures is that
they aremarkers for signicant impact to the head that increasesthe
risk of ICI signicantly; however, it is important tonote that ICI
also occurs in the absence of fractures, andmany fractures are not
associated with ICI. Rarely, the frac-ture itself may lead to a
complication (more common withbasilar or depressed skull fracture).
Before the advent ofCT, skull radiography was an important modality
to identifychildren at risk for complications; however, because
plainradiographs give no direct information about ICI,
currentlythey are of very limited utility. Skull fractures now are
diag-nosed most commonly when a CT scan is obtained.
An exception to the lack of utility of skull radiographsoccurs
when child abuse is suspected. When child mal-treatment is
suspected, the presence of a skull fracture,old or new, with or
without ICI, has important implica-tions; so skull radiographs,
with their higher sensitivityfor fracture, are included as part of
a more comprehensiveskeletal survey. Skull fractures in children
younger than 2years in the absence of a history of appropriate
mechanismshould prompt a more thorough evaluation for inicted
trauma (including skeletal survey) and appropriate report-ing
and referrals.
Fracture of the calvarium is more common than frac-ture of the
base of the skull. Most fractures are linear and,when considered in
isolation (ie, not associated withICI), of little consequence. No
specic therapy need bedirected to the fracture except pain
management. Follow-upwith primary care is appropriate to detect the
exceedinglyrare late complication of a growing fracture.
Depressedskull fractures (those intruded more than the thicknessof
the bone) carry increased risk of primary injury tothe brain
because of intrusion of the fragment and, de-pending on the
location, may have signicant cosmeticsequelae (Fig 2).
Neurosurgical consultation is neces-sary for all depressed skull
fractures, even in the absenceof more serious ICI.
Basilar Skull FracturesBSF requires special consideration for
several reasons. Theycan have unique clinical presentations
providing clinicalclues that often are readily apparent.
Hemotympanumor blood draining from the ear, are the most
commonsigns of a BSF. CSF draining from the ear or draining fromthe
nose (attributable to a cribriform plate fracture), Battlesign, and
raccoon eyes also are signs of BSF. Persistent
Table 2. Modified Coma Scale forInfants (Best Score Is 15)
Activity Best Response Score
Eye opening Spontaneous 4To speech 3To pain 2None 1
Verbal Coos, babbles 5Irritable, cries 4Cries to pain 3Moans to
pain 2None 1
Motor Normal spontaneous 6Withdraws to touch 5Withdraws to pain
4Abnormal flexion 3Abnormal extension 2None 1
Figure 2. This toddler fell from a horse and CT scan
showsdepressed and comminuted parietal skull fracture.
neurologic disorders head injury
402 Pediatrics in Review Vol.33 No.9 September 2012
at UNIV OF CHICAGO on May 24,
2013http://pedsinreview.aappublications.org/Downloaded from
-
clear drainage from the nose after head trauma should alertthe
clinician to the possibility of a BSF. BSF also can occurin the
absence of these clinical ndings and be apparentonly on CT;
conversely, CT scan may not detect all suchfractures.
BSFs are important because they are associated with ICIand have
a higher incidence of complications from thefracture itself, owing
to the unique anatomic location.ICI occurs in about 20% of BSF
patients who have a normalneurologic examination and GCS of 15. (1)
Therefore,when signs of a BSF are noted, CT scanning is
necessary.
BSF is associated also with an increased risk of menin-gitis.
Fractures adjacent to the paranasal or sphenoid si-nuses can lead
to meningitis if bacteria from these areasenter the normally
sterile subarachnoid space. The overallrisk of developing
meningitis after sustaining a BSF isprobably less than a few
percent, but the risk is increasedif there is CSF rhinorrhea or
otorrhea.
