Head trauma (peds)

Definition

• Normal mental status at the initial examination
• No abnormal findings on neuro exam
• No physical evidence of skull fx

Diagnosis

persistence of symptoms such as headache, confusion, and amnesia suggests concussion Worsening of symptoms suggests intracranial injury

A scalp hematoma in a child <2 years of age is associated with an increased risk of skull fracture and intracranial hemorrhage.

Clinical symptoms such as headache, vomiting, and behavior change do not discriminate well between children with and without intracranial hemorrhage. Post-traumatic headache, for example, may be a symptom of concussion or intracranial hemorrhage. Vomiting is relatively common and does not predict intracranial hemorrhage.12 Vomiting after MHI is typically transient (diminishing over a number of hours) and is more common in children >2 years of age.13 One small study, in fact, noted a decreased incidence of vomiting in children with more severe head injuries.13 Vomiting with MHI may also be more prevalent in those children with a history of migraine or a family history of migraine.14 Although studies of adult head injury identify vomiting as a risk factor for intracranial injury,15 it is multiple episodes of vomiting in children that represent a risk factor for intracranial injury

Work-Up

Do I need to obtain a head CT?

<2yr old

• No CT is necessary if ALL are found:

1. Normal mental status
2. No scalp hematoma except frontal
   1. LOC <5s
3. ^Non-severe mechanism
4. No palpable skull fracture
5. Normal behavior per parents

>2yr old

• No CT is necessary if ALL are found:

1. Normal mental status
2. No LOC
3. No vomiting
4. ^Non-severe mechanism

No signs of basilar skull fracture No severe headache

^Non-severe Mechanism:

1. Pedestrian or bicyclist w/o helmet struck by motorized vehicle
2. Fall >2 m or 5 ft (age >2 y) or >1 m or 3 ft (age <2 y)
3. Head struck by high-impact object

Treatment

• sedate & paralize prn (barbiturate coma can decr metabolism & ICP)

• pCO2 (target = 30-35)

• HOB @ 30 degrees,

• prevent jugular venous compression w/ c-collar

• Goal= maintain CPP (MAP-ICP), cpp of 40-65 is goal, better survival if 40-50

• Prevent hypotension

• Keep Hgb >

• Mannitol .25-1g/kg in boluses

• Dilantin

• Must operate on sig depressed skull fx

See Also

GCS (Peds)

Concussion

Skull Fracture

Abuse (Nonaccidental Trauma)

Head Trauma (Adult)

Source

Tintinalli

AAP Guidelines