Sections

Pediatric Head Trauma

DDx

Diagnostic Considerations

The following diagnostic pitfalls are associated with head trauma:

Failure to recognize or suspect child abuse: One study suggests that certain combinations of clinical features may be suggestive of abusive head trauma, though a larger-scale prospective study would be required to develop a more refined tool^[32]
Failure to recognize associated life-threatening injuries
Failure to recognize severe head injury that may initially seem less serious in a patient with multiple trauma: An example is the Waddell triad for a child pedestrian hit by a motor vehicle, which involves chest-abdomen trauma, leg injury, and a countercoup head injury

Differential Diagnoses

Physical Child Abuse

Workup

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Cakmakci H. Essentials of trauma: head and spine. Pediatr Radiol. 2009 Jun. 39 suppl 3:391-405. [QxMD MEDLINE Link].
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Quayle KS, Powell EC, Mahajan P, et al. Epidemiology of blunt head trauma in children in U.S. emergency departments [letter]. N Engl J Med. 2014 Nov 13. 371(20):1945-7. [QxMD MEDLINE Link]. [Full Text].
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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. [QxMD MEDLINE Link].
Haarbauer-Krupa J, Haileyesus T, Gilchrist J, Mack KA, Law CS, Joseph A. Fall-related traumatic brain injury in children ages 0-4 years. J Safety Res. 2019 Sep. 70:127-33. [QxMD MEDLINE Link]. [Full Text].
Kelly P, Thompson JMD, Koh J, et al. Perinatal risk and protective factors for pediatric abusive head trauma: a multicenter case-control study. J Pediatr. 2017 Aug. 187:240-6.e4. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Allard RH, van Merkesteyn JP, Baart JA. [Child abuse]. Ned Tijdschr Tandheelkd. 2009 Apr. 116(4):186-91. [QxMD MEDLINE Link].
Iranmanesh F. Outcome of head trauma. Indian J Pediatr. 2009 Sep. 76(9):929-31. [QxMD MEDLINE Link].
Garcia Garcia JJ, Manrique Martinez I, Trenchs Sainz de la Maza V, et al for the Grupo de Trabajo de Trauma Craneal de la SEUP. [Registry of mild craniocerebral trauma: multicentre study from the Spanish Association of Pediatric emergencies]. An Pediatr (Barc). 2009 Jul. 71(1):31-7. [QxMD MEDLINE Link].
Mackerle Z, Gal P. Unusual penetrating head injury in children: personal experience and review of the literature. Childs Nerv Syst. 2009 Aug. 25(8):909-13. [QxMD MEDLINE Link].
Haider AH, Crompton JG, Oyetunji T, 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. [QxMD MEDLINE Link].
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Shein SL, Bell MJ, Kochanek PM, et al. Risk factors for mortality in children with abusive head trauma. J Pediatr. 2012 Oct. 161(4):716-722.e1. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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Dias MS, Rottmund CM, Cappos KM, et al. Association of a postnatal parent education program for abusive head trauma with subsequent pediatric abusive head trauma hospitalization rates. JAMA Pediatr. 2017 Mar 1. 171 (3):223-9. [QxMD MEDLINE Link].
Rangarajan N, Kamalakkannan SB, Hasija V, et al. Finite element model of ocular injury in abusive head trauma. J AAPOS. 2009 Aug. 13(4):364-9. [QxMD MEDLINE Link].
[Guideline] First comprehensive pediatric concussion guidelines, available now. Medical Xpress. Available at http://medicalxpress.com/news/2014-06-comprehensive-pediatric-concussion-guidelines.html. June 25, 2014; Accessed: July 2, 2014.
Dawson J, Reed N, Bauman S, Seguin R, Zemek R. Diagnosing and managing paediatric concussion: Key recommendations for general paediatricians and family doctors. Paediatr Child Health. 2021 Nov. 26(7):402-7. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Reed N, Zemek R, Dawson J, et al. The Living Guideline for Diagnosing and Managing Pediatric Concussion. Toronto, ON: Ontario Neurotrauma Foundation; 2019. [Full Text].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Maguire SA, Kemp AM, Lumb RC, Farewell DM. Estimating the probability of abusive head trauma: a pooled analysis. Pediatrics. 2011 Sep. 128(3):e550-64. [QxMD MEDLINE Link].
Leeper CM, Nasr I, McKenna C, Berger RP, Gaines BA. Elevated admission international normalized ratio strongly predicts mortality in victims of abusive head trauma. J Trauma Acute Care Surg. 2016 May. 80(5):711-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Puffenbarger MS, Ahmad FA, Argent M, et al. Reduction of computed tomography use for pediatric closed head injury evaluation at a nonpediatric community emergency department. Acad Emerg Med. 2019 Jul. 26(7):784-95. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Sellin JN, Moreno A, Ryan SL, et al. Children presenting in delayed fashion after minor head trauma with scalp swelling: do they require further workup?. Childs Nerv Syst. 2017 Apr. 33(4):647-52. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
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Media Gallery

Pediatric Head Trauma. Epidural hematoma with midline shift.
Pediatric Head Trauma. Subdural hematoma.
Pediatric Head Trauma. Intraventricular hemorrhage.
Pediatric Head Trauma. Epidural hematoma with acute neurologic deterioration.

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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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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

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.

Specialty Editor Board

Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Chief Editor

Muhammad Waseem, MBBS, MS, FAAP, FACEP, FAHA Professor of Emergency Medicine and Clinical Pediatrics, Weill Cornell Medical College; Attending Physician, Departments of Emergency Medicine and Pediatrics, Lincoln Medical and Mental Health Center; Adjunct Professor of Emergency Medicine, Adjunct Professor of Pediatrics, St George's University School of Medicine, Grenada

Muhammad Waseem, MBBS, MS, FAAP, FACEP, FAHA is a member of the following medical societies: American Academy of Pediatrics, American Academy of Urgent Care Medicine, American College of Emergency Physicians, American Heart Association, American Medical Association, Association of Clinical Research Professionals, Public Responsibility in Medicine and Research, Society for Academic Emergency Medicine, Society for Simulation in Healthcare

Disclosure: Nothing to disclose.

Additional Contributors

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.

Pediatric Head Trauma Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

Tables

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