Use of prophylactic antibiotics is controversial. If thereis
ongoing CSF leakage, neurosurgical intervention maybe needed to
facilitate healing of the dural tear. Anatomicadjacency of the base
of the skull to cranial nerve path-ways means that BSF may cause
hearing loss, facial paral-ysis, and a decreased sense of smell, as
well as other cranialnerve dysfunction. Conductive hearing loss
also may oc-cur from blood in the middle ear.
General Intracranial InjuriesPerhaps the most important issue
for the clinician evalu-ating a head-injured child is determining
if there is anICI. With improved CT images and current
neurosurgicalpractice, however, detecting an ICI does not equate
toa need for neurosurgery. Visible lesions on CT scan mayor may not
be associated with functional issues or seriousmorbidity. The two
broad classications of ICIs includefocal hemorrhage (EDH, SDH, SAH,
intracerebral hem-orrhage, and cerebral contusion), which typically
are visi-ble on initial imaging, and diffuse injury (cerebral
edema,diffuse axonal injury), which tends to progress andmay
be-come more visible on subsequent imaging.
Epidural HemorrhageWhen bleeding occurs between the skull and
the duramater, the patient is said to have EDH. The bleedingsource
is arterial in w30%, fewer are clearly identied asvenous, and in
the remainder the source is unclear. EDHis caused most commonly by
a blunt trauma mechanism,with falls most frequent. Often there is
an overlying frac-ture (60% to 80%), and the EDH has a
lens-shapedappearance on CT (Fig 3). Typically, the underlying
brainparenchyma is not injured. Classic teaching suggested
that patients with EDH had LOC, then a lucid interval,and then
deteriorated. However, that clinical presenta-tion is rare; only
w20% of children with an EDH evenexperience LOC. Some children may
present with markedlethargy or focal neurologic ndings and progress
to morefrank signs of herniation.
However, presentation with more subtle signs, such aspersistent
vomiting and headache, is more common, andmore than 30% of patients
who have EDH are alert withnormal neurologic ndings at the time of
diagnosis. Al-though some small epidurals may produce minimal orno
symptoms, they have the potential to expand, whichcan result in
cerebral herniation and death. Fear of miss-ing an expanding EDH,
with its high potential for mor-tality, has, in part, fueled the
marked increase in use of CTscanning occurring in recent
decades.
Patients with EDH require emergent neurosurgicalconsultation and
close monitoring. Patients with largerEDH, midline shift, or
signicant symptoms are treatedwith emergent craniotomy and
evacuation of thehematoma. Because some small EDHs do not
expandsignicantly, relatively asymptomatic patients who havesmall
epidurals may be managed expectantly, at the
Figure 3. This CT scan demonstrates a right epiduralhematoma
with typical lens shape. The mass effect hascaused effacement of
the lateral ventricle and shift of themidline to the patients
left.
neurologic disorders head injury
Pediatrics in Review Vol.33 No.9 September 2012 403
at UNIV OF CHICAGO on May 24,
2013http://pedsinreview.aappublications.org/Downloaded from
-
neurosurgeons discretion, with admission and very
closemonitoring. Patients who have EDH successfully
drainedemergently have a good long-term outcome in more than80% of
cases.
Subdural HemorrhageWhen bleeding occurs between the dura and the
arach-noid membrane, an SDH results. Usually, tearing ofthe
bridging veins is the source of the bleeding and resultsfrom a
direct blow, falls from signicant height, or frominicted head
trauma, as seen in child abuse. SDH is notusually associated with
an overlying fracture and hasa crescent shape on CT (Fig 4).
Unlike the EDH, an SDH usually is associated withunderlying
brain injury and the hemorrhages may be bi-lateral. Children may
present with LOC, altered mentalstatus, seizures, irritability,
vomiting, lethargy, or signsor symptoms of increased ICP (eg,
bulging fontanel, de-creased responsiveness). In about half the
instances ofSDH, the children present in coma or signicantly
de-pressed GCS.
