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Head Injury in the Child

- Discussion:
    - children have relatively fewer intracranial-mass lesions but relatively more intracranial hypertension than adults;
    - tendency to have diffuse brain swelling puts children at increased risk of secondary brain injury;
    - all children with Glasgow coma scores less/= 12 require special monitoring of their neurologic status;
    - since little can be done to alter the extent of primary injury, treatment is directed at preventing secondary injury by attending to gas 
            exchange and circulation and evacuating hematomas if they occur;
    - keep brain-injured children well oxygenated and normotensive;
    - indications for CT scan:
            - in the report by Simon B, et al, the authors sought to define the incidence and identify risk factors for intracranial injury (ICI) 
                   after minor head trauma in children who did not have suspicious neurologic symptoms in the field or on presentation;
                   - 569 blunt trauma patients (age < 16 years) with a Glasgow Coma Scale score of 14 or 15 triaged by American College of 
                          Surgeons Pediatric Mechanism Criteria at a Level I trauma center received head CT scan;
                   - loss of consciousness (LOC) status was known for 429;
                   - this subgroup was retrospectively reviewed for mechanism, age, Injury Severity Score, LOC status, GCS score, associated 
                          injuries, and CT scan findings (normal, fracture only, or intracranial injury);
                   - 14 percent (62 of 429) of study patients (GCS score of 14 and 15) had ICI;
                   - 16 % of patients (35 of 215) with GCS score of 15 and (-)LOC (negative for LOC) had intracranial injury manifesting as 
                          subdural hematoma, epidural hematoma, subarachnoid hemorrhage, or brain contusion;
                   - 3 required surgery for intracranial mass lesions;
                   - neither (+)LOC (positive for LOC) nor GCS score of 14 increased the likelihood of intracranial injury over those patients 
                          without loss of consciousness or with GCS score of 15;
                   - distant injury was also not an independent predictor of ICI for those with GCS scores of 14 or 15, as 84% of the ICI group 
                          had head injury only;
                   - skull fracture was a risk factor for ICI but had poor negative predictive value, as 45% of patients with ICI did not have 
                   - minor craniofacial soft tissue trauma was a significant risk factor (relative risk, 11) that had marginal negative predictive value 
                          (0.95), as 14% (9 of 62) of ICI patients did not have superficial craniofacial injury;
                   - the authors concluded that normal neurologic exam and maintenance of consciousness does not preclude significant rates of
                          intracranial injury in pediatric trauma patients;
                          - they recommended that a liberal policy of CT scanning is warranted for pediatric patients with a high-risk mechanism of 
                                  injury despite maintenance of normal neurologic status in the field and at hospital screening;
    - ventilator management:
            - hyperventilation (partial pressure of arterial carbon dioxide, 3.3 to 4.0 kPa 25 to 30 mm Hg) with adequate oxygenation is the 
                    primary method of reducing intracranial pressure;
            - intubate trachea if the Glasgow coma score is less/= 8 or if there are signs of brain-stem injury or posturing;
    - mannitol
            - intravenous mannitol (0.5 g per kilogram) or furosemide (1 mg per kilogram) can be given in the absence of shock to reduce ICP
                    rapidly when there is evidence of imminent herniation despite adequate hyperventilation;
            - keep head at an elevation of 30 degrees and straight with respect to body to maximize cerebral venous drainage;
    - seizure
            - treat true seizures w/ anticonvulsant agents (0.1 mg of lorazepam per kilogram, followed by 10 to 20 mg of phenytoin per kilogram infused
                    at a rate of 1 mg per kilogram per minute);
            - prophylactic phenytoin is recommended for severe head trauma;
    - fracture care:
            - immobilization of the fracture can decrease pain stimuli to patient, which can help minimize intra-cranial pressure;
            - while intra-cranial injuries are being evaluated, orthopaedist is usually limited to cast application and traction for frx treatment;
            - if patient is brought to OR for management of another system injury, then appropriate operative management of orthopaedic injuries is considered;
    - prevention of contractures:
            - includes splinting, physical therapy, and medications (baclofen)

Pediatric Minor Head Trauma: Indications for Computed Tomographic Scanning Revisited   

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