(Photo contributor: Gregory N. Emmanuel, MD)
*The authors acknowledge the special contributions of Karen Santucci, Bonny J. Baron, Audrey J. Tan, Behrad Aynehchi, Baljeet Kaur Purewal, Christopher I. Doty, Chaiya Laoteppitaks, Cynthia L. Benson, Ee Tein Tay, and Michael Lucchesi to prior edition.
Pediatric head trauma occurs commonly, with most injuries being minor; however, seemingly low-risk presentations may have intracranial injuries, and thus it is important to maintain a high index of suspicion.
Emergency Department Treatment and Disposition
The initial diagnosis and treatment of a head-injured infant or child involves evaluation in a standardized and algorithmic manner performed by a multidisciplinary and interprofessional team of providers. Selected head injury outcomes can worsen when there are delays in the time to definitive care (eg, epidural hematomas). This necessitates a prompt approach to diagnosis and treatment of all head-injured patients. First, providers should assess the airway, breathing, and circulation during a primary trauma survey. During this evaluation, providers may need to implement interventions informed by their assessment (eg, providing oxygen, inserting endotracheal tubes, beginning fluid resuscitations, immobilizing the cervical spine, raising the head of the bed).
This is followed by a more comprehensive and detailed head-to-toe secondary survey. This survey involves a thorough neurologic assessment. Pertinent positive findings on this assessment such as neurologic deficits or pupillary defects provide objective evidence of intracranial injury. 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 a GCS score <9 as severe head injury. Modified versions of this scale for children and infants have been created, such as the AVPU (alert, verbal, painful, unresponsive). Concurrent with the primary and secondary survey, additional point-of-care diagnostic tests, such as laboratories (type and cross-match, coagulation profiles, CBC, complete metabolic panel, toxicology screening) and imaging studies (x-rays and US, especially focused assessment with sonography in trauma [FAST]), are obtained. The definitive test for severely head-injured patients is a noncontrast CT of the head. This test should be obtained in patients with penetrating injury, a high-risk mechanism of blunt 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 (<1 year of age). Any patients with intracranial injury should be promptly evaluated by a neurosurgeon to determine the need for medical or surgical interventions. Patients with foreign bodies should only be manipulated during operative removal by a neurosurgeon.
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 embedded within the occipital-parietal region of the skull. (Photo/legend contributors: Mark Silverberg, MD, and John Amodio, MD.)
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, and John Amodio, MD.)