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The features that place children less than 2 years of age at higher risk of
ciTBI include altered mental status, especially if the parent is concerned the
child is acting abnormally, parietal, temporal, or occipital scalp hematoma,
loss of consciousness >5 seconds, evidence of depressed or basilar skull
fracture, bulging anterior fontanelle, persistent vomiting, posttraumatic
seizure, focal neurologic examination findings, or suspicion of
nonaccidental trauma. The features that place children 2 years of age and
greater at higher risk of ciTBI include altered mental status, evidence of
depressed or basilar skull fracture, posttraumatic seizure, prolonged loss of
consciousness, worsening severe headache, and focal neurologic
examination findings. See Table 113.2 . Emergent neuroimaging should be
performed for any child with one or more of these features.
Just as certain features dictate the use of radiographic imaging, the
absence of these features should allow the clinician to spare the patient
unnecessary radiation exposure. Children less than the age of 2 who have a
normal mental status with normal behavior, lack a scalp hematoma or have
a frontal scalp hematoma, without evidence of skull fracture and a normal
neurologic examination should not undergo radiographic imaging; nor
should older children who have a normal mental status, no loss of
consciousness, no vomiting, no severe headache, without evidence of a
skull fracture, and a normal neurologic examination.
The diagnostically challenging patient population are the children in the
intermediate-risk category. These are the children who may have isolated
features indicative of ciTBI with resolution or improvement of symptoms
and a normal neurologic examination. Observation for 4 to 6 hours after the
injury may offer an alternative to emergent neuroimaging.