Mortality of patients presenting with acute SDH is highand
ranges from 10% to 20%. SDH in infants is associatedwith child
abuse but is not diagnostic that abuse has oc-curred. Child abuse
should be suspected highly when there
is no explanation for the injury, when the mechanism ofinjury
does not match the degree of injury, or in instancesin which there
appears to be evidence of SDH with bothnew and old blood.
A chronic SDH may occur in children with coagulo-pathies, but
usually results from child abuse, and maypresent with subtle
ndings, including macrocephaly, fullfontanel, fussiness, seizures,
and vomiting.
SDH requires emergency neurosurgical consultation. Pa-tients who
have an acute large SDH with evidence of masseffect within the
cranium and altered level of consciousnessare candidates for
surgical drainage. Smaller SDH and morechronic formsmay
bemanagedwithout surgical decompres-sion. Children with SDH often
have signicant long-termmorbidity that may include developmental
delay and seiz-ures. These adverse, persistent neurologic sequelae
are morelikely to occur in patients who present with coma, or
whenCT scan demonstrates underlying brain injury.
Subarachnoid HemorrhageIn more severely injured patients, SAH
occurs about 25%of the time. This lesion results from tearing of
the smallvessels of the pia mater secondary to signicant
blunttrauma and associated shearing forces. Because thebleeding is
in a space that communicates with otherCSF-containing spaces
(within the brain, around thebrain and spinal cord), problems
related to the mass effectthat is seen with EDH and SDH rarely
occur. SAH often isseen in association with other ICIs, so
presentation is vari-able, but SAHs occurring in isolation may
present withLOC, headache, or signs of meningeal irritation (eg,
vom-iting, photophobia, nuchal rigidity).
Cerebral ContusionA cerebral contusion is essentially a brain
bruise causedby a well-localized area of neuronal injury with
bleeding(Fig 5). This injury results from movement of the
brainagainst the skull. Blunt trauma to the head maycause a
cerebral contusion near the site of impact(a coup lesion) or may
cause a cerebral contusion op-posite the site of impact (a
contrecoup lesion). Typicalsigns may be subtle, and can include
vomiting, headache,LOC, or, less commonly, a focal neurologic nding
or aseizure. In most instances, small contusions have littleacute
or long-term sequelae.
Diffuse Axonal InjuryDiffuse axonal injury involves injury to
the white mattertracts within the brain and is likely caused by
shear forces.This type of injury is caused by severe
acceleration,
Figure 4. CT scan demonstrates subdural hemorrhage leftposterior
and left lateral that resulted from child abuse.
neurologic disorders head injury
404 Pediatrics in Review Vol.33 No.9 September 2012
at UNIV OF CHICAGO on May 24,
2013http://pedsinreview.aappublications.org/Downloaded from
-
deceleration, or rotational forces, occurring most com-monly in
motor vehicle crashes. The injury often is atthe gray-white matter
junction but may occur deeperwithin the corpus collosum, brainstem,
or cerebellum.These children usually are in coma at presentation,
althoughoccasionally the child will have only
concussion-typesymptoms. The CT scan shows small areas of
hemorrhagelocated near the gray-white interface that do not
expand.Management of diffuse axonal injury is supportive,mortality
is 10% to 15%, and persistent neurologic dys-function occurs in 30%
to 40%.
Diffuse Brain SwellingThis condition is seen almost exclusively
in children whoexperience severe head trauma and the mechanism
ap-pears to be a reaction to cellular injury. Diffuse brainswelling
may not be apparent on initial imaging; subse-quent CT scans
demonstrate ndings of progressiveedema. The cellular insults may be
varied, and cytotoxicedema, vasogenic edema, and autoregulatory
dysfunctionall may play a role. The children present with marked
de-pression or deterioration of the GCS, and the main threatis the
associated increase in ICP.
Who Needs Computed Tomography?The clinicians goal is to identify
patients who developclinically important ICI so as to prevent
deteriorationand secondary brain injury (eg, from expanding
EDH),while limiting unnecessary radiographic imaging.
