No universally agreed upon criteria for minor head injury exists. In addition to GCS, the AAP’s definition for minor head injury: “those who have normal mental status at the initial examination who have no abnormal or focal findings on neurologic exam and who has no physical evidence of skull fracture.”
History incompatible with children’s age or situation. For instance, 1 month-old rolled off the changing table. 6 month old crawled out of the crib. This can be NAT or neglect.
ABCDEsMake sure that the c-collar is properly fittingHead to toe assessment for trauma. Particularly in the fundoscopic exam. Look for retinal hemorrhages. This can be a clue for non-accidental trauma. Scalp hematomas in < 2 years of age is a/w increased risk of skull fx and intracranial hemorrhage. Basilar skull fracture signs- Periorbitalecchymoses, bruising behind the ears (“Battle sign”), hemotympanum, and CSF drainage from nose.
For Raccoon Eyes, this can be difficult to differentiate from some bruising of the eyes. In a complex trauma case, this can be difficult to find out, but typically, raccoon eyes do not involve the eyelids. It’s more of a pooling of a blood from a broken skull, so the eyelids are not involved as they do not communicate with the skull. CSF can be differential from blood from the nose by the “halo” or “double ring” sign. If you place a drop of nasal fluid onto filter paper, the CSF fluid is at a different density from the blood, so the CSF should travel at a different rate through the filter paper. I could not find much data on the utility of this sign, but some neurosurgery textbooks mention that this sign is unreliable. However, this is one sign that you can have in your back pocket.
One small study found a decreased incidence of vomiting in children with more severe head injuries. Also vomiting is more common in children with a history of migraine. Additionally, preverbal children cannot describe their symptoms. Behavior change by caregivers can be helpful, but again this is very common in children for any head injury.
Asymptomatic patients have less than 0.02% of ciTBI < 2 year old and 0.05% in >= 2 year old. Exact observation time is unclear. Studies have ranged from 2.5 hours to 6 hours as being safe. 4-6 hours appears to be a common number used in textbooksLess than 2 with just mechanism has 0.3% ciTBI. At least 2 years of age has 0.6% if just mechanism. 1 study showed that 0.05 and 0.6% of discharged patients and admitted patients had positive findings upon repeat head CT in those who were clinically high risk but head normal head CT, normal LOC. None required NSS intervention.
Etomidate has rapid onset of action (45 sec) and short duration of action (3-5 minutes) and favorable hemodynamic profile. May have adrenal suppresion but one time dose, may not have clinical significance. May also reduce ICP. Propofol is rapid onset and has anticonvulsant properties. However, have to becareful of hypotension. Short acting agents. Long acting impeded reliable neuro exam, limit ability to see seizure, and may increase risk of PNA. Succ may increase ICP in patients with brain tumors, but evidence is not definitive in humans with brain injury. Also keep in mind possible undiagnosed NM conditions in children.
Pediatric head injury public
Daniel Kwan, MD
Present a case of pediatric head injury.
Examine the uniqueness of pediatric head injuries.
Discuss the clinical presentations and decision rules
for minor head injury
Review the pathophysiology and treatment of
moderate/severe head injury.
Review abusive head injury and other pertinent
pediatric head injury types.
CC: Stat Trauma
HPI: 11 yo boy with no PMH who presents after MVC
rollover. Pt was unrestrained passenger and was
ejected. EMS found pt to be GCS 4. Pt intubated at
outside hospital. Pt decompensated prior going to the
CT scanner. Pt also had emergent left chest
thoracostomy placed. Transferred to CRMC.
Family hx: non-contributory
Social history: lives with mother and father
VS: 98/52, 99, 12, 35.5, 100% (ETT)
Neuro: GCS 4T (decerebrate posturing)
Head: Open comminuted bifrontal skull fractures.
Multiple contusions. 4 cm frontal laceration.
