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Journal of Child Neurology

Original Article Volume 25 Number 2

February 2010 146-156

Head Trauma in Children, Part 1: # 2010 The Author(s)

Admission, Diagnostics, and Findings
Thomas Kapapa, MD, Kathrin König, MD, Ulrike Pfister, MD,
Michael Sasse, MD, Dieter Woischneck, MD, PhD, Hans Heissler, and
Eckhard Rickels, MD, PhD

The objective of this study is to describe and to determine the the severity of trauma according to the Glasgow Coma Score,
preclinical situation and early in-clinical situation, diagnostic the most accurate parameter for outcome is based on the
findings, and factors influencing the outcome of severe head detailed quality of ‘‘eye opening’’ (P ¼ .0155). Pupillary
trauma in children. Records of 48 children (0-16 years) were motoricity at the accident site (P ¼ .002) and emergency
analyzed during a 3-year interval. Correlations with the out- room (P ¼ .0004) are strong predictors. Preclinical measure-
come (Glasgow Outcome Scale) were determined by focusing ments of stabilization and oxygenation have the same impact
on different scales, clinical findings, biochemistry, and as the in-clinical management.
clinical course features. The initial shock index had a major
relevance (P ¼ .0089). Systolic blood pressure (P ¼ .0002) Keywords: head trauma; outcome; prognostic factor; cere-
and bradycardia (P ¼ .035) were important factors. Assessing bral perfusion pressure

hildren’s severe head trauma and traumatic brain number of children with severe head trauma is still high
injury are global challenges with local differ- as stated in a prolonged study from Denmark.4
ences. A French population of 9 million had 671 As stated by the German Federal Statistical Office, the
children with severe traumatic brain injury with need of incidence of head injuries in children younger than
intensive care.1 Based on population counts for children 15 years rose from 2001 to 2006 with 773/100 000 to
(0-14 years) from 2001 in the United Kingdom and Eire 817/100 000. The incidence of intracranial injuries
(N ¼ 22 210 476), the prevalence of severe traumatic remained constant with 568/100 000 in 2001 and 570/
brain injury (February 2001 to August 2003) was 1246 100 000 in 2006.5 Head trauma is one of the major diag-
children with admittance to an intensive care ward.2 The noses after accidents in young patients younger than 15 years
incidence of traumatic head trauma and brain injury old. In 1999, 86 497 children up to 15 years old were
among children (0-14 years) in the United States has esti- admitted and treated for head trauma. In 2001, 158 chil-
mated to be 475 000 injuries each year (1995-2001).3 dren (98 male, 60 female) died as a result of an accident
Even when there has been a decrease of incidences, the and subsequent head trauma. In this regard, traffic acci-
dents (119) are a major cause of death in Germany.6-8
Received October 31, 2008. Received revised January 12, 2009. Accepted
Standards are being sought in the treatment of head
for publication January 12, 2009. trauma because of varying therapeutic concepts in neurosur-
From the Department of Neurosurgery, University of Ulm, Ulm, Germany gery.9 Adapted from the guidelines, we performed and
(TK, DW, ER), Department of Neurosurgery, Krankenhaus Nordstadt, discussed the cerebral perfusion pressure–guided concept
Hannover, Germany (KK), Department of Pediatric Medicine, in the treatment of child head trauma.10-12 Accordingly, all
Clementine Hospital, Frankfurt am Main, Germany (UP), Department
of Pediatric Medicine, Intensive Care Unit (MS), and Department of children with head trauma, a Glasgow Coma Score of 8 (or
Neurosurgery (HH), Medizinische Hochschule Hannover, Hannover, lower) at the accident site, and secondary alterations of
Germany. consciousness were treated in a standardized manner. The
The authors have no conflicts of interest to disclose with regard to this objective of management is the prevention of secondary brain
article. damage. Therefore, prevention of increased intracranial
Address correspondence to: Thomas Kapapa, Universitätsklinik Ulm, pressure through brain edema as well as maintenance of
Neurochirurgische Klinik, Steinhövelstraße 9, 89075 Ulm, Germany;
reasonable cerebral perfusion has been the highest priority.
Hence, the purpose of this part of our study is to
Kapapa T, König K, Pfister U, Sasse M, Woischneck D, Heissler H,
Rickels E. Head trauma in children, part 1: admission, diagnostics, and describe the preclinical and early in-clinical situations and
findings. J Child Neurol. 2010;25:146-156. management in children with severe head trauma. The

