Paediatric Head Injury…

Numbers

75% of children hospitalized for trauma have a head injury.

Most are minor

CNS injuries are the most common cause of paediatric traumatic death

Paediatric head injuries overall mortality for

All severity requiring hospitalisation: 10–13%
Severe only presenting with decerebrate posturing: 71%

Children often have milder injuries than adults

Lower chance of a surgical lesion in a comatose child than in an adult

Differences between adult and paediatric head injury:

responses to head injury of older adolescents are very similar to those of adults

“malignant cerebral oedema”: acute onset of severe cerebral swelling (probably due to hyperaemia) following some head injuries, especially in young children (may not be as common as previously thought)

posttraumatic seizures: more likely to occur within the first 24 hrs in children than in adults

Types of injury: injuries peculiar to paediatrics

birth injuries:

skull fractures,
cephalhematoma
subdural or epidural hematomas
brachial plexus injuries

Perambulator/walker injuries

child abuse (nonaccidental trauma (p. 954)): shaken baby syndrome…

injuries from skateboarding, scooters…

injuries related to the easier penetrability of the paediatric skull: e.g. recreational lawn darts

cephalhematoma:

Leptomeningeal cysts, AKA “growing skull fractures”

retroclival hematoma (p.952)

Management

The PECARN algorithm identified children with mTBI (GCS = 14–15) having a very low risk of clinically-significant brain injuries resulting in these recommendations regarding CT scan:

CT scans should not be routinely used for children with mild TBI fracture
brain MRI imaging should not routinely be used in the acute evaluation of suspected or diagnosed mTBI*

Rapid sequence MRI in nonsedated patients has been successfully used but was not included in the guidelines

Younger than 2 years old


flowchart LR
    A["GCS-14 or other signs of altered mental status; or palpable skull fracture"] --> B{"Yes: 13.9% of population<br>4.4% risk of ciTBI"} & D{"No"}
    B --> C["CT recommended"]
    D --> E["Occipital or parietal or temporal scalp haematoma, or history of LOC ≥5 s, or severe mechanism of injury, or not acting normally per parent"]
    E --> F{"Yes: 32.9% population<br>0.9% risk of ciTBI"} & M{"No: 53.2% of population<br>0-02% risk of ciTBI"}
    F --> G["Observation versus CT on the basis of other clinical factors including:"]
    G --> H["Physician experience"] & I["Multiple versus isolated findings"] & J["Worsening symptoms or signs after emergency department observation"] & K["Age &lt;3 months"] & L["Parental preference"]
    M --> N["CT not recommended"]

    style B fill:#00C853,color:#000000
    style D fill:#D50000
    style F color:#000000,fill:#00C853
    style M fill:#D50000

2 years old or older


flowchart LR
    A["GCS≤14 or other signs of altered mental status"] --> B{"Yes<br>14-0% of population<br>4-3% risk of ciTBI"} & D{"No"}
    B --> C["CT recommended"]
    D --> E["History of LOC, or history of vomiting, or severe mechanism of injury, or severe headache"]
    E --> F{"Yes<br>28-8% of population<br>0-8% risk of ciTBI"} & L{"No<br>57-2% of population<br>0-5% risk of ciTBI"}
    F --> G["Observation versus CT on the basis of other clinical factors including:"]
    G --> H["Physician experience"] & I["Multiple versus isolated findings"] & J["Worsening symptoms or signs after emergency department observation"] & K["Parental preference"]
    L --> M["CT not recommended"]

    style B fill:#00C853, color:#000000
    style D fill:#D50000
    style F fill:#00C853, color:#000000
    style L fill:#D50000

Outcome

As a group, children fare better than adults with head injury.

However, very young children do not do as well as the school-age child.

All aspects of neuropsychological dysfunction following head injury may not always be related to the trauma, as children who get injured may have pre-existing problems that increase their propensity to get hurt (this is controversial).