Pediatric emergency medicine trisk 0824 0824

EVALUATION AND DECISION (SEE CHAPTER 113
NEUROTRAUMA )
The clinical spectrum of head injury in children varies from a small contusion of
the scalp with no neurologic sequelae to severe TBI that causes death. The
general approach is essentially the same as with any child who presents with
trauma, paying particular attention to potential CNS damage. Following the
ABCs (airway, breathing, and circulation) of resuscitation, the physician must
systematically evaluate and stabilize the child with head trauma. The goals of
management are to identify complications of the head trauma and to prevent
secondary brain injury. Because some complications of head trauma may not
manifest immediately, the assessment period includes the initial evaluation in the
ED and a more extended observation period, either in the hospital or as an
outpatient, as clinically indicated. Specific therapy will vary based on specific
diagnosis in each case and may include supportive care and possible
neurosurgical intervention. Although complications are more common in children
with severe head injury, they also occur in children with apparently minor head
trauma; thus, all patients merit some degree of scrutiny.
The immediate management of the child varies with the degree of compromise.
A brief initial assessment is performed to determine immediate stability. In the
older child, verbal response to a question often establishes the adequacy of the
airway, ventilation, and cognitive function. If the child is unconscious or has
unstable vital signs, immediate resuscitation is initiated to ensure a patent airway
(with cervical spine immobilization), effective ventilation, and adequate tissue
perfusion (see Chapter 9 Cardiopulmonary Resuscitation ); efforts to decrease
possible increased ICP may be indicated, depending on the degree of neurologic
compromise (see Chapter 97 Neurologic Emergencies ). The child with airway
and hemodynamic stability and with only mild to moderate depression of mental
status can undergo a more timely evaluation to identify subtle or occult
abnormalities.

CLINICAL ASSESSMENT

History
The history should be obtained from the patient (if age and level of consciousness
permit) and from any witnesses to determine the nature and severity of the impact
and the prehospital course. Specifics of the traumatic event should include how,
when, and where the trauma occurred, as well as details such as height of a fall,