Head Trauma in Children Part 1 / Kapapa et al 147

second part of our study will present benefits and limita- Results
tions of the cerebral perfusion pressure–guided manage-
ment after severe head trauma. Between January 1998 and January 2001, 48 children
were treated at an intensive care unit for severe head
trauma. There were 16 (33.3%) female and 32 (66.7%)
male patients. Age ranged from 19 days to 14.5 years.
Patients and Methods Mean age was 5.9 years. Because of the different levels
of maturation, groups were created according to age
The primary objective was to select factors that would predict a (Table 5). The height ranged from 49 to 165 cm; mean
child’s outcome after severe head trauma. To achieve this height was 110 cm. The minimum weight was 4.4 kg and
objective, 48 children who had suffered a head trauma, which
the maximum weight was 55 kg with the mean calculated
required intensive care, were evaluated retrospectively. Treat-
ment was administered according to a protocol established in
at 22.5 kg.
1998 (Figure 1). This protocol called for early monitoring of
intracranial pressure with the presence of correlating symptoms Accident Site, Transport, and Emergency Room
and cerebral perfusion pressure–guided therapy. The study was
not affected by special drug studies that could have falsified the Frequencies in accident causes, interval without therapy
results. Medical records were evaluated for hospitalized children (between the accident and the administration of first aid
between 0 and 16 years old from January 1998 to January 2001. by paramedics or an emergency physician), and lifesaving
Special attention was paid to the assessment of conscious- measures are given in Table 6.
ness and vital functions so that secondary brain damage due to
hypoxia and hypotension could be prevented with appropriate
treatment. Severity of Trauma According to Glasgow Coma
The severity of head trauma was evaluated according to the Scores
Glasgow Coma Score at the accident site. A Glasgow Coma
Eleven (22.9%) children were evaluated as having a
Score  8 following trauma described a severe head trauma. The
children were examined from the perspective of traumatology
Glasgow Coma Score of >8. A total of 37 children
and neurology. Tests performed after arriving at the emergency (77.1%) had a severe head trauma (Glasgow Coma Score
room included an ultrasound of the abdomen, and radiographs 8). Comparing the Glasgow Coma Score with the
of the chest, cervical spine, and extremities. If indicated, a trauma Glasgow Outcome Scale, a poor outcome is mainly found
scan (computer tomography [CT] of the neurocranium, spine, in patients with a Glasgow Coma Score  8. The lower the
chest, and abdomen in children with a Glasgow Coma Score of Glasgow Coma Score, the higher the probability of a poor
8 was also ordered. The clinical examination, radiograph, CT, outcome (P ¼ .0151). The most accurately calculated
and ultrasound were used to determine the pattern of injury. The parameter for a poor or good outcome is based on detailed
number of injuries and their localization were assessed. qualities such as ‘‘eye opening’’ (P ¼ .0155) and ‘‘best
During intensive care, important parameters were moni- motor response’’ (P ¼ .0159).
tored. If continual sedation was administered, the intracranial
pressure was monitored by inserting an intracranial pressure
transducer (intrapernchymal). If intracranial pressure measure- Level of Consciousness
ment was not necessary and the patient was neurologically asses-
sable, a CT was frequently taken. Additionally, the children’s The majority of patients were found unconscious (n ¼ 31;
intensive care unit also had access to transcranial ultrasound, 64.6%). Twelve children (25%) had a moderately dis-
Doppler ultrasound of the intracranial vessels, and electroence- turbed level of consciousness and 5 (10.4%) were fully
phalogram. Microdialysis was used to determine tissue biochem- oriented. Every fully oriented child who was admitted was
istry (eg, metabolic factors such as glucose, lactate, pyruvate, discharged with a good outcome (Glasgow Outcome Scale
glutamate, or glycerol). A scheme of therapeutical management Group II; Table 4). This also applied to the majority of
is shown in Figure 1. children with a moderately disturbed level of conscious-
Demographic and organizational data were collected ness. The prognosis could not be calculated based on the
retrospectively and are shown in Table 1. The values for mean level of consciousness at the accident site. Only 1 of those
arterial pressure, central venous pressure, heart rate, and cerebral admitted in poor condition had a poor outcome. The
perfusion pressure were matched for age groups to facilitate a bet-
better the level of consciousness, the more likely that it
ter comparison. This was also done for the outcome (Glasgow
Outcome Scale). Classification into Glasgow Coma Score and
will be correlated to a good outcome (P ¼ .0152).
Glasgow Outcome Scale was performed accordingly (Tables 2-4).
Univariant, multivariant, and mainly the regression analysis
with different scale values were used. Especially binary logistic Pupillary Reflex
regression, t test, or 2 test was applied. Level of significance was
defined to P  .05. The study was approved by an ethics Although checking the pupillary motoricity is a standar-
committee. dized examination in head trauma, the pupillary reflex was
148 Journal of Child Neurology / Vol. 25, No. 2, February 2010

Figure 1. Management of children with severe head trauma at emergency room and intensive care ward. CVP, Central venous pressure; CPP,
Cerebral perfusion pressure; CT, Computed tomography; EEG, Electroencephalogram; GCS, Glasgow Coma Score; GOS, Glasgow Outcome Scale;
ICP, Intracerebral/-cranial pressure; MAP, Mean arterial pressure.
Head Trauma in Children Part 1 / Kapapa et al 149

