(Lancet 2009;374:1160; Pediatrics 2011;127:1067)
Minor Head Injury
• Normal mental status at initial exam, no abnormal or focal findings on neurologic (including funduscopic) exam. No physical evidence of skull fracture
Clinical Presentation
• Variable; nml or w/ vomiting, poor feeding, lethargy, seizure, respiratory distress, apnea, and lifelessness
• Pertinent history: When did it happen?, mechanism of injury, when did pt return to nml MS and activity (beware “temporary lucid interval” in epidural hemorrhage)
• Concerning history findings: Loss of consciousness (LOC), assess how long, Δ mental status, any seizure, vomiting, HA (postconcussive syndrome, also sign of ↑ ICP [rare]) abn gait, weakness, visual changes (sign of cerebral injury), amnesia
• Exam: Detailed general exam, eval for fractures, check mental status, cranial nerves, muscle strength, coordination, and gait
• GCS score has limited ability to predict outcome in children. For GCS <14, risk of traumatic brain injury on CT >20%
Diagnostic Studies
• Labs: Consider CBC, w/ platelet count, PT/PTT to evaluate for coagulation disorders, blood bank sample
• Imaging:
• Noncontrast head CT: Obtain immediately as guided above
• Rapid Sequence T2-weighted MR: If available, consider MR as an alternative to CT given risk of radiation w/ CT. MR can demonstrate structural changes (midline shift, mass effect), hematomas, & volume Δ’s. (Arch Phys Med Rehabil 2010;91:1661)
• Skull films: Not sensitive for brain injury; if +fracture, CT is indicated
Management
• Stabilize patient following ABC rules, call trauma team or neurosurgery if needed
• Look for signs suggestive of ↑ ICP and manage if necessary (see later discussion)
• Observation: All children w/ minor head injury obs 4–6 hr in ED. Patients who are observed before making the decision for CT scan have significantly lower rates of CT use and similar rate of clinically important TBI
• Admission criteria
• Δ in mental status, neurologic deficits, seizures, persistent HA, persistent vomiting
• CSF otorrhea/rhinorrhea (requires antibiotics) or hemotympanum
• Linear skull fracture crossing middle meningeal artery groove, venous sinus,
foramen magnum
• Depressed skull fracture, skull base fracture
• Suspected child abuse or bleeding disorder
• Discharge instructions: F/u w/i 24 hr, at least by phone, should be arranged for all children who are discharged following a head injury
• Immediate medical attention required if the following conditions are noted:
• Inability to awaken the child as instructed. Persistent or worsening headache
• Continued vomiting or vomiting that begins/continues 4–6 hr after injury
• Change in mental status or behavior. Unsteady gait or clumsiness/incoordination
• Seizure
Concussion (Pediatrics 2010;126:597)
• Caused by direct or transmitted blow to head/neck. Results in a set of graded clinical sx that may or may not involve LOC. Nml neuroimaging. May result in neuropathologic Δ’s
• Estimated 3.8 million recreation and sports-related concussions annually
• F > M in similar sports. Football highest for boys, soccer for girls
• When seen in the ED, athlete should not return to play the same day
Stepwise Return to Play (AAP Guidelines; Pediatrics 2010;126:597)
• Each stage in concussion rehabilitation should last no less than 24 hr with a minimum of 5 d required to consider a full return to competition. If symptoms recur during the rehabilitation program, the athlete should stop immediately. Once asymptomatic after at least another 24 hr, the athlete should resume at the previous asymptomatic level and try to progress again. Athletes should contact their healthcare provider if symptoms recur. Any athlete with multiple concussions or prolonged symptoms may require a longer concussion-rehabilitation program, which is ideally created by a physician who is experienced in concussion management