Unfor-tunately, dening sensitive and specic clinical predictorsfor
identifying high-risk patients who require a head CThas been
challenging.
Several issues contribute to the challenge of
evaluatinghead-injured children:
Although patients with ICI often have symptoms orfunctional
derangements, many patients with thesesame symptoms have no
ICI.
Patients with normal neurologic examinations who ex-hibit
symptoms as common as vomiting or headachemay harbor an ICI that
has the potential to becomelife-threatening. Repeated examination
of the fundiis prudent because papilledema may not be present
ini-tially but may develop later in the course of
intracranialhypertension.
Many intracranial lesions detected by CT are onlyrarely
associated with signicant morbidity (eg, smallcerebral contusion or
small SAH).
AlthoughCT can effectively identify clinically importantICI,
this imaging modality carries the risks of radiation,including the
long-term sequelae of radiation-inducedmalignancy.
Investigators have identied several clear predic-tors of
ICI:
GCS 14 or altered mental status. Focal neurologic abnormalities.
Skull fracture.
Patients who have any of these ndings should un-dergo CT
imaging.
However, most patients have none of these ndings(ie, they have a
GCS of 15, nonfocal neurologic exami-nation, and no obvious skull
fracture); yet, patientswho lack these features account for a large
proportionof patients who actually have ICI. Within this group,the
incidence of ICI is about 5% and the need for neuro-surgery
-
injuries, and more often are victims of inicted injury.In
addition to the predictors of ICI found in older chil-dren,
nonfrontal scalp hematomas (surrogate markers forskull fracture)
were found to be predictors of ICI, withlarger hematomas in younger
children of greater concern.(2)
In all age groups, because of the variability of
clinicalpredictors in identifying ICI and concern for missing
ICI,clinicians have adopted a very liberal approach to the use ofCT
scans. ED-based studies have shown that this groupwith mild head
injury undergoes CT scanning from 35%to 55% of the time. Head CT
for pediatric minor head in-jury increased in Canada from 15% in
1995 to 53% in 2005for head-injured children. In the United States,
use has in-creased dramatically in the face of relative stability
of seri-ous injury, implying that more and more normal CT scansare
being obtained.
Risk of Head Computed Tomography ScanningWidespread imaging has
increased concerns regardingsafety, specically related to sedation
and radiation risk.Concern for adverse events from sedation is
justied,but with increasing speed of scanners, the need for
sedationshould decrease. Clinical experience and research in
pedi-atric sedation has blossomed, and overall hospital practicesin
this regard have become safer, so that sedation-relatedadverse
events are less of a concern.
The potential for ill effects from ionizing radiation can-not be
overlooked. Evidence for this risk assessment comesprimarily from
information on radiation exposure follow-ing nuclear bomb
detonation and data derived from ther-apeutic use of radiation. It
is estimated that CT scanningwill induce a new malignancy at a rate
ofw1 in 5,000 CTscans. It appears that the greatest lifetime risk
occurs in theyoungest patients (both because of life-years
remainingand susceptibility of tissues), and overall risk decreases
asage increases. From the standpoint of an individual or
in-dividual clinician, this rate does not seem high, but whenone
considers the tens of thousands of normal head CTscans being
performed each year, the public health impactmay not be
trivial.
Recent InvestigationsRecent investigations (3)(4) have better
identied moremeaningful predictors by using multicenter design,
includ-ing large numbers of head-injured children, focusing
ongroups at relatively low risk, and determining decisionrules to
aid clinicians determining the need for CT. Someof these large
studies also altered the primary outcomemeasure from presence of an
ICI, as previous studies
had done, to clinically important traumatic brain injury(TBI).
In a study through the Pediatric Emergency CareApplied Research
Network (PECARN) involving morethan 42,000 pediatric patients at 23
centers, a clinicallyimportant TBI was dened as death, need for
neurosur-gery, intubation >24 hours, or hospitalization for
2nights. (3)
Decision rules are developed to guide the clinicians ina more
thoughtful approach to CT scanning so as to avoidoveruse while
still identifying clinically important ICI. Norules eliminate all
risk unless all patients are scanned, butthey provide a needed
framework for risk assignment.The clinician who appropriately
elects not to scan shouldunderstand the risk of serious ICI.
