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Pediatric Head Trauma Workup

  • Author: Michael J Verive, MD, FAAP; Chief Editor: Timothy E Corden, MD  more...
 
Updated: Dec 31, 2015
 

Laboratory Studies

A complete blood count (CBC) should be monitored serially, especially when bleeding is suspected in patients with head trauma. Blood chemistry studies, including amylase and lipase levels, provides information regarding other organ injuries.

A coagulation profile; a prothrombin time (PT), with international normalized ratio (INR); activated partial thromboplastin time (aPTT); and a fibrinogen level should be obtained in patients with head trauma because these patients may have an underlying or trauma-triggered coagulopathy.

An admission INR measurement of 1.3 or higher appears to be a strong independent prognostic factor for death in children who have suffered abusive head trauma.[28] A retrospective study (2005-2014) of 101 level 1 pediatric (age, 0-17 years) trauma patients with abusive head trauma noted an overall mortality of 24.8%, of which 60% were in children with an INR of 1.3 or greater and 6% in those whose INR was above 1.3. Elevated INR was associated with more early packed RBC transfusions and neurosurgical intervention.[28]

Typing and cross-matching of blood is useful in anticipation of a possible need for transfusion, especially in patients with multiple trauma.

Arterial blood gas values provide information regarding oxygenation, ventilation, and acid-base status and can be used to help 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.

S100β and Glial fibrillary acidic protein

Serum levels of S100β (S100B) protein appear to be a useful adjunct diagnostic tool for detecting intracranial injury in children with mild head trauma, having a high degree of sensitivity (all children, 95%; those aged >2 years, 100%) but poor specificity (all children, 34%; those aged >2 years, 37%).[29]

Glial fibrillary acidic protein (GFAP) appears to outperform S100β as a marker for detecting intracranial lesions on computed tomography (CT) scanning not only in adults but also in children and youth with mild traumatic brain injury.[30]  In one study, the area under the receiver operating characteristic curve (AUC) for distinguishing head trauma from no head trauma for GFAP was 0.84 but 0.64 for S100β, and the AUC for predicting intracranial lesions on CT scanning for GFAP was 0.85 versus 0.67 for S100β. In children 10 years or younger, the AUC for predicting intracranial lesions was 0.96 for GFAP and 0.72 for S100β, whereas in those younger than 5 years, the AUC was 1.00 for GFAP and 0.62 for S100β.[30]

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Computed Tomography

Computed tomography (CT) of the head remains the most useful imaging study for patients with severe head trauma or unstable multiple organ injury.[1, 2]

Indications for CT scanning in a patient with a head injury include anisocoria, GCS score less than 12 (some studies suggest CT scanning in any pediatric patient with a GCS score of < 15), posttraumatic seizures, amnesia, progressive headache, an 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 after multiple trauma. Various studies and prediction algorithms (eg, National Emergency X-Radiography Utilization Study II [NEXUS II], Canadian Assessment of Tomography for Childhood Head Injury [CATCH], among others) have attempted to assess the ability of clinical characteristics to predict the utility of neuroimaging for patients with mild head injury, but there remains considerable variation in clinical practice.

One study noted that CT scanning may be unnecessary for children who are at very low risk for clinically important traumatic brain injury (TBI) after closed head trauma. In this study, the prediction rules for children younger than 2 years were normal mental status, no scalp hematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 seconds, nonsevere injury mechanism, no palpable skull fracture, and normal behavior as deemed by the parents. The prediction rules for children older than 2 years were normal mental status, no loss of consciousness, no vomiting, nonsevere injury mechanism, no signs of basilar skull fracture, and no severe headache.[31]

A noncontrast study is useful in the immediate posttrauma period for rapid diagnosis of intracranial pathology that calls for prompt surgical intervention.

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

In the absence of neurologic deterioration or increasing intracranial pressure (ICP), obtaining a routine repeat CT scan more than 24 hours after the admission and initial follow-up study may not be indicated for decisions about neurosurgical intervention.

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Magnetic Resonance Imaging

MRI is a more sensitive imaging study than CT in this setting, providing more detailed information regarding the anatomic and vascular structures and the myelination process and allowing the detection of small hemorrhages in areas that might escape CT scanning.

