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Minor head injury in children is responsible for almost 400,000 ED visits each year,1 with children 0 to 4 years of age most commonly affected. Of all children with minor head injury coming to the ED, it is estimated that about 5% have intracranial injury,2 and <1% of those with intracranial injury require neurosurgical intervention.3,4

Given the rarity with which head-injured children require intervention, the diagnostic challenge is to distinguish the small subset of seriously injured children, while minimizing evaluation of those at low risk of significant intracranial injury. Therefore, careful risk stratification of children with minor head injury is important for safe and efficient medical care.

This chapter focuses on evaluation of children with minor head injury and concussion, as well as the treatment of children in whom significant intracranial injuries are identified.


The definition of minor head injury varies in the literature. The American Academy of Pediatrics defines children with minor head injury as "those who have normal mental status at the initial examination, who have no abnormal or focal findings on neurologic (including funduscopic) examination, and who have no physical evidence of skull fracture."5 The Glasgow Coma Scale (GCS; Table 138-1), or its derivative for younger, preverbal infants and toddlers, is often used to determine the severity of head injury. Head injuries resulting in a GCS score of ≤8 are severe, those with scores of 9 to 13 are moderate, and those with scores of 14 or 15 are mild.

TABLE 138-1Glasgow Coma Scale Score for Adults and Infants


Head trauma is classified as blunt or penetrating based on the mechanism of injury. In children, the vast majority of head trauma is caused by blunt force with the underlying mechanism varying according to the age of the patient. In younger children, the most common causes of head trauma are falls and assaults/child abuse.6 In fact, in children under 2 years of age, nonaccidental trauma is the leading cause of death due to head trauma. In older children, falls, sports and recreation, assault, and, increasingly, motor vehicle collisions are more common. Penetrating injuries are most frequently ...

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