All that follows is excerpted from the above post.
- More than 500,000 annual emergency department visits and 60,000 hospitalizations for pediatric patients with TBI in the United States (Chen, Int J Environ Res Public Health. 2018., PubMed ID: 29874782)
- Most head trauma is minor, but it is crucial to identify patients with clinically important traumatic brain injury who require further evaluation and management
- CT scans are associated with significant ionizing radiation, which may be harmful to the developing brain (Brenner, NEJM 2007, PubMed ID: 18046031)
- Always consider non-accidental trauma
- History should include (S)AMPLE history as well as details about the trauma (mechanism) and high-risk symptoms (loss of consciousness, vomiting, headache, behavioral changes, worsening of symptoms).
- Physical exam should include a full trauma evaluation where indicated, with specific focus on GCS, mental status, and signs of skull fracture and increased ICP
- Pediatric GCS can be difficult to assess in preverbal patients (see below)
- Multiple clinical decision rules have been derived and validated to identify pediatric clinically important traumatic brain injury
- The PECARN head trauma rule is most frequently utilized in the U.S. (Kupperman, Lancet 2009, PubMed ID: 19758692 , MD CALC)(See below)
- Patients with trivial head trauma and a GCS 14 were excluded
- In an analysis including combined age groups and both the derivation and validation sets 1 in 5,000 with clinically important traumatic brain injury could be missed (high predictive value of a negative test)
- Potential to decrease CT usage
- Rules for < 2 years and > 2 years with specific event, history and physical exam factors associated with clinically important traumatic brain injury.
- Other pediatric head trauma clinical decision tools include the Canadian CATCH rule (MD CALC) and U.K. CHALICE (MD CALC) rule.
- Recent studies suggest the rapid MRI may be an attractive alternative to CT (Ramgopol, BMC Pediatrics 2020, PubMed ID: 31931764, Sheridan, J Neurosurg Pediatr. 2016, PubMed ID: 27885947).
- ABCs take priority, as in all trauma patients
- Management includes maintaining adequate cerebral perfusion pressure, as well as addressing increased intracranial pressure (elevating head of bed, analgesics and sedation, osmotic agents)
- Anticonvulsants should be considered in patients with intracranial abnormalities (e.g. Keppra; recommended dose varies)
- Neurosurgical consult should be called for any patients with abnormal CT findings
- Most patients can be discharged after either a period of observation or after initial evaluation
- Patients with intracranial abnormalities should be managed in conjunction with neurosurgical consultants
- The CHILDA Score can be used to determine the need for ICU admission (Greenberg, JAMA Pediatrics, PubMed ID: 28192567)