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Adapted with permission from Kuppermann 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 2009;374(9696):1160–1170.

Diagnostic Imaging. Plain skull radiography has a limited role in
evaluating blunt head injury as it cannot provide details regarding
intracranial injury. Because computed tomography (CT) is noninvasive and
widely available, it is used for screening and diagnosis of intracranial
injuries. Current generation 16-detector scanners are capable of rendering
very high resolution images along with high speed data acquisition. CT
findings detect mass lesions that may be surgical, early signs of cerebral
edema including compression of the ventricular system and/or
perimesencephalic cisterns, midline shift, or loss of gray to white matter
interface. CT is preferred for detection of fractures and subarachnoid
hemorrhage.
Magnetic resonance imaging (MRI) is more sensitive than CT as it
provides greater anatomical detail of the brain and ventricles, but it can be
less readily available and requires longer periods of time to obtain imaging.
As an alternative, “fast” MRI techniques are being used to assess TBI. This
option is not the current standard protocol in many facilities. MRI utilizing
T1, T2, and fluid-attenuated inversion recovery (FLAIR) images is more
sensitive allowing delineation of the nature and timing of hemorrhage.
Additionally, diffusion-weighted imaging (DWI) outlines hypoxic–ischemic
or DAI.
Management. As with any trauma evaluation, the initial assessment should
focus on Airway, Breathing, Circulation, Disability, and Exposure per
trauma guidelines. Management principles focus on airway management
while maintaining cervical spine immobilization to provide adequate
oxygenation and ventilation to prevent hypoxia and hypercarbia.
Intravascular volume should be maintained to provide adequate cerebral
perfusion pressure, thereby, preventing secondary brain injury. Certain

adjuncts should be used in management of patients with suspected head
injuries. Immobilization of the cervical spine should be maintained until the
determination that there is not a concomitant cervical spine injury. (Spinal
Cord Injury is covered in Chapter 112 Neck Trauma .) This is accomplished
with using the chin lift maneuver thus avoiding jaw thrust, application of