Table 1. Overview of the Collected Data

Admission Accident Emergency Room Various Data

Data of birth Date Cardiovascular system Imaging diagnostics

Gender Time Aeration Pattern of injuries
Height Mechanism Body temperature Scores
Weight Aeration Consciousness Drugs
Body surface Reanimation Duration of reanimation Neurostatus
Date and time of admission Parameters of cardiovascular system Need and time of intubation Laboratory parameters
Age at admission Glasgow Coma Score Glasgow Coma Score of first six days
Date of transfer to Time without therapy or treatment Movements of different extremities Pattern of artificial ventilation
the normal ward Aspiration Status of pupils Glasgow Outcome Scale
Date of discharge Need and time of intubations Brain stem reflexes Circumstances of surgical
Date of admission and Movements of different extremities treatments
discharge from rehabilitation Consciousness
Circumstances of fatality Status of pupils
Brain stem reflexes

Table 2. Normal Mean Arterial Pressure, Central Table 3. Normal Cerebral Perfusion Pressure According
Venous Pressure, and Heart Rate According to Age to Age

Mean Arterial Age Group Cerebral Perfusion Pressure

Pressure Central Venous Heart Rate
Up to 1 month >40
Age Group (mm Hg) Pressure (mm Hg) (BPM)
2 months up to 1 year >45
Up to 1 month 40-70 2-10 80-210 1 year up to 7 years >50
2 months up to 1 year 50-80 2-10 75-200 From year 7 onward >55-60
1 year up to 7 years 55-90 2-10 65-170
From year 7 onward 60-100 2-10 50-160
Note: BPM, beats per minute.

effect on the outcome (P ¼ .0001). One half of the patients

documented in only 34 patients at the accident site and in with initial body temperatures below 35 C (95 F) were
45 patients in the emergency room. Both the pupillary finally discharged with a poor outcome.
motoricity at the accident site (P ¼ .002) and in the
emergency room (P ¼ .0004) significantly influenced the
outcome. The more pathological the pupillary reflex Stabilization Procedures at the Accident Site
(anisochoria, mydriasis, and fixed pupils), the higher the Eight children (16.7%) required advanced procedures to
probability of a poor outcome. stabilize their cardiopulmonary status when the emer-
gency physician arrived. One case required repeated
resuscitation attempts in the emergency room. Overall,
Cardiopulmonary Status
10 (20.8%) children required stabilization procedures
Initial shock index at the accident site was significantly (accident site or emergency room). The necessity of
associated with a poor outcome (P ¼ .0089). A systolic resuscitation correlates significantly with the outcome
blood pressure (P ¼ .0002) and bradycardia (P ¼ .035) (P ¼ .0003). All patients survived the acute stabilization
under age-adjusted normal values were important factors procedures. The first fatality occurred 1 day after stabili-
indicating a poor outcome. Furthermore, a low systolic zation. With regard to stabilization and subsequent
blood pressure in the emergency room (P ¼ .035) was outcome, 6 patients died, 1 patient remained in a persis-
associated with a poor outcome. The diastolic blood pres- tent vegetative state (Glasgow Outcome Scale Group I:
sure, heart rate, and shock index in the emergency room N ¼ 7; 70%), and 3 patients achieved a favorable outcome
were not significantly related to outcome. (Glasgow Outcome Scale Group II: N ¼ 3; 30%).

Body Temperature Status at Admission and Outcome

Bladder catheter or external body temperature measured in To compare the status at admission and the outcome
the emergency room and intensive care unit had a significant according to age, patients were assigned to groups of
150 Journal of Child Neurology / Vol. 25, No. 2, February 2010

Table 4. Classification According to Glasgow Outcome Table 5. Classification According to Age

Scale, Dichotomization of Glasgow Outcome Scale, and
Group Age N
Glasgow Coma Score
Poor Outcome Good Outcome Group 1 Up to the year 1 7 (14.6%)
Group 2 Year 1 to year 7 25 (52.1%)
Glasgow Outcome Glasgow Outcome Scale Group II 1-3 years 6 (24%)
Scale Group I 3-7 years 19 (76%)
Glasgow Outcome Glasgow Outcome Scores 3, 4, and 5 Group 3 From year 7 onward 16 (33.3%)
Scores 1 and 2

Score Translation Statistics Four patients (8.3%) remained in a persistent vegeta-

