Closed Head Injury in Children

Aka: Closed Head Injury in Children, Pediatric Traumatic Brain Injury

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II. Epidemiology

  1. Head Injury is the leading cause of Traumatic death in children

III. History

  1. See Trauma History
  2. Establish mechanism of injury
    1. Obtain complete history by any available bystanders and family
    2. Consider Nonaccidental Trauma
    3. Consider Unknown Ingestion or Intoxication (esp. older children and teens)
    4. Head Injury in Sports is most common Head Injury in older children and teens

IV. Symptoms

  1. Headache (most common)
  2. Loss of consciousness (10% of Concussions)
  3. Confusion, Disorientation or Altered Mental Status
  4. Amnesia surrounding the injury
  5. Fussiness or Somnolence (preverbal children)

V. Exam

  1. See Closed Head Injury
  2. See Glasgow Coma Scale (GCS)
  3. See Neurologic Exam
  4. Red Flag Findings
    1. Focal neurologic deficits
      1. Evaluate gait
    2. Basilar Skull Fracture
      1. See Basilar Skull Fracture
      2. Clear Otorrhea or Rhinorrhea
      3. Hemotympanum
      4. Battle Sign (delayed by hours to 24 hours)
      5. Racoon Eyes (occurs soon after injury)
    3. Skull Fracture signs
      1. Boggy, non-frontal Hematoma >2 cm
      2. Localized skull depression or step-offs
      3. Crepitation on skull palpation
    4. Increased Intracranial Pressure
      1. Bulging Fontanel
      2. Papilledema
    5. Vascular injury findings
      1. Carotid Bruit
    6. Hypotension is seen in pediatric Closed Head Injury
      1. Contrast with adults with TBI who often present with Hypertension (Cushing's Response)
      2. Patrick (2002) Am J Surg 184:555-60 [PubMed]

VI. Imaging: Head

  1. See Pediatric Head Injury Algorithm (PECARN)
  2. See Head Injury CT Indications in Children
  3. General red flags
    1. Severe Headache
    2. Vision changes
    3. Confusion (or irritability if preverbal) or significant mood changes
    4. Multiple Vomiting episodes (esp. >4)
      1. Harper (2020) CJEM 22(6): 793-801 [PubMed]
    5. High mechanism injury
      1. Vehicle rollover
      2. Ejection from vehicle
      3. Death of another passenger from the same vehicle
      4. Fall from height >5 feet (1.5 meters)
      5. Struck in head by a high velocity or high impact object
      6. Unhelmeted Bicycle accident
  4. Age under 2 years (more challenging Assessment)
    1. Age under 3 months is most challenging assessment
      1. Decision rules including PECARN have lower Test Sensitivity in this population
    2. Red Flags suggestive of serious injury
      1. Skull Fracture
      2. Scalp swelling (80-100% of Skull Fracture)
      3. Younger the age, the greater the risk
      4. Non-accidental Trauma (Child Abuse)
      5. No clear history of Trauma
    3. Symptoms that do not predict serious Head Injury
      1. Loss of consciousness
      2. Vomiting
    4. References
      1. Dachs (2012) AAFP Board Review Express, San Jose

VII. Imaging: Neck

  1. See Cervical Spine Imaging in Acute Traumatic Injury
  2. See NEXUS Criteria
  3. Precautions
    1. MVAs are the most common cause of neck Trauma in Children
    2. Proportionally larger head predisposes to higher risk of Head Injury and Cervical Spine Injury
      1. Upper Cervical Spine is more susceptible to restraint related injury in children <8 years old
      2. Younger children are prone to spinal Ligamentous Injury (see SCIWORA below)
        1. Older children experience Vertebral Fractures
      3. Center of gravity lowers as children grow >8-10 years old
    3. Young children have more severe spine injuries associated with permanent deficits
      1. Mortality rates are higher in young children (30% in some series)
      2. Kokaska (2001) J Pediatr Surg 36(1): 100-5 [PubMed]
    4. Risk of SCIWORA (esp. young children)
      1. Occult spinous injury despite negative XRay or CT spine (spinal ligamentous laxity)
      2. Trauma is unlikely in an asymptomatic child with normal Neurologic Exam
        1. Imaging should not be based solely on mechanism
    5. Neck Bruising
      1. See Neck Vascular Injury in Blunt Force Trauma
      2. Increases risk of vascular injury
      3. Consider CT angiography of neck