MRI is useful for estimating the initial mechanism and extent of injury and predicting its outcome in the neurologically stable patient. It is not practical in emergency situations, because the magnetic field precludes the use of the monitors and life-support equipment needed by unstable patients. In addition, the time required for obtaining the appropriate MRI studies can cause unacceptable delays in the management of patients with severe traumatic brain injury.

Although MRI sensitivity is understood to be superior to CT for intracranial evaluation, it is not as easily obtained acutely after injury and has not been as widely validated in large studies, particularly regarding influence on management decisions. In current practice, little evidence supports the use of MRI in influencing management of patients with severe TBI.[32]

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Ultrasonography

Ultrasonography can be performed in neonates and small infants with open fontanel and may provide information regarding intracranial bleeding or obstruction of the ventricular system.

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ICP Monitoring and CSF Drainage

ICP should be monitored in all salvageable patients with severe TBI (GCS score of 3-8 after resuscitation) and an abnormal CT scan. An abnormal CT scan of the head is one that reveals hematomas, contusions, swelling, herniation, or compressed basal cisterns.

ICP monitoring is also indicated in patients with severe TBI with a normal CT scan in the presence of unilateral or bilateral motor posturing or a systolic blood pressure less than the fifth percentile for age.

In certain conscious patients with CT findings suggesting risk of neurologic deterioration (hematomas, contusions, swelling, herniation, or compressed basal cisterns), however, monitoring may be considered based on the opinion of the treating physician. Inability to perform serial neurologic examinations, because of pharmacologic sedation or anesthesia, may also influence a clinician’s decision to monitor ICP in an individual patient.

External ventricular drains are often used as a therapeutic modality, especially when the removal of cerebrospinal fluid (CSF) during episodes of increased ICP or drainage of hemorrhage-induced hydrocephalus may be required.

Lumbar drains may also 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 before placement of a lumbar drain.

ICP can also be monitored by transducers placed via small burr holes, especially when an intraventricular catheter cannot be placed. The theoretical advantages (eg, ease of placement, reduced risk of infection, and decreased risk of hemorrhage) should be weighed against the inability to remove CSF. The recent introduction of tissue partial pressure of oxygen monitoring allows direct measurement of brain tissue oxygenation. If brain oxygenation monitoring is used, maintenance of partial pressure of brain tissue oxygen greater than 15 mm Hg may be considered.[32]

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Contributor Information and Disclosures
Author

Michael J Verive, MD, FAAP Pediatrician, UP Health System Portage

Michael J Verive, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, Society for Pediatric Sedation

Disclosure: Nothing to disclose.

Coauthor(s)

Arabela Stock, MD Consulting Staff, Department of Pediatrics, Division of Critical Care, All Children's Hospital

Arabela Stock, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians

Disclosure: Nothing to disclose.

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.

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, Wisconsin Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

G Patricia Cantwell, MD, FCCM Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami, Leonard M Miller School of Medicine; Medical Director, Palliative Care Team, Director, Pediatric Critical Care Transport, Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Manager, FEMA, Urban Search and Rescue, South Florida, Task Force 2; Pediatric Medical Director, Tilli Kids – Pediatric Initiative, Division of Hospice Care Southeast Florida, Inc

G Patricia Cantwell, MD, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

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.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References
  1. Trenchs V, Curcoy AI, Castillo M, et al. Minor head trauma and linear skull fracture in infants: cranial ultrasound or computed tomography?. Eur J Emerg Med. 2009 Jun. 16(3):150-2. [Medline].

  2. Ringl H, Schernthaner R, Philipp MO, et al. Three-dimensional fracture visualisation of multidetector CT of the skull base in trauma patients: comparison of three reconstruction algorithms. Eur Radiol. 2009 May 14. [Medline].

  3. Boggs W. Point-of-care ultrasound finds skull fractures in children. Medscape Medical News. May 24, 2013. Available at http://www.medscape.com/viewarticle/804784. Accessed: June 3, 2013.

  4. Rabiner JE, Friedman LM, Khine H, Avner JR, Tsung JW. Accuracy of Point-of-Care Ultrasound for Diagnosis of Skull Fractures in Children. Pediatrics. 2013 Jun. 131(6):e1757-64. [Medline].

  5. Cakmakci H. Essentials of trauma: head and spine. Pediatr Radiol. 2009 Jun. 39 Suppl 3:391-405. [Medline].

  6. Hand L. Major causes of head trauma in children identified. Medscape Medical News. November 13, 2014. [Full Text].

  7. Quayle KS, Holmes JF, Kuppermann N, Powell EC, Mahajan P, Hoyle JD Jr, et al. Epidemiology of blunt head trauma in children in U.S. emergency departments. N Engl J Med. 2014 Nov 13. 371(20):1945-7. [Medline].