Glasgow Coma Poor admission Glasgow Coma Score  8 tive state (Glasgow Outcome Scale 2). They were
Score 3 to 8 transferred directly to clinical rehabilitation. Severe
Glasgow Coma Good admission Glasgow Coma Score > 8 impairments (Glasgow Outcome Scale 3) could be found
Score 9 to 15 in 8 (16.7%) patients after treatment in the intensive care
Glasgow Outcome Poor outcome Glasgow Outcome
unit; 5 were transferred directly to clinical rehabilitation.
Scale 1 and 2 Scale Group I
Glasgow Outcome Good outcome Glasgow Outcome Of the 5 patients (10.4%) with moderate impairment
Scale 3 to 5 Scale Group II (Glasgow Outcome Scale 4) and 21 (43.8%) patients
without any impairment (Glasgow Outcome Scale 5),
5 patients participated in a brief period of rehabilitation
Glasgow Outcome Scale 1 and 2 ¼ Glasgow Outcome following inpatient treatment.
Scale Group I and Glasgow Outcome Scale 3-5 ¼ Glasgow
Outcome Scale Group II (Table 4). There was no instance
of a good admission (Glasgow Coma Score > 8) and a sub- Imaging Diagnostics
sequent poor outcome (Glasgow Outcome Scale Group I).
The age group ‘‘up to year 1’’ had 5 patients (71.4%) with a Cranial CT. Cranial CT was performed on 44 patients
poor admission (Glasgow Coma Score  8) and a subse- on the day of admission. Only 4 patients exhibited moder-
quent good outcome (Glasgow Outcome Scale Group II). ate or light head trauma. In these patients, cranial CT was
The age group in ‘‘year 1 to year 7’’ had 5 (20%) patients and performed 1 day later. Twelve (25%) of 48 patients had no
the age group ‘‘from year 7 onward’’ had 4 (25%) patients pathological findings in the cranial CT. The remaining
with the identical course (Figure 2, Table 7). results can be seen in Table 8. Significant correlations
Children with a poor status on admission (Glasgow of imaging results and outcome were found only if
Coma Score  8) and a good outcome (Glasgow Outcome cofactors such as hypoxia (P ¼ .0011) and brain edema
Scale Group II) are mainly found in the age group ‘‘year 1 (P ¼ .0001). Twenty-two children (71%) suffered from
to year 7’’ which contains 13 (52%) patients (Table 7). The severe brain edema accompanied by compression of the
age group ‘‘from year 7 onward’’ had 10 (62%) patients and subarachnoid space and basal cisterns. Because of this,
the age group ‘‘up to year 1’’ had 1 (14.3%) patient with 12 (38.7%) patients were discharged with a poor outcome
this course. Overall, the results showed a good outcome and 10 (32.3%) patients with a good outcome. One patient
(Glasgow Outcome Scale Group II) after a good admission died as a result of cerebral herniation. Of the 8 patients
(Glasgow Coma Score > 8). The majority of patients (N ¼ (25.8%) with moderate brain swelling, 1 patient died.
34, 70.8%) could be discharged in good condition accord-
ing to the Glasgow Outcome Scale (Figure 2). Chest radiograph and ultrasound. In 17 patients (35.4%),
In 27 survivors (56.3%) with a Glasgow Coma Score of the routine chest radiograph was deemed to be unremark-
8, 14 patients (29.2%) could be transferred to rehabilita- able in the emergency room. Other results are shown in
tion. They exhibited paresis, plegia, paresis of the cranial Table 9. Neither rib fractures nor lung pathology corre-
nerves, speech disorders, mental and coordination disor- lated significantly with the outcome.
ders, and organic psychological problems. Only 1 partici- Ultrasound detected blunt abdominal trauma and
pant suffered from seizures. Headaches and sensory intra-abdominal bleeding in 2 cases as well as perirenal
disorders were rare. Results for the precarious preschool bleeding in 1 case. These injuries were not correlated to
age of 1 to 3 years and 3 to 7 years are given in Table 7. the outcome.

Morbidity and Mortality Pattern of Injuries

Head trauma resulted in 10 fatal cases (20.8%). The Head trauma had the greatest impact in 21 children.
majority died during the first 4 days in the intensive care Fifteen (31.3%) of those were discharged with a favorable
unit; 2 patients died on day 6, and 9 after admission. outcome (Glasgow Outcome Scale Group II) and 6
Head Trauma in Children Part 1 / Kapapa et al 151

Table 6. Accident Causes, Interval Without Therapy, and Lifesaving Measures

Interval Without Therapy
Accident Causes N (S ¼ 43 Minutes; Table 4) Minutes Lifesaving Measures N

Traffic accident 26 (54.2%) Glasgow Outcome Scale Group I 15 Helicopter 13 (27.1%)

Fall 14 (29.2%) Glasgow Outcome Scale Group II 9.5 Paramedics and emergency physician 30 (62.5%)
Other (falling objects, kicked 8 (16.7%) Paramedic alone 3 (6.3%)
by horse, and confrontations) Parents 2 (4.2%)
No statistical relationship between Difference is not statistically No relationship between the
the accident mechanism and the outcome significant measures and the outcome