In the PECARN study, (3) when only children withGCS of 14 to 15
are considered, high-risk criteria (w4%incidence of clinically
important ICI) were GCS 14,other signs of altered mental status,
and palpable skull frac-ture (if age 2 years) forwhich CT was
recommended.
Other risk factors (w1% incidence of clinically impor-tant ICI)
for age >2 years: loss of consciousness, severeinjury mechanism,
vomiting, and severe headache; andfor age
-
at least 4 to 6 hours from the time of injury is a
reasonablealternative.
It is clear from a subanalysis of the PECARN study
thatclinicians sometimes use observation before deciding toobtain a
CT. When observation is chosen, the appearanceof additional new
symptoms, evidence of worsening symp-toms, or clinical
deterioration should prompt imaging. Ininstances in which multiple
risk factors are present orsymptoms are more severe, imaging
probably is favored.Other factors that may inuence the decision to
image in-clude quality of observation (eg, caretaker reliability,
timeof day), the ability to return for worsening symptoms,
phy-sician experience, and parental preference. Table 6 lists
cri-teria typical of patients for whom imaging is not
necessary.
DispositionIn general, patients with depressed skull fracture or
anyICI should be hospitalized with emergent
neurosurgicalconsultation for their lesions; however, some small
cere-bral contusions or SAHs may have little short- or long-term
clinical signicance, and deterioration is rare. Patientswith normal
CT scans and resolution of symptoms typically
do not require hospitalization. Patients with persistentsymptoms
(despite normal CT scans) who would not be
Table 3. Emergent HeadComputed Tomography Scan IsRecommended
Penetrating injuryGlasgow Coma Scale (GCS) 14 or other evidence
of
altered mental statusFocal neurologic abnormalitiesSigns of
depressed or basilar skull fractureWorsening headacheProlonged loss
of consciousness (LOC) (more than a
few minutes)Clinical deterioration during observation or
significant
worsening of symptomsSeizure (other than impact seizure) or any
prolonged
seizurePre-existing condition that places child at increased
risk
for intracranial hemorrhage (eg, bleeding disorder)In addition
for children
-
managed easily at home (persistent vomiting, severe head-ache,
abnormal mental status) also should be admitted.For any child
deemed stable for discharge (both those withand without imaging),
symptoms concerning for ICIshould be reviewed with reliable
caretakers who are ableto return to the ED should concerns
arise.
Home Management of Minor Head InjuryCalls to practitioners from
caregivers regarding pediatrichead injury are frequent. In many
instances, ongoing ob-servation at home without an ED or ofce visit
is reason-able, if there is a reliable caretaker with the means to
seekadditional care if needed, if there is no concern for
inictedinjury, and if there are no underlying conditions that
wouldpredispose the child to an ICI. In cases in which there isa
low-risk mechanism (typically a ground level fall fromchilds own
height) and there are no other injuries, noLOC or mental status
changes, no vomiting (one episodeshortly after injury is of less
concern), no signicant head-ache, and no nonfrontal scalp hematomas
(for children
-
studies. Both sets of guidelines share some
commonrecommendations.
Athletes suspected of having a concussion should beremoved from
participation immediately and they shouldnot return while signs or
symptoms are present. Athletessymptomatic for >15 minutes should
not return to playuntil they are asymptomatic for 1 week.
Most recently, amultidisciplinary panel published a con-sensus
guideline advocating abandoning acute gradingscales in favor of
clinical measures of recovery. (5) Returnto play should be based on
resolution of symptoms andnormalization of neurocognitive function
for the individ-ual, rather than based on a predetermined amount of
time.Recommendations are for physical and cognitive rest
untilasymptomatic, followed by a graduated, monitored returnto
play. This graduated return to play guideline from thisconsensus
paper is presented in Table 7.
