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PATHOPHYSIOLOGY Pediatric skull is more distensible due to sutures thus ingeneral LESS brain injury < 1yo have higher mortality than those > 1yo DAI more common and mass lesions less common than adults CLINICAL FEATURES GCS difficult to apply Modified pediatric GCS scales developed by not validated Seizures MORE common in kids than adults; most occur within 24hrs and do NOT predict long term seizures post HI Post concussive blindness = brief loss of vision (minutes-hrs) after occipital head injury Infants can have significant injury with minimal findings IRRITABILITY can be the only presenting feature in intfants Always consider NAT: retinal hemorrhages, SDH, SAH, no external signs Hypotension from head injuries IS POSSIBLE Intracranial blood accumulation Sugaleal hematomas Examine for BULGING FONTANELLE as a sign of increased ICP Mannitol can cause a transient increase cerebral blood flow thus use a lower dose (0.250.5 g/kg) and use slower administration (15 min) Burr holes less effective because of diffuse injuries more common Scalp hematomas suggest skull fractures Leptomeningeal cysts Leptomeninges tear with skull fractures, CSF accumulates and prolapses through the fracture margin and prevents fracture healing Leads to cyst formation Cysts can become large and have mass effect Linear fractures require follow up for this Unclear what follow-up should be: ? CT head if symptoms


TRAUMA REPORTS 2000 Skull fractures were most predictive of structural brain lesions Large scalp hematomas were the best clinical sign of skull fractures Suggests CT head for significant scalp hematomas PEDIATRICS MAY 2001, VOL 17 (5) Looked at kids < 2yo High Risk Features LOC > 1 min Seizures Worsening vomiting Decreasing LOC Focal findings Basal or any skull # signs Irritability Bulging fontanelle Low Risk Features Trivial Mechanism Age > 3 mo No signs or symptoms > 2 hrs post injury PEDIATRICS 2001: 107(5); 983-993 High Risk (CT) Decreased LOC Focal neuro findings Signs of depressed or basilar skull fracture Seizure Persistent irritability Acute skull fracture Bulging fontanelle Vomiting > 5 times LOC > 1 min Intermediate Risk (CT or observe) Vomiting 3-4 times LOC < 1min Hx of lethargy/irritability that is now resolved Low Risk (observe) Low energy mechanism (< 3 feet, etc) No signs or symptoms > 2hrs since injury Older age (>12mo) PEDIATRICS 1999 Clinical Indicators of Intracranial injury in Head-Injured Infants Risk increases with decreasing age Risk increases with increasing hematoma size OR 3 with big scalp hematoma


93% of significant intracranial injury had large scalp hematoma Persistent lethargy Persistent irritability Large scalp hematoma

ANN EMERG MED. PALCHAK 2003: 42(4). Decision Rule Prospectively derived in 2043 patients Not yet balidated Outcome = need for acute intervention Predictors Headache GCS < 15 Skull fracture clinically Vomiting Scalp hematoma in < 2yo Sensitivity 99% (94-100) AAP GUIDELINES FOR 2YO-20YO Indications for CT scanning Decreased GCS Signs of basillar skull fracture Signs of depressed or open skull fracture Focal neurological findings Bleeding diathesis Suspected N.A.T. Polytrauma LOC Lethargy, vomiting, unreliable observation = CT No lethargy, vomiting, reliable observation = observation 0-7% with positive CT scans Biased spectrum Rate of clinically important injuries much lower NO LOC Observation at home by reliable caregiver or in ED Incidence of clinically important injury is < 1/5000

PEDIATRICS GUIDELINE FOR < 2YO: Pediatrics Vol 107 No.5 2001 Inclusion Criteria Children < 2yo History or physical signs of head trauma Alert or awakens with voice or light touch Exlcusion Criteria Suspected N.A.T.

Penetrating trauma Bleeding disorder Multi trauma High Risk = CT head Depressed level of consciousness Focal neurlogic deficit Signs of depressed or basillar skull fracture Seizure Persistent irritability or lethargy LOC > 1 minute Vomiting > 5 times Bulging fontanelle Intermediate Risk CT or Observe in ED X 6 hrs History of lethargy or irritability but is now normal Vomiting 3-4 times LOC < 1 min Abnormal current behavior Additional risk factors present? Lowers threshold to CT Large scalp hematoma Fall > 3 feet High speed MVC Mechanism unwitnessed by signs of trauma Non-frontal location of hematoma Low Risk = Discharge Low mechanism: fall < 3 feet, etc No signs or symptoms > 2 hours since injury Older age No large scalp hematoma

SPECIFIC INJURIES Skull Fractures Linear are most common; rarely require therapy; not prone to leptomeningeal cysts Diastasis of sutures are prone to leptomingeal cysts Leptomeningeal cysts Leptomeninges tear with skull fractures, CSF accumulates and prolapses through the fracture margin and prevents fracture healing Leptomeninges extend outside of the head! Leads to cyst formation Cysts can become large and have mass effect Linear fractures require follow up for this Tell parents with kid with head injury to watch for a persistent lump: may be the development of leptomeningeal cysts May require surgical correction ? do all kids need Xrays to look for fractures so you know who to follow? No, tell parents to watch for a mass Epidurals Venous bleeding relatively more common when compared to adult EDHs Subdurals

Common injury in the shaken baby What are the indications for skull Xrays? Skeletal survey with NAT Foreign body NOT minor head injury: if they need imaging, they need CT!