Chapter 56 Head Trauma
GENERAL
1 How common and important is head trauma in children?
Head trauma accounts for approximately 650,000 emergency department (ED) visits and 50,000 hospitalizations per year. Traumatic brain injury is the most common cause of death and disability in childhood.
Palchak MJ, Holmes JF, Vance CW, et al: A decision rule for identifying children at low risk for brain injuries after blunt head trauma. Ann Emerg Med 42:492–506, 2003.
2 What kinds of head injuries commonly present to the ED?
Head trauma includes injuries to the scalp, skull, and intracranial contents. Although most injuries are minor, there is a wide spectrum ranging from simple contusion to lethal brain injury. Lacerations and contusions are common scalp injuries. Injuries to the cranial vault result in skull fractures, and intracranial injuries include concussion, cerebral contusion, hematoma (epidural, subdural, subarachnoid, and intracerebral), and acute brain swelling. Most head injuries result from blunt head trauma, but penetrating injuries rarely occur and are caused by bullets, teeth (e.g., dog bites), or other sharp objects (e.g., dart, pellet, pencil).
3 How is head trauma severity defined?
There is no standard definition for minor head trauma, which accounts for about 80% of injuries evaluated. Many definitions of minor head trauma have been based on the Glasgow Coma Scale (GCS) score; however, there has been no consistency, with various sources, including children with GCS scores of 13–15, 14–15, or 15. The American Academy of Pediatrics defined children with minor head injury as those who have normal mental status at the initial examination, normal neurologic examination, and no physical evidence of skull fracture. Moderate head trauma is typically defined as a GCS score of 9–12, and severe head trauma as a GCS score of 3–8.
Committee on Quality Improvement, American Academy of Pediatrics: The management of minor closed head injury in children. Pediatrics 104:1407–1415, 1999.
Schutzman S, Greenes D: State of the art: pediatric minor head trauma. Ann Emerg Med 37:65–74, 2001.
4 How many children evaluated for minor head trauma have intracranial injuries?
Approximately 3–7% of children with minor head injury have an intracranial injury noted on computed tomography (CT). Approximately 0.5–1.5% require surgical intervention. Overall, about 50% of intracranial injuries occur in kids with a GCS score of 15.
Schutzman S, Greenes D: State of the art: Pediatric minor head trauma. Ann Emerg Med 37:65–74, 2001.
5 Name the ways in which infants differ from older children with regard to head trauma
Children younger than 1–2 years of age differ in several ways that make a low threshold for head imaging prudent:
Clinical assessment is more difficult.
Intracranial injury is frequently asymptomatic.
Skull fractures and intracranial injuries may result from relatively minor trauma.
Schutzman SA, Barnes P, Duhaime AC, et al: Evaluation and management of children younger than two years of age with apparently minor head trauma: Proposed guidelines. Pediatrics 107:983–993, 2001.
6 How common is abuse in infants and young children with head trauma?
Although most head trauma is accidental, up to 10% of children brought to the ED with traumatic injury are victims of intentional injury, and abusive head trauma is the most common cause of traumatic death in children. Because these children are preverbal and abusive caretakers are rarely forthcoming, the clinician must have a heightened sense of awareness to diagnose nonaccidental trauma. This is important to guide appropriate therapy and to prevent further trauma.
Jenny C, Hymel KP, Ritzen A, et al: Analysis of missed cases of abusive head trauma. JAMA 281:621–626, 1999.
Ludwig S: Child abuse. In Fleisher G, Ludwig S, Henretig FM (eds). Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 1761–1801.
SKULL FRACTURES
7 Why are skull fractures important?
Skull fractures are important because they are predictors of intracranial injury (the presence of a skull fracture increases the likelihood of an intracranial injury by approximately twentyfold). In addition, fractures themselves occasionally lead to complications and may be important evidence of child abuse.
Quayle KS, Jaffe DM, Kuppermann N, et al: Diagnostic testing for acute head injury in children: When are head computed tomography and skull radiographs indicated? Pediatrics 99:E11, 1997.
8 Describe the different types of skull fractures
Skull fractures are described in terms of location and characteristics. They may occur in the frontal, parietal, occipital, and temporal bones of the skullcap (calvarium). The skull base consists of portions of the temporal and occipital bones, along with the maxillary, sphenoid, and palatine bones. Fractures in this area are referred to as basilar skull fractures.
Fractures may be linear, depressed (if the inner table of the skull is displaced by more than the thickness of the entire bone), or diastatic (traumatic separation of the cranial bones at one or more suture sites). Compound fractures communicate with lacerations, and comminuted fractures are those with several fragments.
9 Since CT is available, are skull films ever indicated?
CT is the imaging modality of choice to evaluate for acute injury since skull radiography gives no direct information about intracranial injuries (ICI). Rarely, skull radiography may be considered in:
Alert, asymptomatic infants with scalp hematomas: These infants are at risk for harboring occult ICIs, and skull fractures are one of the best predictors for ICI. Skull radiography offers the advantage of requiring no sedation and having significantly less radiation. The practitioner or radiologist should be proficient at reading skull radiographs (if ordered) since they may be challenging to interpret. CT should be performed if a fracture is identified.
Possible nonaccidental injury: Skull radiography sometimes detects fractures missed by CT, and are indicated (as part of a skeletal survey) for the evaluation of possible abuse.
Suspicion of possible depressed fracture, penetrating trauma, or foreign body.
Chung S, Schamban N, Wypij, et al: Skull radiograph interpretation of children less than age two: How good are pediatric emergency physicians? Ann Emerg Med 43:718–722, 2004.
10 Name the most important complications of basilar skull fractures
Intracranial injury: 10–40% of patients with basilar skull fracture have an associated ICI, and about 20% of alert children with basilar skull fractures and a normal neurologic status have an ICI.
Cerebrospinal fluid (CSF) leak: An associated dural tear may lead to CSF leak through the nose or ear and occurs in approximately 15–30% of children with basilar skull fractures.
Meningitis: Meningitis occurs in 0.7–5% of children with BSF (due to CSF leak and exposure to microorganisms); the rate is < 1% for children with GCS score > 13 and no ICI.
Cranial nerve impairment: This occurs in 1–23% of cases, with cranial nerves VI, VII, and VIII most commonly injured. The impairment may be transient or permanent.
Hearing loss: This occurs in up to half of patients with basilar skull fracture; it can be conductive (from hemotympanum or otic canal disruption) or sensorineural.
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