Pupils: Fixed and non-reactive (4 mm bilaterally)
Neck: Contusions/ecchymosis to right anterior neck.
Carotid pulses 2+
Chest: chest contusions. L chest tube
Heart: RRR, no m/g/r
Abd: soft, distended
Pelvis: stable, atraumatic
GU: Normal genitalia
Rectal: normal tone
BUE: Contusions, swelling. Decerebrate posturing
RLE: Contusions, abrasions
LLE: Midshaft left femur deformity
Back: No signs of blunt or penetrating trauma.
L residual PTX
Chest tube in place
midline shift of 7
IPH and DAI
Pelvis XR- no fracture
L femur XR- midshaft femur fracture
CT C spine- no fracture
FAST- possible minimal fluid on bladder view
650,000 to 1 million children evaluated for head trauma per year
80-90% are mild
In developed countries, TBI is the most common cause of death and
disability in childhood.
Toddlers: Abuse and falls
School-aged: Injuries (play and sports) and MVCs
MVCs and assault
ETOH can complicate assessments of injuries.
Across all age groups, males > females in minor head injuries.
Moving object hits stationary head
Moving head strikes stationary object.
Most severe brainstem injuries
Head hit at an angle
Widespread injury including large SDH
Direct blow fracture
EDH from either middle meningeal artery or dural venous sinuses
Younger children have more distensible skulls
Less protection in infants/toddlers
Infant cranial sutures are open
Toddler cranial cortex is thin.
Very young children have higher mortality than older
children with the same injury.
Limited history and exam at young age
Underestimation of injuries
Reluctance to start invasive procedures
Increased probability of injury in infants/toddlers
Large calvaria and weak cervical muscles
Coordination and balance is poor
Dependent on caregivers
For supervision and safety equipment
Stronger frontal bone
Frontal sinus develops after 8-10 years old.
Types of TBI
Less traumatic mass lesions (except SDH)
Less hemorrhagic contusion
More diffuse brain swelling and axonal injury
Degrees of Head Injury
Minor: GCS 13-15
Moderate: GCS 9-13
Severe: GCS <= 8
Minor Head Injury
85% of pediatric head injuries are classified as mild.
About 400,000 ED visits per year particularly children
ages 0 to 4.
Mechanism from caregivers, witnesses, EMS
History incompatible with children’s age or situation.
Clinical decision rules- PECARN
Temporal changes or persistence of symptoms.
Worsening sx- intracranial injury
Persistence of HA, confusion, amnesia concussion
Ask child directly if verbal. Ask caregiver if preverbal
Suspicion of child abuse
Altered mental status
Seizure following injury
Loss of consciousness (> 5 seconds)
Vomiting that is self-limited
LOC that is brief (< 5 seconds)
Resolved lethargy or irritability
Behavior change by caregiver
High risk mechanism (fall > 3 feet, ejection, etc.)
Unwitnessed trauma of concern (e.g.: fall in another room with possible LOC)
Age < 3 months with nontrivial trauma
Proper fitting C-Collar
Head to toe assessment for trauma.
Fundoscopic: particularly retinal hemorrhages
Suspicion of child abuse
Focal neurologic findings
Acute skull fracture, including depressed or basilar skull fracture
Scalp hematoma (particularly nonfrontal and < 2 years old)
Skull fracture > 24 hours old (non-acute)
To CT or Not to CT
Benefits of CT
Early identification can reduce morbidity/mortality.
Children have atypical or vague symptoms
(vomiting, behavior change).
Head CT can be expensive (Avg charge ~$996)
1 head CT 1/1500 lifetime risk of death 2/2 cancer in 1 year old
1/5000 lifetime risk in 10 year old
Test threshold- no imaging was when probability of ciTBI
was less than 0.9%.1
1. Hennelly, KE., et al. Pediatric Traumatic Brain Injury and Radiation Risks: A Clinical
Decision Analysis. The Journal of Pediatrics. 2012;162:392-397.
