Pediatric head trauma

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This page is for the general approach to pediatric head trauma; see head trauma (main) for adult patients.

Background

  • TBI in the pediatric population is rare, occuring in 0.9% of the 42,412 PECARN population
  • PECARN rules have become standard of care
    • In patients <2 yrs the aid is 100% sensitive with NPV of 100%
    • In patient >2 yrs the aid is 96.8% sensitive with NPV of 99.95% (with validation studies showing sensitivity of 100% for TBI and injury requiring neurosurgery

Clinical Features

Differential Diagnosis

Head trauma

Evaluation

Pediatric GCS[1][2]

Eye Opening Verbal Motor
6: Normal spontaneous movement
5: Smiles, coos, babbles 5: Withdraws to touch
4: Opens eyes spontaneously 4: Irritable, crying (but consolable) 4: Withdraws to pain
3: Opens eyes to speech only 3:Inconsolable crying or crying only in response to pain 3: Abnormal flexion to pain (Decorticate response)
2: Opens eyes to pain only 2: Moans in response to pain 2: Abnormal extension to pain (Decerebrate response)
1: Does not open eyes 1: No response 1: No response

Note:

  • For Motor score 4, pain is defined flat, fingernail pressure (often performed with the barrel of a pencil).
  • For Motor scores 2 and 3, pain is defined by pressing hard on the supraorbital notch. If this unsuccessful, sternal pressure may also be attempted.

Adult GCS

Eye Opening Verbal Motor
6: Obeys commands
5: Oriented 5: Localizes to pain
4: Spontaneously opens 4: Confused speech 4: Withdraws from pain (normal flexion)
3: Opens to command 3:Inappropriate words 3: Decorticate posturing (abnormal flexion)
2: Opens to pain 2: Incomprehensible sounds 2: Decerebrate posturing (extension)
1: Does not open 1: No response 1: No response
  • 14-15: Mild
  • 9-13: Moderate
  • 3-8: Severe

Work-Up

Rules below are with the application of PECARN [3]

Management

<2 years old

PECARN Under Age 2

Any 1 of the following?

Then obtain a Non-Con Brain CT (4.4% risk of cTBI)

1 or more of the following?

  • Non-frontal scalp hematoma
  • LOC ≥ 5 seconds
  • Severe injury mechanism
    • pedestrian or bicyclist without helmet struck by motorized vehicle
    • fall >1m or 3ft
    • head struck by high-impact object
  • Abnormal activity per parents

Then consider a Non-Con Brain CT or Observation (0.9% risk of cTBI)

≥2 years old - 18 years

PECARN Age 2 and Up

Any 1 of the following?

Then obtain a Non-Con Brain CT (4.3% risk of cTBI)

1 or more of the following?

  • History of vomiting^
  • LOC
  • Severe injury mechanism
    • Pedestrian or bicyclist without helmet struck by motorized vehicle
    • Fall >2m or 5ft
    • Head struck by high-impact object
  • Severe headache

Then consider a Non-Con Brain CT or Observation (0.9% risk of cTBI)

^Consider observation in place of imaging in children with isolated vomiting (no other indication) as the sole risk factor (0.2% risk of cTBI)[4]

Disposition

  • Discharge if:
    • Asymptomatic after 2-4hr obs (not vomiting, nl neuro exam, nl mental status)
    • Head CT normal (delayed deterioration after normal CT is near zero)
  • Consider discharge if:
    • Nondisplaced fracture with out intracranial injury (in consultation with neurosx)

See Also

General/Adult

Pediatric

External Links

References

  1. Holmes JF, Palchak MJ, MacFarlane T, et al. Performance of the pediatric glasgow coma scale in children with blunt head trauma. Acad Emerg Med. 2005 Sep;12(9):814-9.
  2. James HE. Neurologic evaluation and support in the child with an acute brain insult. Pediatr Ann. 1986 Jan;15(1):16-22.
  3. PECARN Rule Kupperman N, Holmes JF, Dayan PS, 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
  4. Dayan PS, et al. "Association of Traumatic Brain Injuries with Vomiting in Children with Blunt Head Trauma. June 2014. Annals of EM. 63(6):657-665