  8. Guilliams K, Wainwright MS. Pathophysiology and management of moderate and severe traumatic brain injury in children. J Child Neurol. 2016 Jan. 31 (1):35-45. [Medline].

  9. Toda N, Ayajiki K, Okamura T. Cerebral blood flow regulation by nitric oxide: recent advances. Pharmacol Rev. 2009 Mar. 61(1):62-97. [Medline].

  10. Yeates KO, Taylor HG, Rusin J, et al. Longitudinal trajectories of postconcussive symptoms in children with mild traumatic brain injuries and their relationship to acute clinical status. Pediatrics. 2009 Mar. 123(3):735-43. [Medline].

  11. Hymel KP, Stoiko MA, Herman BE, et al. Head injury depth as an indicator of causes and mechanisms. Pediatrics. 2010 Apr. 125(4):712-20. [Medline].

  12. Allard RH, van Merkesteyn JP, Baart JA. [Child abuse]. Ned Tijdschr Tandheelkd. 2009 Apr. 116(4):186-91. [Medline].

  13. Iranmanesh F. Outcome of head trauma in children. Indian J Pediatr. 2009 May 27. [Medline].

  14. Garcia Garcia JJ, Manrique Martinez I, Trenchs Sainz de la Maza V, et al. [Registry of mild craniocerebral trauma: Multicentre study from the Spanish Association of Pediatric emergencies.]. An Pediatr (Barc). 2009 May 21. [Medline].

  15. Mackerle Z, Gal P. Unusual penetrating head injury in children: personal experience and review of the literature. Childs Nerv Syst. 2009 May 19. [Medline].

  16. Haider AH, Crompton JG, Oyetunji T, Risucci D, DiRusso S, Basdag H, et al. Mechanism of injury predicts case fatality and functional outcomes in pediatric trauma patients: the case for its use in trauma outcomes studies. J Pediatr Surg. 2011 Aug. 46(8):1557-63. [Medline].

  17. Shein SL, Bell MJ, Kochanek PM, Tyler-Kabara EC, Wisniewski SR, Feldman K, et al. Risk Factors for Mortality in Children with Abusive Head Trauma. J Pediatr. 2012 May 11. [Medline].

  18. Kapapa T, Pfister U, Konig K, et al. Head trauma in children, part 3: clinical and psychosocial outcome after head trauma in children. J Child Neurol. 2010 Apr. 25(4):409-22. [Medline].

  19. Ley EJ, Srour MK, Clond MA, et al. Diabetic patients with traumatic brain injury: insulin deficiency is associated with increased mortality. J Trauma. 2011 May. 70(5):1141-4. [Medline].

  20. Pinto PS, Poretti A, Meoded A, Tekes A, Huisman TA. The unique features of traumatic brain injury in children. Review of the characteristics of the pediatric skull and brain, mechanisms of trauma, patterns of injury, complications and their imaging findings--part 1. J Neuroimaging. 2012 Apr. 22(2):e1-e17. [Medline].

  21. Pinto PS, Meoded A, Poretti A, Tekes A, Huisman TA. The unique features of traumatic brain injury in children. review of the characteristics of the pediatric skull and brain, mechanisms of trauma, patterns of injury, complications, and their imaging findings--part 2. J Neuroimaging. 2012 Apr. 22(2):e18-41. [Medline].

  22. Prigatano GP, Gale SD. The current status of postconcussion syndrome. Curr Opin Psychiatry. 2011 May. 24(3):243-50. [Medline].

  23. Rangarajan N, Kamalakkannan SB, Hasija V, et al. Finite element model of ocular injury in abusive head trauma. J AAPOS. 2009 May 4. [Medline].

  24. [Guideline] First Comprehensive Pediatric Concussion Guidelines, Available Now. Medical Xpress. Jun 25 2014. [Full Text].

  25. Brunelle C, Hennecker JL, Scordidis V. [Loss of consciousness after a minor trauma revealing an aneurysm rupture in a child]. Arch Pediatr. 2012 Aug. 19(8):815-8. [Medline].

