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TBI is the leading cause of acquired disability in children. Neurologic
and cognitive deficits are related to patient age at time of injury, severity of
injury, and degree of structural injury. Unique considerations should be
given to children with shunt-dependent hydrocephalus and bleeding
diatheses or platelet disorders, such as hemophilia.
Clinical Considerations (See Also Chapter 41 Injury: Head )
Clinical Recognition. The historical and physical features of TBI
encompass a wide spectrum of signs and symptoms. For a detailed review
of signs and symptoms, please review Chapter 41 . The presentation of
infants may be nonspecific and include poor feeding, vomiting, irritability, a
bulging anterior fontanelle, altered mental status defined as a Pediatric
Glasgow Coma Score of less than or equal to 14 ( Table 113.1 ), lethargy,
seizure and presence of scalp hematoma and/or depression. Typical
complaints in children include headache, progression of headache with
increasing severity, vomiting, confusion, altered mental status defined as a
Glasgow Coma Scale (GCS) of less than or equal to 14 ( Table 113.1 ),
seizure, lethargy, focal neurologic abnormality, obtundation, or signs of a
basilar skull fracture, such as Battle sign, periorbital ecchymosis
hemotympanum, and cerebral spinal fluid (CSF) otorrhea or rhinorrhea.
Signs of impending cerebral herniation include altered mental status,
pupillary changes, bradycardia, hypertension, and respiratory depression.
Recent clinical decision rules to assist in the determination for emergent
radiography have stratified ciTBI risk based on key historical and physical
examination features. The clinical decision rules are applied to two separate
patient populations, children less than 2 years of age and children 2 years of
age and greater. Children less than 2 years of age provide a unique
challenge to the clinician as they commonly present after minor trauma but
may be asymptomatic or clinical assessment may be difficult. Additionally,
the clinician must always have a low index of suspicion for nonaccidental
trauma, as the incidence of child abuse in this age group is high. Head
injury accounts for the highest mortality in nonaccidental or intentional

injury. For a detailed review of inflicted injuries, please refer to Chapter 87
Child Abuse/Assault .