eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Critical Care

Head Trauma: Differential Diagnoses & Workup

Author: Arabela Stock, MD, Consulting Staff, Department of Pediatrics, Divisions of Critical Care and Pulmonology, Florida Pediatric Association
Coauthor(s): Jagvir Singh, MD, Director, Division of Pediatric Emergency Medicine, Lutheran General Hospital of Park Ridge
Contributor Information and Disclosures

Updated: Jun 1, 2009

Differential Diagnoses

Child Abuse & Neglect: Physical Abuse

Workup

Laboratory Studies

  • A CBC count, including platelets, provides a baseline hematocrit and should be monitored serially, especially when bleeding is suspected in patients with head trauma.
  • Blood chemistry, including an amylase and lipase, provides information regarding other organ injury.
  • Coagulation profile, prothrombin time (PT)/activated partial thromboplastin time (aPTT), and fibrinogen should be obtained in patients with head trauma because they may have an underlying or trauma-triggered coagulopathy.
  • Type and cross is useful in anticipation of need for transfusion, especially in patients with multiple traumas.
  • ABG provides information regarding oxygenation and ventilation, and results direct further treatment.
  • A blood or urine toxicology screen should be obtained in addition to the routine panel, especially in patients who have altered mental status, seizures, and an unclear history.
  • Wound cultures from lacerations or open skull fractures should be taken; findings might help guide further therapy when infection is suspected.

Imaging Studies

  • CT scanning
    • CT scanning of the head remains the most useful imaging study for patients with severe head trauma or with unstable multiple organ injury.8,9
    • Indications for CT scanning in a patient with a head injury include posttraumatic seizures, amnesia, progressive headache, unreliable history or examination because of possible alcohol or drug ingestion, loss of consciousness for longer than 5 minutes, physical signs of basilar skull fracture, repeated vomiting or vomiting for more than 8 hours after injury, and instability following multiple traumas.
    • A noncontrast study is useful in the immediate posttrauma period for rapid diagnosis of intracranial pathology that requires prompt surgical intervention. A contrast-enhanced study should follow when the patient is stable and IV contrast is no longer a contraindication.
    • CT scanning provides information regarding the following:
      • The integrity of soft tissue and bone, the size of the fontanel and suture lines, and the presence of foreign bodies
      • The appearance of the normal structures, the presence or absence of hemorrhage, and signs of edema, infarct, or contusion
      • Mass effect as indicated by midline shift
      • The appearance of the ventricles and cisterns: Compression of the ventricles is suggestive of mass effect. Ventricular enlargement may suggest development of hydrocephalus from intraventricular hemorrhage or blockage by mass effect.
      • The presence of cerebral edema as indicated by loss of gray-white matter demarcation
  • MRI
    • MRI is a more sensitive imaging study providing more detailed information regarding the anatomic and vascular structures, the myelination process, and detection of small hemorrhages in areas that might escape CT scanning.
    • MRI is not practical in emergency situations because the magnetic field precludes the use of monitors and life-support equipment needed by unstable patients.
    • MRI is useful for estimating the initial mechanism and extent of injury and predicting its outcome in the neurologically stable patient.
  • Skull radiography: This is not routinely indicated except in the following situations:
    • Patients younger than 1 year
    • Loss of consciousness for 3 minutes or longer
    • Skull penetration
    • Preexistent shunt
    • Scalp hematoma and/or depression
    • Otorrhea and/or rhinorrhea
    • Hemotympanum
    • Battle sign
    • Raccoon eyes
    • Altered mental status
    • Focal neurologic examination
  • Ultrasonography: This can be performed in neonates and small infants with open fontanel and could provide information regarding intracranial bleed or obstruction of the ventricular system.
  • Xenon CT scanning: This is a modality that may be useful in assessing the impact of medical management on the cerebral perfusion of a patient with head trauma but is not widely available and requires special equipment.

Other Tests

  • ECG: Patients with head trauma are prone to developing dysrhythmias through a reentry mechanism. ST-T wave abnormalities and prolonged QT interval could be present.

Procedures

  • External ventricular drains
    • The standard for intracranial pressure (ICP) monitoring, they are also used as a therapeutic modality allowing for cerebrospinal fluid (CSF) removal during episodes of increased ICP or draining hemorrhage-induced hydrocephalus.
    • Placement is indicated for patients with severe head trauma and Glasgow Coma Scale (GCS) less than 8, abnormal CT scan findings on admission, and rapidly deteriorating neurologic examination results or for patients in whom subsequent rises in the ICP are expected.
  • Lumbar drains
    • Lumbar drains are used for patients with refractory increased ICP, allowing further CSF removal.
    • An external ventricular drain should be placed initially; basilar cisterns must be open on CT scan prior to placement of a lumbar drain.
  • Subarachnoid and epidural monitors
    • Subarachnoid and epidural monitors have been used more often in the past, especially when an intraventricular catheter could not be placed. Their use has decreased since the development of fiberoptic transducers.
    • The theoretical advantages, such as ease of placement, reduced risk of infection, and decreased risk of hemorrhage should be weighed against the risk of inaccurate readings and inability to remove CSF.
    • Some other disadvantages include zero drift, hysteresis in measurement, and temperature sensitivity.

More on Head Trauma

Overview: Head Trauma
Differential Diagnoses & Workup: Head Trauma
Treatment & Medication: Head Trauma
Follow-up: Head Trauma
Multimedia: Head Trauma
References
Further Reading
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Keywords

head trauma, head injury, brain trauma, brain injury, primary head trauma, secondary head trauma, intracranial pressure, ICP, hypotension, hypoxia, hypercapnia, traumatic brain injury, scalp injury, skull fracture, basilar skull fracture, concussion, contusion, intracranial hemorrhage, subarachnoid hemorrhage, epidural hematoma, subdural hematoma, intraventricular hemorrhage, penetrating injuries, diffuse axonal injury, skull fracture, Battle sign, raccoon eyes, birth trauma, seizures, respiratory distress, shaken baby syndrome, spinal cord injury, paralysis, accidents, falls, assaults, recreational activities, child abuse, seizure disorder, attention deficit disorder, treatment, diagnosis

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Contributor Information and Disclosures

Author

Arabela Stock, MD, Consulting Staff, Department of Pediatrics, Divisions of Critical Care and Pulmonology, Florida Pediatric Association
Arabela Stock, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Jagvir Singh, MD, Director, Division of Pediatric Emergency Medicine, Lutheran General Hospital of Park Ridge
Jagvir Singh, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

G Patricia Cantwell, MD, Associate Clinical Professor, Department of Pediatrics, University of Miami; Director of Pediatric Critical Care Medicine, Miller School of Medicine, Jackson Children's Hospital
G Patricia Cantwell, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Barry J Evans, MD, Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center
Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Professor of Clinical Pediatrics, State University of New York at Stony Brook; Director of Children's Sleep Services, Winthrop University Hospital
Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians
Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Timothy E Corden, MD, Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin
Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society
Disclosure: Nothing to disclose.

 
 
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