PEDIATRIC HEAD INJURYMyra Lalas Pitt

PEDIATRIC HEAD INJURY More than 1.5 million head injuries occur in the

US annually 2M: 1F Motor vehicle collisions- most common cause of

pediatric head injury, followed by falls Football is the most common of sports-related

injury.

ANY HEAD TRAUMA CAN TRANSFER ENERGY FROM THE SKIN, THROUGH THE SKULL AND MENINGES, TO THE BRAIN.

SUBDURAL HEMATOMA

Subdural Hematoma - classic presentation is an acute and persistent LOC associated with the initial injury.

EPIDURAL HEMATOMA

Epidural Hematoma - brief period of unconsciousness, followed by a lucid period, and then a subsequent deterioration over 15-30 minutes.

Usual cause is tearing of the middle meningeal artery secondary to an associated temporal skull fracture.

SUBARACHNOID HEMORRHAGE

Subarachnoid Hemorrhage - Worsening headache and other signs of increasing intracranial pressure will gradually grow after the initial event.

SUBARACHNOID HEMORRHAGE

Trauma to the blood vessels in the pia mater or in the brain can lead to leakage of blood in the subarachnoid space.

INTRACEREBRAL HEMORRHAGE

Parenchymal damage occurs as the result of contact forces, inertial forces, and global hypoxia/ischemia.

ASSESSMENT

Stabilize ABC’s. Prevention of hypoxia, ischemia, and

increased intracranial pressure is essential. Intubate any child with a GCS of 8 or less. Prompt neurosurgical intervention is

necessary in the majority of seriously head-injured or multisystem-injured children.

Physical exam for associated injuries and neurologic examination followed by neuroimaging.

CT Scan

Indications: focal neurologic examination findings, signs or symptoms of increased intracranial pressure, GCS score less than 15, and seizures related to trauma, LOC

Imaging study of choice in evaluating an acute head injury. 1. Better imaging of an acute hemorrhage2. Speed of the study3. Improved ability to monitor the patient.

MRI

Imaging study of choice for patients who have prolonged symptoms (> 7 d) or for a late change in an individual's neurologic signs or symptoms.

Offers a more detailed examination and possibly detects more subtle findings.

Delayed or slowly developing bleeds may be easier to detect on MRI.

FOR SUSPECTED CHILD ABUSE

Associated injuries include skull, metaphyseal, and rib fractures; retinal hemorrhages; and intracranial bleeding, especially subdural hematomas.

Do Ophtho Exam. Bone Scan

TREATMENT

ABC’s In the ER, mild hyperventilation and

correlation with end-tidal CO2 may be used in unconscious patients, prior to insertion of an ICP monitor.

Hypotension should be treated with isotonic fluid boluses and inotropic medications prn to maintain an adequate MAP and cerebral perfusion pressure.

Mannitol is often used to maintain optimal intracranial pressure by reducing intravascular volume.

SIADH or DI may occur in children with serious head injury- monitor fluid & electrolyte balance.

Seizures: Those with serious injuries are treated with fosphenytoin either to treat active seizures or for prophylaxis.

QUESTION

You are evaluating an 18-month-old girl for vomiting. She has a history of febrile seizures and recurrent ear infections. She is receiving no medications. Over the past several weeks, her parents have noticed that she has been "increasingly clumsy." She has vomited each of the last three mornings but has had no diarrhea or fever. Physical examination findings are normal except for an ataxic gait and hyperreflexia.

Of the following, the MOST appropriate next step is

A. administration of an antiemetic B. computed tomography scan of the head C. electroencephalography D. lumbar puncture E. reassurance and re-evaluation in 3 to 5 days

B Initial symptoms of increased intracranial pressure often

consist of headaches and confusion that may be accompanied by lethargy.

The child described in the vignette exhibits signs of a progressive increase in pressure, such as vomiting (especially in the morning) and changes in motor tone.

CT or MRI of the head is the first priority in evaluating suspected increased intracranial pressure.

Meningitis is unlikely in this patient due to the chronicity of symptoms and absence of fever. Accordingly, lumbar puncture is not indicated at this time.

Electroencephalography might be indicated if atypical migraines or seizures were suspected, but the initial priority is to evaluate the patient for potential life-threatening disease processes.

The child has no evidence of viral infection, and reassurance or administration of antiemetics is not appropriate.

REFERENCES

Atabaki, S. Pediatric Head Injury. Pediatr. Rev. 2007;28;215-224

Baker Robert J, "Chapter 34. Acute Head and Neck Trauma" (Chapter). Dilip R. Patel, Donald E. Greydanus, Robert J. Baker: Pediatric Practice: Sports Medicine: http://www.accesspediatrics.com/content/6981964

Quayle Kimberly S, "Chapter 29. Head Trauma" (Chapter). Gary R. Strange, William R. Ahrens, Robert W. Schafermeyer, Robert A. Wiebe: Pediatric Emergency Medicine, 3e: http://www.accesspediatrics.com/content/5330570.

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