Expert Panel Recommendations
In 1999, a study of 608 infants and children < 2 years of
5% incidence of ICH
Higher incidence in infants < 2 months old
½ of pts with ICH had clinical symptoms or signs
suggestive of brain injury.
Virtually all had scalp hematoma.
Skull fx and ICH correlated with hematoma size (med to
large), character (boggy), and location (non-frontal)
2. Schutzman SA, et al. Evaluation and management of children younger than two years old with apparently
minor head trauma: Proposed guidelines. Pediatrics 107: 983, 2001
Expert Panel Recommendations
High Risk Intermediate
Risk for ICH
Risk for Skull
Vomiting 3-4 times Significant
Low risk mech
Focal Neuro Finding LOC < 1 min Large nonfrontal
Acute (<24h) Skull
Resolved lethargy or
Fall onto hard
>2h since injury
Basilar or depressed
Caretaker concern Vague hx but signs or
sx of head trauma
Older age (>12 Mo)
Irritability Skull fx > 24h old
Vomiting > 5x in 6h
LOC > 1 min
Recommendation Recommendation Recommendation Recommendation
CT Scan Obs 4-6 h or CT scan Obs 4-6h or CT or
Assisting clinical decision making about
neuroimaging in children with minor head trauma.
3 of the largest derived rules
Canadian Assessment of Tomography for Childhood
Head injury rule (CATCH)
Children's Head Injury Algorithm for the Prediction of
Important Clinical Events (CHALICE)
Pediatric Emergency Care Applied Research Network
Only PECARN has been derived and validated.
Purpose: Identify high risk criteria 3
4000 children including GCS 13
4 high risk factors and 3 medium risk factors
Sensitivity 98% for intermediate factors, 100% for high
Requires 52% of pts undergo CT
Not prospectively validated
3. Osmond MH, et al. CATCH: a clinical decision rule for the use of computed tomography in children
with minor head injury. CMAJ 2010; 182:341.
CATCHCT is required only for children with minor head injury* and any of one of
the following findgings:
High risk (need for neurologic intervention)
1. GCS < 15 at 2 hours after injury
2. Suspected open or depressed skull fracture
3. History of worsening Headache
4. Irritability on examination
Medium risk (brain injury on CT scan)
5. Any sign of basal skull fracture
6. Large, boggy hematoma of the scalp
7. Dangerous mechanism of injury (e.g.: MVC, fall from elevation > 3 ft or 5 stairs,
fall from bicycle with no helmet)
*Injury 24 hours associated with witnessed LOC, definite amnesia, witnessed
disorientation, persistent vomiting (> 1 episode) or persistent irritability (in
children < 2 years of age) in a pt with GCS 13-15
Purpose: Identify high risk criteria 4
22,772 children with head injuries
10 hospitals in England
281 ICH detected on CT scan
14 high risk variables
Sensitivity 98.6% and Specificity 87% for ICH
For pts with GCS 13-15, sensitivity 97.6%
In a retrospective study, rate of head CT increased from 6.5 to 10%
with very few additional skull fx found.
In another retrospective observation study, head CT rate increased
from 19 to 46% and missed six with intracranial injury.
4. Dunning J, et al. Derivation of the children’s head injury algorithm for the prediction of important clinical
events decision rule for head injury in children. Arch Dis Child 91: 885, 2006.
History Mechanism Physical Examination
Witnessed LOC > 5 min MVC > 40km/h or 25
GCS < 15 for < 1 year of
Amnesia > 5 min Fall > 3 m or 10 ft GCS <14 for >1 year of age
3 or more episodes of
High-velocity projectile Depressed or basilar skull
Traumatic Seizure Penetrating injury
Suspicion of NAT Tense fontanelle
Drowsiness Focal Neuro Deficit
laceration > 5 cm if < 1
year of age
Derived and validated prediction rule to decide when to forgo
head CT. 5
Multicenter study- 25 EDs
Among enrolled children (GCS 14-15, < 18 years old)
< 2 years of age: 8502 in derivation, 2216 validation
>=2 years of age: 25,283 in derivation, 641 in validation.