From year 7 onward

Despite the brief period of investigation, the number
of participants is useful. Because of this, the distribu-
tion according to age and severity of head trauma was
inhomogeneous. Thus, a normal age distribution had
Year 1 to year 7 to be generated according to circulation and chemical
parameters as well as the cerebral perfusion pressure.
This provided comparability. All children were given
Up to year 1
optimal care with the consequence that there is no
control group when comparing intracranial pressure
therapy or surgical treatment. This complicates a
20% 40% 60% 80% 100% direct comparison.
GCS ≤ 8; GOS Group I (= GOS 1 and 2)
GCS ≤ 8; GOS Group II (= GOS 3-5)
GCS > 8; GOS group II ( = GOS 3-5)

Figure 2. Admission and outcome according to age.
Age and Sex

(12.5%) with a poor outcome. A more complex injury pat- Age ranged between 0 and 15 years. The mean age was
tern involving head trauma was found in 27 patients. 5.9 years. The majority of patients were male 3 (66%).
However, the head trauma was the predominant injury. These results are comparable to other epidemiological
Of those patients suffering from multiple trauma, 19 findings.1-3,7,10-12,14-16
(39.6%) could be discharged in good condition (Glasgow A comparison of age groups revealed that children
Outcome Scale group II) and 8 (16.7%) with a poor out- up to year 1 with severe head trauma (Glasgow Coma
come. A comparison of patients with isolated head trauma Score  8) composed the majority in poor outcome
and patients with multiple traumas revealed no significant (83%). The proportion of poor outcome within the other
differences. age groups was 29%. This finding is also comparable to
other studies.1,17
According to the traumatic coma data bank, Levin
et al18 have described a poor outcome in children less than
4 years. This is the result of high mortality (62%) during
Scores from the Glasgow Outcome Scale (Glasgow the first year. Subdural hematomas (20%) and hypoten-
Outcome Scale), Pediatric Risk of Mortality Score, Version sion (32%) dominated the cases. The best outcome was
III, Abbreviated Injury Score, and Injury Severity Score found in children between 5 and 10 years old. Of these,
were determined retrospectively based on patient medical 66% could be discharged with a favorable outcome. A sig-
records. The Pediatric Risk of Mortality Score correlates nificant correlation between age and outcome could not
significantly with the outcome (P ¼ .0006). Abbreviated be confirmed by Bruce et al and Ong et al.19,20 Gruskin
Injury Score and Injury Severity Score were focused on only and Schutzman21 and Engberg and Teasdale4 described
those patients who were classified as a polytrauma, accord- a higher risk for skull fractures and intracranial injury in
ing to the definition of Injury Severity Score, N ¼ 11 (Injury children younger than 12 months (29%) compared to
Severity Score > 16).13 These scores did not correlate. children aged 13 to 24 months (4%; P < .001).
152 Journal of Child Neurology / Vol. 25, No. 2, February 2010

Table 7. Preclinical, In-hospital Conditions, CT Findings, Intracranial Pressure Decision, and Outcome in Preschool Age
Children (With Abbreviations)

GCS at
Accident Consciousness at Status at Admission Morbidity and ICP
25 Children in 3 to 7 years Site Accident Site and Outcome (GOS) Mortality CT Measurement

1-3 years, N ¼ 6; Falls: > 8; N ¼ 1 Full orientated; In GCS > 8, out GOS Death; N ¼ 2 (8%; Diffuse injuries; Yes;N ¼ 3
N ¼ 4, Traffic accident: (4%) N ¼ 1 (4%) II N ¼ 1 (4%) Herniation) N ¼ 2 (8%) (12%)
N¼2 Disturbed In GCS 8, out GOS Persistent vegetative Severe intracerebral
consciousness; II; N ¼ 2 (8%) state N ¼ 0 (0%) lesions; N ¼ 3
N ¼ 1 (4%) (12%)
8; N ¼ 5 Unconscious; In GCS > 8, out GOS Severe impaired; Brain edema and/or No; N ¼ 3
(20%) N ¼ 4 (16%) I; N ¼ 0 (0%) N ¼ 1 (4%) brain shift; (12%)
N ¼ 4 (16%)
In GCS  8, out GOS No impairments; Fracture; N ¼ 3 (12%)
I; N ¼ 3 (12%) N ¼ 3 (12%)
3-7 years, N ¼ 19; >8; N ¼ 5 Full orientated; In GCS > 8, out GOS Death Diffuse injuries; Yes; N ¼ 3
Falls: N ¼ 5; (20%) N ¼ 1 (4%) II; N ¼ 5 (20%) N ¼ 1 (4%) N ¼ 10 (40%) (12%)
Hit/Kick by Horse: N ¼ 3; disturbed In GCS  8, out GOS Persistent vegetative Severe lesions;
Traffic accident: N ¼ 11 consciousness; II; N ¼ 11 (44%) state; N ¼ 2 (12%) N ¼ 9 (36%)
N ¼ 7 (28%)
8; N ¼ 14 Unconscious; In GCS > 8, out GOS Severe impaired; Brain edema; brain No; N ¼ 16
(56%) N ¼ 11 (44%) I; N ¼ 0 (0%) N ¼ 2 (8%) shift; N ¼ 9 (36%) (64%)
In GCS  8, out GOS No impairments; Fracture; N ¼ 7 (28%)
I; N ¼ 3 (12%) N ¼ 14 (56%)
Note: CT, computer tomography; GCS, Glasgow Coma Scores; ICP, intracerebral/-cranial pressure.

