eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Critical Care
Head Trauma: Follow-up
Updated: Jun 1, 2009
Follow-up
Further Inpatient Care
- Criteria for hospitalization in patients with head trauma should be directed on an individual basis. Usual indications for admission include the following:
- Documented loss of consciousness longer than 5 minutes
- Coma, altered mental status, or seizures
- Focal neurologic deficit
- Protracted vomiting, severe and persistent headache
- Intoxication with substances such as alcohol or drugs that interfere with the neurologic examination
- Suspected child abuse
- Unreliable caregiver
- Underlying pathology such as coagulopathy or hydrocephalus
- ICU admission should be based upon the severity of the trauma and associated injuries.
Further Outpatient Care
- Patients with minor head injury (ie, Pediatric Glasgow Coma Scale [PGCS] of 14-15) can be discharged with observation instructions in the care of a reliable adult.
- Patients who sustained loss of consciousness less than 5 minutes and have normal findings on neurologic examination, no symptoms of increased intracranial pressure (ICP) such as vomiting or headache, no signs of basilar skull fracture, and normal findings on CT scanning or skull radiography can also be discharged with close observation by a reliable adult.
Inpatient & Outpatient Medications
- Tetanus immunization status should be checked and updated for any patient, especially when lacerations or contaminated wounds are present.
- Anticonvulsants may be needed to control or provide prophylaxis for seizure activity.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used for minor pain control.
- Beta-blockers can be prescribed for patients with trauma-induced migraines.
Transfer
- Transfer may be required to hospitals where consultation with a neurosurgeon is available, especially when surgical intervention is necessary.
Deterrence/Prevention
- Passenger seat belts and airbags may be useful in preventing head injury.
- Helmet use by children and adolescents during certain sport activities may reduce head trauma risk.
- Education regarding avoidance of alcohol and drug use may also help in decreasing the incidence of alcohol- and drug-related accidents.
- Children younger than 12 years should ride in the back seat of the car away from the airbag.
Complications
- Seizures are more commonly observed with contusions (subdural hematoma more so than epidural hematoma), depressed skull fracture, and severe head injury (PGCS of 3-5).
- Leptomeningeal cyst or growing fracture represents extrusion of leptomeninges and brain tissue through a dural defect.
- Meningitis could develop secondary to basilar skull fracture.
- Cranial nerve injury may develop secondary to basilar skull fracture. Oculomotor palsy is due to injury of cranial nerves VI, III, or IV. Trauma to nerve VII leads to facial nerve palsy. Hearing loss may occur because of injury of cranial nerve VIII.
- Posttraumatic syndrome may develop following mild-to-moderate head trauma and consists of irritability, inability to concentrate, nervousness, and occasionally behavioral or cognitive impairment.
- Cortical blindness, described as an acute loss of vision following head trauma, usually resolves spontaneously within 24 hours. Several mechanisms have been implicated, including acute cerebral edema and transient vasospasm. Cortical blindness is now considered to result from minor transient alterations in the brain function triggered by the traumatic event.
- Trauma-induced migraine may begin from minutes to hours following the injury and may last from hours to days. Beta-blockers are the drugs of choice for this complication.
- Hydrocephalus results from either an obstruction caused by an intraventricular hemorrhage or decreased reabsorption of cerebrospinal fluid (CSF) due to proteinaceous obstruction of the arachnoid villi.
- Neurogenic pulmonary edema is thought to be due to medullary ischemia that leads to increased sympathetic tone with subsequent increase in pulmonary vascular pressure and a shift in blood distribution from the systemic to pulmonary bed.
- Pulmonary infections are often present in patients with head trauma because of either an initial aspiration process or prolonged mechanical ventilation.
Prognosis
- Patients with severe head trauma and a PGCS of 3-5 have a mortality rate of 6-35%; the rate increases to 50-60% for those with a PGCS of 3.
- Of those with a PGCS of 3-5 who survive, 90% require rehabilitation following hospital discharge and most of them eventually return to school.
- Patients with a PGCS of 3 have poor neurologic outcomes.
- Patients with a PGCS of 6-8 are most likely to regain consciousness within 3 weeks, but one third are left with focal neurologic deficits and learning difficulties, especially when coma persists beyond 3 weeks.
Patient Education
- Refer children for early intervention and rehabilitation services.
- Refer the family and the child for psychosocial counseling.
- Children should be referred for neuropsychiatric testing, especially when learning difficulties are present.
- For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center, Back, Neck, and Head Injury Center, and Eye and Vision Center. Also, see eMedicine's patient education articles Concussion, Bicycle and Motorcycle Helmets, Black Eye, and Child Passenger Safety.
Miscellaneous
Medicolegal Pitfalls
- Failure to recognize or suspect child abuse
- Failure to recognize associated life-threatening injuries
- Failure to recognize severe head injury that may initially seem less serious in a patient with multiple traumas (An example is the Waddell triad for a child pedestrian hit by motor vehicle, involving chest-abdomen trauma, leg injury, and a countercoup head injury.)
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 |
| « Previous Page | Next Page » |
References
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Further Reading
- Relevant clinical guidelines include the following:
- American College of Radiology Appropriateness Criteria for Head Trauma
- Head (trauma, headaches, etc., not including stress & mental disorders)
- Practice parameter: Antiepileptic drug prophylaxis in severe traumatic brain injury: report of the Quality Standards Subcommittee of the American Academy of Neurology
- Evaluation of suspected child physical abuse
- Relevant clinical trials include the following:
- Related eMedicine topics include the following:
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