Death from TBI
Intubation >24 hrs duration
Hospital admission >= 2 nights
CTs obtained in 37% (derivation) and 35% (validation) of pts
Follow: Caregivers called at day 7 and 90
5. Kupperman, N, et al. Identification of children at very low risk of clinically-important brain
injuries after head trauma: a prospective cohort study. Lancet 374 (9696): 1160, 2009.
Age Group Low-risk Criteria Sensitivity NPV
<2 years Normal Mental
100% (86-100%) 100% (99.7-100%)
No scalp hematoma
LOC < 5 sec
No palpable skull fx
>=2 years Normal mental
96.8% (89-100%) 99.95% (99.8-
No signs of basilar
No severe headache
Prevalence of ciTBI was
approximately 1% in both
derivation and validation
Defined further risk
Otherwise, may increase CT
Intermediate risk: 0.9%
(About 30% of all patients)
High risk: >4%
Modified form of PECARN was externally validated 6
High clinician satisfaction (96%)
High adherence to rule (94%)
Identified all 3 children with ciTBI at first visit
Non-statistically significant increase of Head CT (7 to 8%)
Gives physicians room for clinical judgment
A tool for physicians to risk stratify
Very low rate of clinical significant head injury
Lower bounds of 95% confidence intervals are low than other
adult head CT rules.
6. Bressan, S., et al. Implementation of Adapted PECARN Decision Rule for Children with Minor Head Injury in
the Pediatric Emergency Department. Academic Emergency Medicine. 19 (7); 801-807, 2012.
If greater than 2-4 hrs postinjury, can d/c home.
Can discharge if no suspicion of NAT, easily aroused with normal neuro exam, return
to baseline level of function, tolerating PO fluids, no extracranial injuries, reliable
Return precautions: lethargy, irritability, focal deficits, vomiting in 24 hours.
Unclear exact time but 4-6 hours is common
> 1 risk factors or any in < 3 months
High risk- Head CT and/or Neurosurgery
Normal Head CT: Clinical judgment for obs vs admission
Non-displaced Fracture (no ICH): NSS follow up
ICH: NSS and admission
Moderate/Severe Brain Injury
Moderate TBI: 10% of all head injuries
Mortality < 20%
Long term disability as high as 50%
Mortality: ~40% (mostly in first 48 hours)
Moderate recovery: < 10%
75% of children with multiple trauma have TBI
~80% of all trauma deaths a/w severe brain injury
TBI accounts for 95% of severe and fatal injuries.
Children < 4 yrs old: fall accounted for 41%
Adolescents: 43% from MVC
<1 year old in ICU: 52% Assaulted
Brain sensitive to ischemia and hypoxia
Consumes 20% of total body oxygen and 15% of cardiac
Changes in blood volume, pH, PO2, PCO2regulates
blood flow (O2 delivery and metabolism)
Vasoconstriction occurs with
hypertension, hypocarbia, and alkalosis.
Cerebral perfusion pressure
Surrogate indicator for cerebral blood flow
CPP = MAP - ICP
Skull is a closed space with three intracranial
Brain parenchyma, CSF, intravascular blood
When one increases, the others will decrease to
maintain ICP (Monro-Kellie Hypothesis)
Adult/Older children: < 10- 15 mm Hg
Children: 3-7 mm Hg
Infants: 1.5- 6 mm Hg
CPP normally > 60 mm Hg
Contusions, hematomas, DAI, direct cellular damage,
tearing/shearing of tissues, loss of blood-brain barrier
Downstream effects from primary injury
Excessive glutamate released into presynaptic space activation of
Flood of Ca2+ intracellularly
Disrupts Na and K and normal function of cells.