  26. Chelly H, Chaari A, Daoud E, et al. Diffuse axonal injury in patients with head injuries: an epidemiologic and prognosis study of 124 cases. J Trauma. 2011 Oct. 71(4):838-46. [Medline].

  27. Maguire SA, Kemp AM, Lumb RC, Farewell DM. Estimating the Probability of Abusive Head Trauma: A Pooled Analysis. Pediatrics. 2011 Aug 15. [Medline].

  28. Leeper C, Nasr I, McKenna C, Berger RP, Gaines BA. Elevated admission INR strongly predicts mortality in victims of abusive head trauma. J Trauma Acute Care Surg. 2015 Dec 26. [Medline].

  29. Manzano S, Holzinger IB, Kellenberger CJ, et al. Diagnostic performance of S100B protein serum measurement in detecting intracranial injury in children with mild head trauma. Emerg Med J. 2016 Jan. 33 (1):42-6. [Medline].

  30. Papa L, Mittal MK, Ramirez J, et al. In children and youth with mild and moderate traumatic brain injury, glial fibrillary acidic protein out-performs s100β in detecting traumatic intracranial lesions on computed tomography. J Neurotrauma. 2016 Jan 1. 33 (1):58-64. [Medline].

  31. Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3. 374(9696):1160-70. [Medline].

  32. Kochanek PM, Carney N, Adelson PD, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition. Pediatr Crit Care Med. 2012 Jan. 13 Suppl 1:S1-82. [Medline].

  33. [Guideline] Christian CW, Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse. Pediatrics. 2015 May. 135 (5):e1337-54. [Medline].

  34. Holmes JF, Borgialli DA, Nadel FM, et al. Do children with blunt head trauma and normal cranial computed tomography scan results require hospitalization for neurologic observation?. Ann Emerg Med. 2011 Oct. 58(4):315-22. [Medline].

  35. Thomas M, Haas TS, Doerer JJ, et al. Epidemiology of sudden death in young, competitive athletes due to blunt trauma. Pediatrics. 2011 Jul. 128(1):e1-8. [Medline].

  36. Robinson N, Clancy M. In patients with head injury undergoing rapid sequence intubation, does pretreatment with intravenous lignocaine/lidocaine lead to an improved neurological outcome? A review of the literature. Emerg Med J. 2001 Nov. 18(6):453-7. [Medline]. [Full Text].

  37. Haque IU, Zaritsky AL. Analysis of the evidence for the lower limit of systolic and mean arterial pressure in children. Pediatr Crit Care Med. 2007 Mar. 8(2):138-44. [Medline].

  38. Brown CV, Sowery L, Curry E, et al. Recombinant factor VIIa to correct coagulopathy in patients with traumatic brain injury presenting to outlying facilities before transfer to the regional trauma center. Am Surg. 2012 Jan. 78(1):57-60. [Medline].

  39. [Guideline] Kellogg ND. Evaluation of suspected child physical abuse. Pediatrics. 2007 Jun. 119(6):1232-41. [Medline]. [Full Text].

  40. Choe MC, Blume HK. Pediatric posttraumatic headache: a review. J Child Neurol. 2016 Jan. 31 (1):76-85. [Medline].

 
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Epidural hematoma with midline shift.
Subdural hematoma.
Intraventricular hemorrhage.
Epidural hematoma with acute neurologic deterioration.
Table 1. Pediatric Glasgow Coma Scale: Eye Opening
Score ≥1 Year 0-1 Year
4 Opens eyes spontaneously Opens eyes spontaneously
3 Opens eyes to a verbal command Opens eyes to a shout
2 Opens eyes in response to pain Opens eyes in response to pain
1 No response No response
Table 2. Pediatric Glasgow Coma Scale: Best Motor Response
Score ≥1 Year 0-1 Year
6 Obeys command N/A
5 Localizes pain Localizes pain
4 Flexion withdrawal Flexion withdrawal
3 Flexion abnormal (decorticate) Flexion abnormal (decorticate)
2 Extension (decerebrate) Extension (decerebrate)
1 No response No response
Table 3. Pediatric Glasgow Coma Scale: Best Verbal Response
Score > 5 Years 2-5 Years 0-2 Years
5 Oriented and able to converse Uses appropriate words Cries appropriately
4 Disoriented and able to converse Uses inappropriate words Cries
3 Uses inappropriate words Cries and/or screams Cries and/or screams inappropriately
2 Makes incomprehensible sounds Grunts Grunts
1 No response No response No response
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