Cause of Accidents if treatment is started in the intensive care unit. In adults,

the fatality rate is specified at 35% to 45%.17,23
The majority of authors mention traffic accidents as the
main cause of head trauma in children. Traffic accidents
were followed by falls.7,8,15,22 Our study confirmed traffic Evaluation of Consciousness and Severity of
accidents (54.2%) as the major cause of severe head trauma. Head Trauma
Falls were responsible for 29.2% of the head trauma cases in
children. There was no statistical relationship between the The physical examination of children with head trauma
causes of an accident and the final outcome. must be quick and safe to evaluate the severity. There is
a great variety of neurotrauma pediatric scales.26-32 They
manage the assessment of neurological status according
children’s age, cognitive abilities such as speech and obey-
ing, motor function, papillary reflexes, and consciousness.
According to the German Federal Statistics Office, They are also considering causation of trauma. In addition
86 497 children were admitted and subsequently treated to these tests, the Trauma-Infant-Neurological-Score is
for head trauma in 1999.8 This includes children who increasingly used.26
were admitted for a 24-hour period of monitoring. In our study, the Glasgow Coma Score is an important
A direct comparison of data from different countries is predictive factor. To evaluate the initial severity of head
virtually impossible because of the markedly different study trauma, the Glasgow Coma Score is widely used.33,34 This
designs and the differences in measures and scales. For the is a reliable and comparable classification system.
United Kingdom, a mortality rate up to 23% for severe head Furthermore, the Glasgow Coma Scores exhibit predictive
trauma is reported.2,14 For the United States, a rate of up to qualities with respect to the outcome.15,19,35,36
35% was reported in various studies.3,17,23,24 The annual In the medical literature, traits such as the ‘‘best motor
death rate from head trauma was reported at 22 per response’’ appear to have a notable impact on predicting
10 000 in France (region of Aquitaine).25 the outcome, because they can be more readily evaluated
In a previous study, we reported a mortality rate of 22% in children than activities such as ‘‘eye opening’’ and ‘‘best
in children with severe traumatic brain injury after admis- verbal response.’’17,37,38
sion.7 These results were supported by new study results Ong et al20 calculated a predictive value that is 2 to
that yielded a mortality of 20.8%. This proportion changes 4 times higher at the limits of Glasgow Coma Score  8
to a value of 27% if the mortality rate is based only on in the presence of hypoxia. Our study showed the use of
children with a Glasgow Coma Score  8 at admission and sedative drugs at the accident site in 54.2% of the cases.
Head Trauma in Children Part 1 / Kapapa et al 153

Table 8. Results of Cranial Computed Tomography Table 9. Results of Radiography Investigations