Postconcussion SyndromePostconcussive symptoms develop within a
few days of theinitial concussion and can last anywhere from a few
days toa few months. Typical symptoms include headache,
fatigue,dizziness, cognitive impairment (particularly
concentra-tion), and neuropsychiatric symptoms. Some children
andteens may experience long-term behavioral and cognitiveproblems
temporally related to experiencing a concussion.
About 80% of high school athletes who experiencesports-related
concussions have resolution of symptoms
within 1 week, and fewer than 2% are symptomatic longerthan
1month. For patients whose symptoms persist beyonda few weeks,
referral to a pediatric neurologist, neuropsy-chologist, sports
medicine physician, or other specialist withexpertise in head
injury probably is indicated. Investigationsinto understanding
postconcussion syndrome risk and ef-fectiveness of interventions is
limited.
References1. Kadish HA, Schunk JE. Pediatric basilar skull
fracture: do childrenwith normal neurologic ndings and no
intracranial injury requirehospitalization? Ann Emerg Med.
1995;26(1):37412. Greenes DS, Schutzman SA. Clinical signicance of
scalp abnor-malities in asymptomatic head-injured infants. Pediatr
Emerg Care.2001;17(2):8892
Table 7. Graduated Return to Play
Stage Activity Stage Objective
No activity Complete physical and cognitive rest RecoveryLight
aerobic exercise Walking, swimming, stationary cycling, low
moderate intensityIncrease heart rate
Sport-specific exercise Skating drills ice hockey, running
drills, no impact Add movementNoncontact training More complex
training drills (eg, passing drills), may start
progressive resistance trainingExercise, coordination,
cognitive
effortFull-contact practice Normal training activities after
medical clearance Assess skills by coaches; restore
confidenceReturn to play Normal game play
In general, the athlete who has sustained a concussion should
proceed to the next level if without symptoms at the current level.
Each step generally takes 24hours. If symptoms recur, then the
patient drops back to previous asymptomatic level. (Adapted from
Table in Consensus statement on concussion in sport. JClin
Neuroscience. 2008;16:755763, with permission.)
Summary
Pediatric head injury is very common and usuallyminor but can
result in serious morbidity and is themost common cause of lethal
trauma.
Based on strong research evidence, a thorough historyand
physical examination with emphasis on neurologicstatus and signs of
skull fracture (including size,character, and location of scalp
hematomas in infants)provide the clues necessary to assess the
relative risk ofserious intracranial injury (ICI). (1)(3)(4)(6)
Based on strong research evidence, computedtomography (CT) scan
remains a highly useful adjunctin evaluation of the head-injured
child but should beused selectively for children at higher risk for
ICI. (2)(3)(4)
Based on research evidence or consensus opinion,observation can
be used selectively in lieu of CTscanning for patients who are not
at higher risk for ICI,minimizing the risks of CT-associated
ionizingradiation. Any concerns during the observation periodshould
prompt CT imaging. (3)(7)(8)
Concussion from head injury in athletics has recentlyreceived
increased public attention. Based onconsensus opinion, premature
return to play mayconfer increased risk to the athlete. (9)(10)
neurologic disorders head injury
Pediatrics in Review Vol.33 No.9 September 2012 409
at UNIV OF CHICAGO on May 24,
2013http://pedsinreview.aappublications.org/Downloaded from
-
3. Kuppermann N, Holmes JF, Dayan PS, et al; Pediatric
EmergencyCare Applied Research Network (PECARN). Identication of
childrenat very low risk of clinically-important brain injuries
after head trauma:a prospective cohort study. Lancet.
2009;374(9696):116011704. Osmond MH, Klassen TP, Wells GA, et al;
Pediatric EmergencyResearch Canada (PERC) Head Injury Study Group.
CATCH:a clinical decision rule for the use of computed tomography
inchildren with minor head injury. CMAJ. 2010;182(4):3413485.
