Pediatric head trauma

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Background

  • TBI in the pediatric population is rare, occuring in 0.9% of the 42,412 PECARN population
  • PECARN rules have become standard of care
    • In patients <2 yrs the aid is 100% sensitive with NPV of 100%
    • In patient >2 yrs the aid is 96.8% sensitive with NPV of 99.95% (with validation studies showing sensitivity of 100% for TBI and injury requiring neurosurgery

Clinical Features

Differential Diagnosis

Intracranial Hemorrhage

Concussion

Maxillofacial Trauma

Orbital trauma

Acute

Subacute/Delayed

Evaluation

Pediatric GCS[1][2]

Eye Opening Verbal Motor
6: Normal spontaneous movement
5: Smiles, coos, babbles 5: Withdraws to touch
4: Opens eyes spontaneously 4: Irritable, crying (but consolable) 4: Withdraws to pain
3: Opens eyes to speech only 3:Inconsolable crying or crying only in response to pain 3: Abnormal flexion to pain (Decorticate response)
2: Opens eyes to pain only 2: Moans in response to pain 2: Abnormal extension to pain (Decerebrate response)
1: Does not open eyes 1: No response 1: No response

Note:

  • For Motor score 4, pain is defined flat, fingernail pressure (often performed with the barrel of a pencil).
  • For Motor scores 2 and 3, pain is defined by pressing hard on the supraorbital notch. If this unsuccessful, sternal pressure may also be attempted.

Adult GCS

Eye Opening Verbal Motor
6: Obeys commands
5: Oriented 5: Localizes to pain
4: Spontaneously opens 4: Confused speech 4: Withdraws from pain (normal flexion)
3: Opens to command 3:Inappropriate words 3: Decorticate posturing (abnormal flexion)
2: Opens to pain 2: Incomprehensible sounds 2: Decerebrate posturing (extension)
1: Does not open 1: No response 1: No response
  • 14-15: Mild
  • 9-13: Moderate
  • 3-8: Severe

Work-Up

Rules below are with the application of PECARN [3]

Management

PECARN Head CT Rule Algorithm

<2 years old

Any 1 of the following?

Then obtain a Non-Con Brain CT (4.4% risk of cTBI)

1 or more of the following?

  • Non-frontal scalp hematoma
  • LOC ≥ 5 seconds
  • Severe injury mechanism
    • pedestrian or bicyclist without helmet struck by motorized vehicle
    • fall >1m or 3ft
    • head struck by high-impact object
  • Abnormal activity per parents

Then consider a Non-Con Brain CT or Observation (0.9% risk of cTBI)

≥2 years old - 18 years

Any 1 of the following?

Then obtain a Non-Con Brain CT (4.3% risk of cTBI)

1 or more of the following?

  • History of vomiting^
  • LOC
  • Severe injury mechanism
    • Pedestrian or bicyclist without helmet struck by motorized vehicle
    • Fall >2m or 5ft
    • Head struck by high-impact object
  • Severe headache

Then consider a Non-Con Brain CT or Observation (0.9% risk of cTBI)

^Consider observation in place of imaging in children with isolated vomiting (no other indication) as the sole risk factor (0.2% risk of cTBI)[4]

Disposition

  • Discharge if:
    • Asymptomatic after 2-4hr obs (not vomiting, nl neuro exam, nl mental status)
    • Head CT normal (delayed deterioration after normal CT is near zero)
  • Consider discharge if:
    • Nondisplaced fracture with out intracranial injury (in consultation with neurosx)

See Also

General/Adult

Pediatric

External Links

References

  1. ↑ Holmes JF, Palchak MJ, MacFarlane T, et al. Performance of the pediatric glasgow coma scale in children with blunt head trauma. Acad Emerg Med. 2005 Sep;12(9):814-9.
  2. ↑ James HE. Neurologic evaluation and support in the child with an acute brain insult. Pediatr Ann. 1986 Jan;15(1):16-22.
  3. ↑ PECARN Rule Kupperman 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 374(9696): 1160, 2009
  4. ↑ Dayan PS, et al. "Association of Traumatic Brain Injuries with Vomiting in Children with Blunt Head Trauma. June 2014. Annals of EM. 63(6):657-665
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