N % Chest Radiograph Radiographic
Findings N % Fracture Findings N %
Diffuse injuries
Cerebral concussion 12 25.0 Pneumothorax 9 18.8 Cervical spine 1 2.1
Contusion of the brain, unilateral 29 60.4 Hemothorax 10 20.8 Scapula 1 2.1
Contusion of the brain, bilateral 6 12.5 Pleural effusion 7 14.6 Clavicle 4 8.3
Severe lesions Pulmonary contusion 4 8.3 Shoulder 1 2.1
Epidural hematoma 9 18.8 Reduced ventilation 30 62.3 Humerus 1 2.1
Subdural hematoma 10 20.8 Pneumonia 3 6.3 Radius/ulna 1 2.1
Subarachnoid hemorrhage 5 10.4 Rib fracture 3 6.3 Finger bones 4 8.3
Contusion of the brain 22 45.8 Femur 2 4.2
Ventricular rupture 5 10.4 Tibia/fibula 1 2.1
Cerebral infarction 4 8.3
Disturbances in circulation of cerebrospinal fluid 4 8.3
Cerebral hypoxia 4 8.3 periodically after head trauma for prognostic evaluation.
Brain edema Taylor et al41 reported a dysfunction of pupil motoricity
Moderate compression of subarachnoid space 8 16.7
after an intracranial pressure > 30 mm Hg due to diffuse
Severe compression of subarachnoid space 22 45.8
Herniation 1 2.1 brain edema. If the elevated intracranial pressure
Brain shift (cm) (>20 mm Hg) is accompanied by a brain shift, it was
1 10 20.8 possible to detect a delay in the pupillary response of up
>1 5 10.4 to 0.6 mm/s on the side of compression.
Lesions of brain stem
Pontine hemorrhage 4 8.3
Fractures Injury Pattern
Fractures of the cranium (unspecified) 6 12.5
Fracture of the roof of the skull/depressed fracture 14 29.2 The likelihood and type of additional injuries in children
Separation of cranial sutures 5 10.4 with head trauma are not equally represented. This is the
Midfacial fracture 3 6.3 result of a different presentation in the severity and pat-
Fracture of the sphenoid bone 2 4.2
Fracture of petrous bone 5 10.4
tern of head trauma. In 43.8% of the patients, multiple
Fracture of the base of the skull 2 4.2 injuries with head trauma occurred. The majority of addi-
Fracture of the orbital floor/cap 6 12.5 tional injuries were thoracic injuries, followed by injuries
Fracture of the zygomatic bone 4 8.3 of the extremities and abdomen. In the medical literature,
Fracture of maxilla/mandible 1 2.1 the incidence of combined injuries was reported at
between 14% and 60% with the main proportion being
accounted for injuries to the extremities.17,40,42 Our study
In 56.3% of the cases, artificial ventilation was required. did not confirm a negative effect of additional injuries on
Before stabilization of the cardiopulmonary system, the outcome like the study of Pfenninger and Santi.40
children were assessed according to the Glasgow Coma However, other studies did.15,20
Score. The preclinical management improved because of
goal-orientated therapy at the accident site and a reduced
Cardiopulmonary Status
rescue time. However, particularly with regard to the
indication of artificial ventilation, drugs are required and A readily available blood supply and a stable status for
this complicates the assessment of consciousness after good gas exchange and stabile circulation determines the
hospital admission.39 prognosis following head trauma in children.43 Circula-
In our study, the Glasgow Coma Score exhibits a tion must guarantee adequate perfusion in all vital organs,
probable correlation to poor outcome at the lower level of most especially the brain.44
Glasgow Coma Score scale. The best calculated likelihood Many studies report the occurrence of hypotension
of outcome is based on detailed qualities such as ‘‘eye open- during shock after severe head trauma in children. There
ing’’ and ‘‘best motor response.’’ Of these qualities, the first is a consensus about what constitutes a sufficient mean
category is mainly associated with a good outcome. arterial blood pressure in children. However, whether and
how this influences the outcome is under dispute.10,17,20
Pigula et al45 reported an increased mortality with a
Pupillary Reflex
systolic blood pressure < 90 mm Hg. Accompanied by
Much is known about the poor outcome associated with hypoxia (PaO2 < 90mm Hg), low systolic blood pressure
bilaterally disturbed pupillary reflexes after head increases secondary brain damage and mortality by up to
trauma.17,23,37,40 We confirm these results. Assessment 4 times.6,7,45 He stated that children with hypoxia and
of pupil motor function is quick and should be performed physiological blood pressure do not exhibit a higher risk
154 Journal of Child Neurology / Vol. 25, No. 2, February 2010