McCrory P, Meeuwisse W, Johnston K, et al. Consensus statementon
concussion in sportthe 3rd International Conference on con-cussion
in sport, held in Zurich, November 2008. J Clin
Neurosci.2009;16(6):7557636. Schutzman SA. Minor head trauma in
infants and children. In:Wiley JF, ed. UpToDate. 2011. Accessed at
http://www.uptodate.com/contents/minor-head-trauma-in-infants-and-children7.
Brenner DJ, Hall EJ. Computed tomographyan increasing sourceof
radiation exposure. N Engl J Med. 2007;357(22):227722848. Nigrovic
LE, Schunk JE, Foerster A, et al; Traumatic BrainInjury Group for
the Pediatric Emergency Care Applied ResearchNetwork. The effect of
observation on cranial computed tomog-raphy utilization for
children after blunt head trauma. Pediatrics.2011;127(6):106710739.
Evans RW. Concussion and mild traumatic brain injury. In:Wilterdink
JL, ed. UpToDate. 2011. Accessed at
http://www.uptodate.com/contents/concussion-and-mild-traumatic-brain-injury10.
Halstead ME, Walter KD, Council on Sports Medicine andFitness.
American Academy of Pediatrics. Clinical
reportsport-relatedconcussion in children and adolescents.
2010;126(3):597615
Suggested ReadingCommittee on Quality Improvement. The
management of minor
closed head injury in children. Committee onQuality
Improvement,American Academy of Pediatrics. Commission on Clinical
Policiesand Research, American Academy of Family Physicians.
Pediatrics.1999;104:14071415
Halstead ME, Walter KD; Council on Sports Medicine andFitness.
American Academy of Pediatrics. Clinical reportsport-related
concussion in children and adolescents. Pedi-atrics.
2010;126(3):597615
Blackwell CD, Gorelick M, Holmes JF, Bandyopadhyay S,Kuppermann
N. Pediatric head trauma: changes in use ofcomputed tomography in
emergency departments in the UnitedStates over time. Ann Emerg Med.
2007;49(3):320324
Evans RW. Postconcussion syndrome. In: Wilterdink JL,
ed.UpToDate. 2011. Accessed at
http://www.uptodate.com/contents/postconcussion-syndrome
Frush DP, Donnelly LF, Rosen NS. Computed tomography
andradiation risks: what pediatric health care providers
shouldknow. Pediatrics. 2003;112(4):951957
Greenes DS. Neurotrauma. In: Fleisher GR, Ludwig S, eds.Textbook
of Pediatric Emergency Medicine. 6th ed. Philadelphia,PA:
Lippincott Williams & Wilkins; 2010:14221440
Greenes DS, Schutzman SA. Occult intracranial injury in
infants.Ann Emerg Med. 1998;32(6):680686
Schutzman SA, Barnes P, Duhaime AC, et al. Evaluation
andmanagement of children younger than two years old withapparently
minor head trauma: proposed guidelines.
Pediatrics.2001;107(5):983993
PIR QuizThis quiz is available online at
http://www.pedsinreview.aappublications.org. NOTE: Since January
2012, learners cantake Pediatrics in Review quizzes and claim
credit online only. No paper answer form will be printed in the
journal.
New Minimum Performance Level RequirementsPer the 2010 revision
of the American Medical Association (AMA) Physicians Recognition
Award (PRA) and creditsystem, a minimum performance level must be
established on enduring material and journal-based CME activities
thatare certified for AMA PRA Category 1 CreditTM. In order to
successfully complete 2012 Pediatrics in Review articles forAMA PRA
Category 1 CreditTM, learners must demonstrate a minimum
performance level of 60% or higher on thisassessment, which
measures achievement of the educational purpose and/or objectives
of this activity.