Mitochondria uptakes excess Ca Free radicals and more cellular
Leads to necrosis inflammation apoptosis/membrane integrity
cytotoxic edema and extracellular edema increase in ICP
compression and herniation.
Assessment Neurological assessment
Pupillary exam for size, reactivity, symmetry
Brainstem reflexes (corneal and gag reflexes)
Response to pain
Signs of herniation
CN III nerve palsy
Changes in resp pattern, pupil size,
vestibuloocular reflexes, posture.
Prevent secondary insult
Identify Treatable Mass Lesions
Identify Other Life-Threatening Injuries
Secondary Insult- hypoxemia, hypotension, anemia, hyperglycemia,
hyperthermia, intracranial mass
Single episode of hypotension or hypoxia a/w 150% increase in
Intubation (GCS < 8 or deteriorating)
Cuffed tubes to prevent aspiration
No nasotracheal intubation with midface trauma or basilar skull fractures
Preinduction agents do not improve outcome.
Induction: limited effect on ICP or MAP
Etomidate, 0.3 mg/kg IV
Propofol 1-3 mg/kg IV
Ketamine 1.5-2.0 mg/kg IV 7
Succinylcholine 1-1.5 mg/kg IV
Rocuronium 0.6-1 mg/kg IV
7. Filanovsky, Y., et al. Myth: Ketamine should not be used as an induction agent for intubation in
patients with head injury. CJEM. 12 (2):154-7. 2010.
In severe TBI, 1 hypotensive episode doubles mortality.
Aggressive fluid resuscitation (isotonic solution)
Maintain MAP > 80 mm Hg
Relative Hypotension- Normal BP but not sufficient perfusion
SBP < 100 mm Hg rarely associated with MAP > 80 mm Hg.
Fix sources of bleeding on the external head
Vasopressors to keep MAP at 80 mm Hg.
Hypertension could be a sign of cushing’s reflex.
Head positioning 30 degrees
Associated with poor outcomes
In 1 study, for children < 14 years old going for emergent
craniotomy for TBI
Perioperative hyperglycemia (glc > 200 mg/dL) found in 45%
A/w <4 years, GCS <=8, multiple traumatic lesions
Hyperthermia- prevent and treat aggressively
ICP > 20 mm Hg increases morbidity and mortality.
headache, nausea, vomiting, seizure, lethargy, Cushing’s
triad, agonal respirations
Unilateral or bilateral pupillary
dilatation, hemiparesis, motor posturing, and/or
progressive neurological deterioration.
lowers ICP; improves CBF, CPP and brain metabolism
Free radical scavenger
Expands plasma volume
Diuretic so maintain euvolemia
Bolus or infusion
Reduces intracranial pressure.
Adverse effects: rebound intracranial hypertension, central pontine
Not recommended as prophylactic intervention
Reduces ICP and causes vasoconstriction. Decreased CBF and hypocapnia a/w
Keep PaCO2 at 35-40mm Hg and O2 sat > 95%
If pending herniation, PCO2 30-35 mm Hg
Not initiated in the ED
Treats refractory intracranial hypertension in ICU.
ICP monitoring recommended
SZs raise ICP
Prophylactic anticonvulsants reduced post-traumatic seizures
within first week, but do not improve long-term outcome.
Prophylaxis is controversial, but experts suggest
anticonvulsant therapy for 1 week after seizure.
Steroids- no role in TBI or increased ICP
Burr hole- emergent treatment for epidural hematoma
Abusive Head Trauma
In US, abusive head trauma (AHT) incidence in <2 years
old is 17 per 100,000 person-years
Previous abuse noted in up to 60% of cases.