of mortality. He concluded that a physiological blood pres- In prior studies, they performed a second cranial CT in
sure has a higher impact on the outcome than the arterial every child. This resulted in no additional surgical conse-
oxygen saturation. The ideal systolic blood pressure was quences, because every child with neurological deteriora-
determined to be 135 mm Hg; there was a gradually tion had already received maximum surgical care.
decreasing probability of survival below these levels. Guide- In our study, 34 patients exhibited single hemorrha-
lines recommend the lower limit of systolic blood pressure ging in 37.5% of the cases and multiple hemorrhaging in
(fifth percentile) for age as 70 mm Hg plus (2 age in 33.3% of the cases as detected by a cranial CT.
years) and an initial therapy with 100% oxygen.46 These frequencies are comparable to those mentioned in
We concur with these findings and recommendations the medical literature for intracerebral hemorrhaging
regarding the detrimental effect of decreased initial blood (n ¼ 22), subdural hematomas (n ¼ 10), and epidural
pressure at the accident site as well as in the emergency hematomas (n ¼ 9).
room and a resulting poor outcome. Our study confirms Bruce et al19 stated that intracranial hemorrhaging is rarely
a poor outcome after ongoing bradycardia following head found in children but is more frequent in adults. This could
trauma, because this could be a sign of severe brain dam- represent a different pathophysiological response of the brain.
age. According to Dhellemmes et al,42 bradycardia is an Primarily, brain contusions subdural and epidural
indication for neuroimaging even without a concomitant hematomas are found in the cranial CT after head trauma;
deterioration of the neurological status. a subarachnoid hemorrhage occurs rarely.10,53 For a long
time, acute subdural and epidural hemorrhage was
assumed to be associated with a poor or fatal outcome in
Body Temperature
neurosurgery.23,24 This was based on complicated diag-
There is a correlation between initial hypothermia and a poor nostics and delayed therapeutic intervention. Especially
outcome. Episodes of hypothermia and hyperthermia during in children, there is a latent deterioration of neurological
the following course had no deleterious effect on the out- status or pathology. After an initially rising intracranial
come. Some studies indicate that hypothermia has a protec- pressure which is compensated, an acute impairment of
tive or intracranial pressure lowering effect.47-49 However, consciousness and the neurological situation occurs.42
initial posttraumatic hypothermia which could be the result In our opinion, the varying hematoma volumes
of a brainstem lesion is a detrimental prognostic factor.19,50,51 accounted for the absent correlation between removing
the intracranial hematoma and simply leaving it in place.
In 31.3% (n ¼ 15) participants, a midline shift of the
brain was detected by cranial CT. Twelve of these
The cranial CT is one of the fastest and most exact methods occurrences had intracerebral hematomas, and all of them
of detecting a brain injury. Although in the United States a exhibited varying brain edema. We were not able to
cranial CT is performed even in mild brain injury to avoid determine a significant prognostic effect for the midline
costs associated with inpatient care, in Germany a cranial shift. However, other studies reported a detrimental effect
CT is performed in children because of the severity of of the midline shift on the outcome in adults.56-58
trauma and the clinical presentation. This limitation holds The literature frequently reports a cumulative appear-
to avoid unnecessary radiation exposure in children. There ance of diffuse brain edema after severe head trauma. The
is agreement that the radiation exposure in a radiograph incidence is given at 2 times higher than in adults.59-61 In
and a cranial CT of the infant neurocranium is comparable, this study, the cranial CT detected a brain edema of
although the radiograph yields less information.52 Never- varying extent (47.9% severe, 17% mild) in 64.6% of the
theless, a radiograph of the cranium is often performed. patients. In a majority of the patients (77.4%), the diagnosis
Maier et al52 reported that the detection rate for fractures already was made with the initial cranial CT, whereas in
with cranial CT was 2 times higher than with a radiograph. 22.6% of the cases the brain edema developed during the
The time point of the initial cranial CT as well as the subsequent course. The increased susceptibility to edema
period between the first and the second cranial CT is and a decreased tolerance for hypoxia exhibited by the
hardly ever discussed. In a second cranial CT, our study brains of children as well as the elevated rate of the blood
detects new findings such as hemorrhages (n ¼ 11), cycle and the metabolic instability of the young organism
contusions (n ¼ 3), hypoxic changes (n ¼ 5), and diffuse are possible causes of frequent brain edema in children.53
generalized brain edema (n ¼ 7). The time interval should Several studies could demonstrate that both hypoxia
be between 12 and 48 hours.53,54 Tabori et al55 noted a and hypotension (especially the combination of both) are
second cranial CT after admission as being important for serious complications. They aggravate secondary brain
children with mild to severe head trauma to obtain more damage and correlate with a poor outcome.15,20,45 We were
information about the dynamics of any morphological also able to determine a significant effect of hypoxia in cra-
changes. This additional examination should only be nial CT and a poor outcome; this also holds for arterial
performed in children without neurological improvement. hypotension during posttraumatic shock. With values
Head Trauma in Children Part 1 / Kapapa et al 155

ranging between 12.5% and 53%, a generalized brain 5. Federal Statistical Office Germany. Diagnosedaten der Kran-
edema is usually associated with a poor prognosis.59,61 kenhäuser ab 2000, Gliederungsmerkmale: Jahre, Region,
ICD10. In: Germany FsO, editor. Federal Statistical Office
Germany; 2008. Available at:
Pediatric Risk of Mortality Score, Version III 6. Chiaretti A, Piastra M, Pulitano S, et al. Prognostic factors and
The Pediatric Risk of Mortality Score consists of clinical outcome of children with severe head injury: an 8-year experi-
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7. Drommer S. Untersuchungen zum schweren Schädel-Hirn-
ues. It is widely used in the United States to predict the Trauma bei Kindern [dissertation ed]. Hannover; 1999.
outcome of sick or injured children. It appears to be 8. Federal Statistical Office Germany. Statistics to Death Causes
extremely reliable and is characterized by a high prognos- 2001. Wiesbaden: Federal Statistical Office Germany; 2003.
tic value for determining case fatality and survival.62 Pol- 9. Guidelines for primary management of patients with craniocer-
lack et al63 proposed the lowest systolic blood pressure, a ebral trauma. Intensive Care Medicine and Neurotraumatology
pathological pupillary reaction, and a reduced level of con- Working Group of the German Society of Neurosurgery. Scien-
sciousness as parameters having the highest predictive tific Neuroanesthesia Circle of the German Society of Anesthe-
value. Cantais62 reported a significant correlation between siology and Intensive Care Medicine [in German]. Zentralbl
a Pediatric Risk of Mortality Score >35 and mortality. Our Neurochir. 1997;58:13-17.
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perfusion pressure and survival in pediatric brain-injured
Mortality Score >20 and a poor outcome.
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