Head Injury

Anna D. Jarvis

Introduction

Causes:

Minor Head Injury: Definition

Considerable controversy over definition of head injury; terminology varies
Consider circumstances surrounding injury and estimate probable forces involved
Low-velocity, low-impact injury may result in swelling, erythema, laceration, or pain, but child remains alert and responsive
High-velocity injuries (e.g., motor vehicle accidents) or falls greater than patient’s height require careful evaluation to rule out major life-threatening injuries

Table 7.1 Severity Classification

Mild	No loss of consciousness (LOC)
	Normal physical examination
	Initial Glasgow Coma Scale (GCS) 15
	Minor soft-tissue injuries
Moderate	LOC < 5 minutes
	Normal physical examination
	Initial GCS 13-15
Severe	LOC > 5 minutes
	One or more high-risk criteria
	GCS < 13

High-Risk Criteria for Significant Brain Injury

Altered level of consciousness:
- Unconscious
- Decreased level of consciousness GCS < 13
- Irritability
Local bony abnormalities of head:
- Skull fracture; particularly if depressed
- Penetrating injuries
Evidence of basal skull fracture:
- Hemotympanum
- Battle’s sign (mastoid hematoma): may have delayed onset
- Raccoon’s eyes (periorbital hematomas): may have delayed onset
- CSF rhinorrhea
Unexplained focal neurologic signs
History of previous craniotomy with shunt in site
Posttraumatic amnesia
Severe and worsening headache
Posttraumatic seizure
Blood dyscrasia or any anticoagulant medication

Scales to Assess Neurologic Status

Glasgow Coma Scale

AVPU Scale

A valuable rapid quick assessment tool is the AVPU scale:
- A = Awake and aware (alert)
- V = Responsive to verbal stimuli
- P = Responsive to painful stimuli
- U = Unresponsive

Table 7.2 Glasgow Coma Scale: Standard and Modified for Infants

*GLASGOW COMA SCALE*			*MODIFIED COMA SCALE FOR INFANTS*
ACTIVITY	BEST RESPONSE	SCORE	ACTIVITY	BEST RESPONSE	SCORE
Eye opening	Spontaneous	4	Eye opening	Spontaneous	4
	To verbal stimuli	3		To speech	3
	To pain	2		To pain	2
	None	1		None	1
Verbal	Oriented	5	Verbal	Coos, babbles	5
	Confused	4		Irritable, cries	4
	Inappropriate words	3		Cries to pain	3
	Nonspecific sounds	2		Moans to pain	2
	None	1		None	1
Motor	Follows commands	6	Motor	Normal spontaneous movements	6
	Localizes pain	5		Withdraws to touch	5
	Withdraws to pain	4		Withdraws to pain	4
	Flexion response to pain	3		Abnormal flexion	3
	Extension response to pain	2		Abnormal extension	2
	None	1		None	1