Missed AHT in 31% of children
Most often: Viral GE, influenza, accidental head trauma, “rule
Infant: perinatal illness, birth defects, incessant crying, male
Family: Familial dysfunction (i.e.: drugs/ETOH), young
maternal age, family disruption/separation, history of abuse
in child or family members
Retinal hemorrhages- 60-85% of abusive head injury
Facial cutaneous bruising- linear strap marks, buttocks
bruising, 54% do not have bruising.
C-spine injury- 4% of abusive head injury
Rule out coagulopathy- CBC, Coags
Rule out other organ injury- Electrolytes, LFT, UA
Rule out meningitis- CSF RBC/Xanothochromia (83% of
abusive head injury)
Skeletal Survey X-ray
MRI- follow up CT or asymptomatic but non-cranial injuries
Blood accumulation between dura mater
and the arachnoid mater
Sudden acceleration-deceleration of brain
parenchyma tearing bridging veins
Blood collects more slowly because venous.
Chronic (> 2 weeks)
A/w other brain and parenchymal injuries
High risk populations: Elderly and alcoholics (atrophic brains) and children < 2
years old (NAT)
Acute: Severe trauma + LOC (possible lucid period)
Chronic: progressive AMS and behavior change
SDH + long bone/posterior rib fx NAT
Strong correlation with NAT (50% of reviewed SDH cases a/w NAT)
Can be a/w perinatal birth trauma (cranial sutures tearing dural veins)
Crescent shaped lesions that cross suture lines
Subacute SDH are isodense and harder to identify
Head CT IV contrast
Chronic: hypodense (dark)
Treatment: NSS Obs vs surgery
Diffuse Axonal Injury
Disruption of axonal fibers in the white matter
and brainstem by sudden deceleration.
Mechanism: Blunt trauma and shaken baby
Edema can develop quickly.
Classically: punctuate hemorrhagic injury along
grey-white junction of cerebral cortex and deep
structures of brain
Can be normal
Prevent secondary injury by reducing edema and
limiting increases in ICP
Shaken Baby Syndrome
Life threatening injury in children < 2 years
Rapid acceleration and rotation of cranium
Impact on solid object angular rotation
Shearing injuries of intracranial
vessels, cervical spine injury, and intraocular
Increased drowsiness, lethargy, decreased
40% had no signs of external injury on initial
Taken to the OR for evacuation of L sided EDH with bone flap removed.
L femur fracture treated ORIF
Developed VAP with Acinetobacter and Enterobacter.
Transferred to Children’s 3 weeks later.
Taken back to the OR with plastics and NSS for scalp wound debridement and tissue rearrangement.
Developed neutropenia 2/2 bactrim and seroquel.
Extubated but had persistent fevers and had a tracheostomy placed 2/2 to respiratory distress.
Plastics took pt to OR for completing skin graft over scalp.
Pt transferred to floor and eventually weaned off ventilator for 2 weeks.
Kirsch, TD, et al. Head Trauma in Adults and Children. In: Tintinalli, JE, ed.
Tintinalli’s Emergency Medicine- A Comprehensive Study Guide, 7th Edition.
China. The McGraw-Hill Companies, Inc. 2011. Chapter 254
Tintinalli, JE. Minor Head Injury in Infants and Children. In: Tintinalli, JE, ed.
Tintinalli’s Emergency Medicine- A Comprehensive Study Guide, 7th Edition.
China. The McGraw-Hill Compaines, Inc. 2011. Chapter 132.
Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine:
Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2014.
Bressan, S., et al. Implementation of Adapted PECARN Decision Rule for
Children With Minor Head Injury in the Pediatric Emergency Department.
Academic Emergency Medicine. 2012; 19:801-807.
Hennelly, KE., et al. Pediatric Traumatic Brain Injury and Radiation Risks: A
Clinical Decision Analysis. The Journal of Pediatrics. 2012;162:392-397.
Schonfeld, D., et al. Effect of Duration of Emergency Department Observation
on Computed Tomography Use in Children With Minor Blunt Head Trauma.
Annals of Emergency Medicine. 2013;62:597-603.