Pediatric emergency medicine trisk 208

should also be evaluated. Obviously, a complete physical examination with
attention to possible thoracic, abdominal, pelvic, and extremity injuries should be
performed.

Radiographic Investigation
Complications of head trauma may be identified with radiographic studies. CT
scan of the head quickly provides excellent images of the intracranial contents
and is the diagnostic modality of choice when acute intracranial pathology is
suspected. CT imaging, however, has some disadvantages, including exposure to
ionizing radiation and the possible requirement for pharmacologic sedation,
especially in younger patients. Ideally, CT imaging should be used selectively for
patients at higher risk for TBI, limiting potentially unnecessary studies for those
who are at low risk. Patients at intermediate risk can undergo CT versus
observation based on the clinical scenario, provider experience, and parental
preference.
Although MRI is an additional imaging modality for the cranial contents (and
has no associated ionizing radiation), limited availability, prolonged study time,
and frequent need for patient sedation limit its utility for evaluation of acute
trauma at this time though emerging MRI modalities may be increasingly
employed for the diagnosis and management of mild TBI. Skull radiographs (SR)
are of very limited utility as they give no direct information about TBI. However,
they are useful for demonstrating skull fractures and have the advantages of
delivering lower doses of ionizing radiation, being more universally available,
less costly, and not requiring sedation. Any child for whom there is significant
concern for TBI should undergo CT imaging; however, there may still be a very
small role for SRs in certain select circumstances when immediate CT is not
warranted, yet significant chance of fracture exists to justify the test. Examples
would include SRs as part of a skeletal survey, to evaluate for the presence of a
radiopaque foreign body, and in rare instances to screen for fracture in selected
asymptomatic patients 3 to 12 months of age with concerning scalp hematoma or
question of depression. Those with fractures identified on SR would need to have

CT scans performed because they are at increased risk for associated TBI. In
general, SRs should be performed only if they will be reviewed by a radiologist
trained in their interpretation as they can be very challenging to interpret in young
children, and the utility of the study depends on an accurate reading.
All children with significant head trauma should be evaluated for associated
cervical spine injuries. This evaluation will be clinical, with or without
radiographic studies, based on the specific circumstances (see Chapter 112 Neck
Trauma ).


Approach
The goals of management are to define specific anatomic lesions (e.g., skull
fracture and TBI) and to prevent secondary brain injury, while limiting
unnecessary cranial irradiation. Pediatricians and emergency physicians will be
the initial clinicians to evaluate and manage most children with head trauma.
Neurosurgical consultation should be considered for all children with penetrating
trauma, abnormal mental status or neurologic examination, skull fractures, and
intracranial complications. The urgency of neurosurgical involvement varies with
the acuity of the patient’s clinical condition.
One approach to diagnosing complications of head trauma involves
determining whether a penetrating injury has occurred. If so, brain or vascular
injury is likely and emergent CT scanning and neurosurgical consultation are
mandated in addition to stabilization.
If the head injury has resulted from blunt trauma, it must be determined
whether a TBI is likely ( Fig. 41.1 ). Since preverbal children may have
differences in the presenting signs/symptoms of TBI compared to older children,
the approach in evaluating for TBI should take age into account.
In children <2 years of age, high-risk historical features and physical findings
include altered mental status, focal neurologic abnormality, signs of a skull
fracture, a bulging fontanel, history of seizure, or concern for abuse. Children

with any of these high-risk findings should be referred for emergent imaging.
Special attention should be paid to infants <3 months of age who may present
with a paucity of symptoms in the setting of TBI. Other historical or examination
findings in children <2 years of age that suggest an increased risk of TBI include
LOC ≥5 seconds, severe or unclear injury mechanism, caregiver concern, or
persistent vomiting. Nonfrontal hematomas of greater concern include those that
are temporoparietal, larger, and/or those that are present in younger children.
While any of these factors may increase the risk of TBI, observation (versus
emergent imaging) may be considered for children with only one finding (or two
mild findings), based on the clinical scenario, provider experience, and parental
preference. However, if emergent imaging is deferred, children should be
observed in the ED for at least 4 to 6 hours after the injury for signs and
symptoms of complications. These would include neurologic abnormalities,
mental status depression, persistent vomiting, lethargy, or irritability. A CT scan
should be obtained if these signs or symptoms develop. Abnormalities on CT
might include intracranial hemorrhage or contusion, diffuse cerebral swelling, or
skull fracture; if the CT scan is normal, then concussion or extracranial injury has
likely occurred.


In children ≥2 years, high-risk clinical features include altered mental status,
focal neurologic deficits, signs of a skull fracture, or seizures. Children with any
of these features should be referred for emergent imaging. Additional findings
concerning for increased risk of ICI include LOC, persistent vomiting,
persistent/progressive or severe headache, or severe mechanism of injury. In
children with one of these features (or two mild features), observation (versus
emergent imaging) may be considered based on the clinical scenario, provider
experience, and parental preference. If observation is initiated, the child should be
observed for 4 to 6 hours for any signs of clinical deterioration, which would
include neurologic abnormalities, mental status depression, persistent vomiting,

or increasingly severe headache. A CT scan should be obtained if these signs or
symptoms develop. As previously stated, discrete abnormalities may be identified
on CT scan, but if the scan is normal, then the child has suffered a concussion or
extracranial injury. It is important to note that symptomatic children without
evidence of TBI on CT scan may still suffer from persistent and/or debilitating
symptoms that require admission or close outpatient follow-up.


FIGURE 41.1 Approach to the child with head trauma. CT, computed tomography; LOC, loss
of consciousness; GCS, Glasgow Coma Scale.