Head Trauma

Abstract

Trauma is the leading cause of death in the pediatric population, and brain injury is the most significant cause of trauma-related mortality. The best “treatment” is prevention through the use of car seats, seat belts, and bike helmets. Even with effective preventative measures, a large number of patients with head injuries still present every day to emergency rooms and trauma centers and their outcome is greatly affected by prompt and effective neurosurgical care.

Appendices

Summary Points

Trauma is the leading cause of death in children, and brain injury is the leading cause of trauma-related mortality.

The best “treatment” is prevention: car seats, seat belts, and bike helmets.

The initial management of the head-injured child is supportive and requires efficient management of airway, breathing, and circulation.

Hypoxia and hypotension can lead to secondary neurologic injury.

Ideally, the head-injured child should get necessary imaging studies within 30 min of arrival to the trauma bay.

Editor’s Comment

The child with a potential head injury should be managed according to standard ATLS protocols, with initial assessment of airway, breathing, and circulation, and rapid but thorough primary and secondary surveys. Time is of the essence and the patient needs to have a CT scan of the head as soon as possible; but sending an unstable patient to the CT scanner defeats the purpose. Temperature should be regulated to avoid both hyperthermia and hypothermia. Despite its potential benefit in the case of spinal cord injury, at this time corticosteroids have no role in the management of traumatic brain injury. The comatose patient (GCS≤8) should be intubated prior to leaving the trauma bay, with careful in-line traction of the neck and minimal extension of the neck. An orogastric tube should be used to decompress the stomach; nasogastric tubes are avoided due to the possibility of a cribiform plate fracture and subsequent intracranial penetration. During the primary survey the scalp should be carefully inspected and palpated. Scalp lacerations can bleed extensively and in a small child this can lead rapidly to exsanguination. Puncture wounds of the scalp or forehead in an infant can be a sign of a penetrating head injury. To avoid dangerous intracranial pressure elevation, seizures should be treated aggressively with rapid IV administration of fosphenytoin. Finally, it should be kept in mind that brain injury can result in ­significant ­coagulopathy due to release of brain tissue thromboplastins, which can have significant systemic consequences.

Nowadays, there appears to be a very low threshold to recommend head CT in children with a potential head injury. Although regional and institutional protocols vary, for the most part any child with evidence of injury above the clavicles, a suggestive mechanism, or a history of loss of consciousness or even the slightest mental status change or neurologic deficit will get a scan. Although a period of observation with serial neurologic assessment is probably just as safe and avoids unnecessary exposure of the developing brain to ionizing radiation, there seems to be a widespread belief that frequent scanning is the best way to avoid a missed injury (and a lawsuit). MRI is also being used with increasing frequency to assess the degree of diffuse axonal damage and previously under-appreciated cervical ligamentous injuries. Whether this is of any clinical significance in most cases is unclear. Nevertheless, head CT remains the initial study of choice in the assessment of acute brain injury.

Differential Diagnosis

Diffuse axonal injury

Intraparenchymal hemorrhage

Epidural hematoma

Subdural hematoma

Linear skull fracture

Depressed skull fracture

Growing skull fracture with leptomeningeal cyst

Parental Preparation

The goal for treatment after a head injury is to prevent secondary brain injury from hypoxia, hypotension, and increased intracranial pressure.

Fractures and hematomas are not dangerous in and of themselves, but only to the extent that they cause underlying brain injury.

Even after the initial management of the injury, there is often a long period of physical rehabilitation required to achieve maximal recovery.

Preoperative Preparation

Airway, Breathing, Circulation

Intravenous access

Fluid resuscitation

Arterial cannula

Prophylactic antibiotics

ICP monitoring

Detailed imaging

Diagnostic Studies

CT scan

Arterial blood gas

Serum sodium level

Intracranial pressure measurement

Technical Points

Every patient with a head injury should be presumed to have a spine injury until proven otherwise: cervical spinal immobilization and transportation on a rigid backboard.

The presence of an epidural or subdural hemorrhage is often a neurosurgical emergency requiring immediate evacuation to lower intracranial pressure.

Patients with severe head trauma who do not have a reliable exam should undergo placement of an ICP monitor.

Hyperventilation (PaCO₂ 30–34 mmHg) is used only transiently until other medical therapies are instituted.

The patient with persistent ICP elevation can be treated with hypertonic saline to maintain a sodium level of 155 mmol/L.

Patients with refractory ICP elevation can be treated by pentobarbital-induced coma.

If medical management of increased ICP is inadequate, move to surgical decompression (hemi- or bifrontal craniectomy).

With a depressed skull fracture, indications for operation are: large underlying hematoma, neurologic deficit, break in the skin with gross contamination of wound, CSF leak, and location that will result to poor cosmetic outcome.