Starting with the 2012 issues of Pediatrics in Review, AMA PRA
Category 1 CreditTM may be claimed only if 60% ormore of the
questions are answered correctly. If you score less than 60% on the
assessment, you will be givenadditional opportunities to answer
questions until an overall 60% or greater score is achieved.
1. A 5-year-old boy was in a motor vehicle collision as a
restrained back seat passenger. He has a large lacerationon his
right forehead. On arrival to the emergency department, he opens
his eyes with painful stimuli, but doesnot open his eyes when his
name is called. He is mumbling, but is not using words. He
withdraws to pain. Hisbrain injury is best described as a
A. mild traumatic brain injuryB. moderate concussionC. moderate
traumatic brain injuryD. severe concussionE. severe traumatic brain
injury
neurologic disorders head injury
410 Pediatrics in Review Vol.33 No.9 September 2012
at UNIV OF CHICAGO on May 24,
2013http://pedsinreview.aappublications.org/Downloaded from
-
2. A 15-month-old girl is seen for fussiness, crying, and poor
oral intake. On physical examination, she is fussy,but consolable.
Her vital signs are stable. She is well hydrated. She has
unilateral hemotympanum. The mostappropriate initial intervention
at this time is
A. computed tomography (CT) scan of the brainB. magnetic
resonance imaging of the brainC. prescription for antibioticsD.
skull radiographic filmsE. skeletal survey
3. You see a 6-month-old girl with history of vomiting who
presents with lethargy and irregular respirations.After intubating
and stabilizing her, you obtain CT imaging of the brain that shows
a parietal skullfracture and a crescent-shaped intracranial
hemorrhage underlying the fracture. This radiographic finding
ismost consistent with a
A. cerebral contusionB. diffuse axonal injuryC. epidural
hematomaD. subarachnoid hemorrhageE. subdural hemorrhage
4. A 15-year-old boy was the unrestrained passenger in a motor
vehicle collision. He was ejected from the vehicleand was found
unconscious 20 feet from the vehicle. A CT scan shows areas of
hemorrhage at the gray-whitejunction. His clinical presentation and
radiographic findings are most consistent with
A. cerebral contusionB. diffuse axonal injuryC. epidural
hematomaD. subarachnoid hemorrhageE. subdural hemorrhage
5. You are evaluating a 6-year-old boy who sustained a head
injury when he fell out of a tree. Clear fluid is notedto be
draining from his nose. His parents deny any recent respiratory
infection or history of nasal allergy. Youorder a CT scan. The most
likely abnormality to show up on the scan will be
A. basilar skull fractureB. cerebral contusionC. depressed skull
fractureD. epidural hemorrhageE. subdural hemorrhage
neurologic disorders head injury
Pediatrics in Review Vol.33 No.9 September 2012 411
at UNIV OF CHICAGO on May 24,
2013http://pedsinreview.aappublications.org/Downloaded from
-
DOI: 10.1542/pir.33-9-3982012;33;398Pediatrics in Review
Jeff E. Schunk and Sara A. SchutzmanPediatric Head Injury
ServicesUpdated Information &
http://pedsinreview.aappublications.org/content/33/9/398including
high resolution figures, can be found at:
References
http://pedsinreview.aappublications.org/content/33/9/398#BIBLat:
This article cites 13 articles, 6 of which you can access for
free
Subspecialty Collections
_subhttp://pedsinreview.aappublications.org/cgi/collection/neurologyNeurologybhttp://pedsinreview.aappublications.org/cgi/collection/trauma_suTraumay_medicine_subhttp://pedsinreview.aappublications.org/cgi/collection/emergencEmergency
Medicinefollowing collection(s): This article, along with others on
similar topics, appears in the
Permissions & Licensing
/site/misc/Permissions.xhtmltables) or in its entirety can be
found online at: Information about reproducing this article in
parts (figures,
Reprints/site/misc/reprints.xhtmlInformation about ordering
reprints can be found online:
at UNIV OF CHICAGO on May 24,
2013http://pedsinreview.aappublications.org/Downloaded from