VIII. Management: Mild Head Injury

  1. See Mild Head Injury (GCS 13 to 15 at two hours)
  2. See Concussion (mildest subset of Mild Traumatic Brain Injury)
  3. See Mild Head Injury Home Management
  4. See Return to Play after Concussion
  5. Admission Indications
    1. Unknown Ingestion or Intoxication
    2. Comorbid Traumatic injuries
    3. Bleeding Disorder
    4. Unable to tolerate oral intake despite Antiemetics (e.g. ODT Ondansetron)
    5. Severe, refractory pain to Analgesics
    6. Incoordination or Abnormal Gait
    7. Altered Vision
    8. Focal neurologic deficits
    9. Unreliable Caregiver (e.g. does not understand Discharge Instructions or precautions)
    10. Suspected Nonaccidental Trauma (e.g. Shaken Baby Syndrome)
  6. Emergency Department Observation (esp. if head imaging is NOT performed)
    1. Low risk children may continue observation at home
    2. Observation for 2 to 3 hours after Mild Head Injury (in ED and at home)
    3. Significant Head Injury is unlikely if child has not worsened by 6 hours
    4. Repeat Neurologic Exam (including gait, GCS and Vision) prior to discharge
  7. Discharge
    1. Referral indications (e.g. neurology, Concussion specialist)
      1. Concussion in Sports
      2. Multiple Concussions
      3. Persistent Migraine Headaches or other postconcussion symptoms
      4. Cognitive Deficit following Concussion
    2. Anticipatory Guidance
      1. See Postconcussion Syndrome
      2. Expect gradually improving Concussion symptoms over a 1 to 2 weeks period
      3. Prolonged post-Concussion symptoms may occur with repeat Head Injury or lack of cognitive rest
      4. Allow for gradual Return to School and activity (non-collision) as tolerated
      5. Limit Screen Time (electronic devices)
      6. Follow-up clinic in 1 to 2 weeks
      7. Symptomatic management
        1. Antiemetic (e.g. Ondansetron)
        2. Analgesics for Headache (e.g. Acetaminophen, Ibuprofen)
    3. Precautions
      1. See Mild Head Injury Discharge Instructions
      2. Return Indications
        1. Lethargy, Altered Level of Consciousness or difficult to arouse
          1. However, allow child to nap as needed
          2. Waking a child from normal sleep to reevaluate is NOT typically needed
        2. Headache that has worsened
          1. Expect post-ConcussionHeadache
        3. Vomiting that has increased
        4. Focal neurologic deficits (e.g. new Unilateral Weakness)

IX. Management: Moderate to Severe Head Injury

  1. Imaging in all patients (see above)
  2. See Management of Moderate Head Injury (GCS 9 to 12 at two hours)
  3. See Management of Severe Head Injury (GCS 3 to 8 at two hours)

X. Prevention

  1. Car Restraints significantly reduce the risk of injury and death, but must be used properly
    1. Car Seats should be used up to age 4 years old (rear facing until age 2 years)
    2. Booster Seats should be used from age 4-8 years old (until height >=57 inches)
      1. Premature use of the adult Shoulder-Lap belt risks neck extension and flexion injuries
      2. See Seat Belt Syndrome

XI. Resources

  1. Haydel (2022) Pediatric Head Trauma, StatPearls, Treasure Island, Florida
    1. https://www.ncbi.nlm.nih.gov/books/NBK537029/

XII. References

  1. Kosoko, Murphy and Spring (2023) Crit Dec Emerg Med 4-9
  2. Mannix (2020) Ann Emerg Med 75(6): 762-6 [PubMed]

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