Abstract
This chapter discusses the recommendations for care of pediatric head and neck injuries in the urgent care setting.
Keywords
blunt neck trauma, intracranial bleeding, nonaccidental trauma, pediatric head injuries, penetrating neck trauma, skull fractures
Head Injuries
A 3-year-old female is brought in by her mother for evaluation of a head injury after a fall off a bunk bed. She had no loss of consciousness, crying immediately on impact. She had one episode of vomiting but is now calm and acting normally according to her mother. The child denies having a headache currently.
1
How common are head injuries in children?
Pediatric head injuries account for approximately 600,000 emergency department visits per year in the United States. These injuries result in 60,000 hospital admissions and an estimated 7,000 deaths in children ≤18 years of age. Head injuries are the most common cause of death and acquired disability for children in developed countries.
2
What are some of the most common mechanisms leading to pediatric head injury?
Falls are the most common cause of head injury in children. Other common mechanisms include motor vehicle collisions, pedestrian or bike accidents, and sports. It is also important to consider nonaccidental trauma, as this is a potentially life-threatening cause of head injury in infants and younger children and should not be missed.
3
How do we define clinically important traumatic brain injury?
Many children sustain head injuries, but only a few will have injuries that fall into the category of clinically important traumatic brain injury (ciTBI). These injuries cause significant immediate or long-term impact to the child, or result in the child’s death. Generally, these include depressed or basilar skull fractures, bleeding requiring neurosurgical intervention, injury requiring the child to be intubated for more than 24 hours, or injury severe enough to warrant hospital admission longer than 48 hours.
4
What types of injuries are considered ciTBI?
Head injuries are frequently characterized into diffuse and focal injury patterns. Diffuse injuries include diffuse axonal injury (DAI), cerebral edema, hypoxic ischemic encephalopathy, and diffuse vascular injury. Concussion also falls under the purview of diffuse injury. Focal injuries include cerebral contusions and hemorrhage in the subdural, subarachnoid, or epidural spaces.
5
How do diffuse injuries usually occur?
Diffuse injuries occur from shearing forces, often with a rapid acceleration-deceleration event or rotational force. Infants may suffer these types of injuries when shaken vigorously back and forth. Cerebral edema can also occur as a result of hypoxia or changes in cerebral blood flow and from inflammatory mediators and vascular leak postinjury.
6
What are the different types of focal injuries?
A cerebral contusion occurs from a direct impact of the brain against the intracranial bony surfaces and may lead to focal neurologic deficits. Subdural hemorrhage occurs when the bridging veins rupture, causing bleeding between the dura mater and the arachnoid space. This type of injury is more common in children two years of age and younger. It may occur as a result of nonaccidental trauma. Subarachnoid hemorrhage occurs from bleeding of the vessels that supply the pia mater. Accumulation of blood occurs in layers along the bony surface, and bleeding can be quite extensive. Epidural hemorrhage is the result of vascular injury to the middle meningeal or dural venous sinus, resulting in bleeding between the dura and the bone. Because these are venous bleeds, they tend to accumulate slowly, leading to a classic “lucid” interval after injury with subsequent decompensation.
7
What are important age-related considerations when evaluating a child with a head injury?
Younger children (<2 years) should be considered separately from older children. Clinical assessment is decidedly more difficult in infants, who may be asymptomatic or have subtle or nonspecific signs of injury. It is important to consider the risk of inflicted or abusive injury in children. Traumatic brain injury is a leading cause of death from abuse in children. Clinicians need to consider the possibility of inflicted trauma in infants who present with head injury.
8
I need to evaluate a child who just sustained a head injury at my urgent care facility. Are there specific things I should consider when determining a plan of care?
The primary goal of evaluating a child with a head injury is to determine the severity of the injury and recognize injuries that require further management. Children with potentially serious injuries need to be rapidly identified and transferred to an appropriate facility for definitive care. Ideally, this would be a pediatric certified trauma center. The secondary goal of evaluation includes minimizing unnecessary radiation exposure.
9
Why should minimizing radiation be a priority?
Many clinicians use head computed tomography (CT) as a means of rapidly assessing patients with head injury. However, young brains are exquisitely sensitive to radiation. There is a significant risk of cancer mortality associated with head CTs in children. Therefore, it is important to balance the risk of the child having a significant injury with the potential future risk of malignancy.
10
Are there established guidelines that can help me determine a child’s risk of clinically important TBI and make an educated decision about imaging?
Yes! The Pediatric Emergency Care Applied Research Network (PECARN) has developed and validated clinical decision rules for children with a low risk of serious head injuries. The rules are derived from a large, multicenter, prospective trial that included over 43,000 patients. These guidelines help to standardize patient evaluations, rapidly identify children with potentially serious intracranial injury, and minimize the use of CT scans in low-risk patients. Such rules are useful when evaluating healthy children who present to the emergency department within 24 hours of injury, and in whom there is no suspicion for nonaccidental trauma. For children in the younger age group, the low-risk rule had a sensitivity of 100% and a negative predictive value of 100%. In the older age group, the sensitivity of the low-risk rule was 96.8% with a negative predictive value of 99.95%.
11
Can I use the PECARN criteria for all children with head injuries?
Not all children will be eligible for the PECARN pathway. The PECARN rules are intended to identify low-risk children not requiring further assessment. Children who are moderate or high risk for significant intracranial injury, including those with Glasgow Coma Scale (GCS) <14, require transfer to a pediatric trauma center. Children with underlying neuropathology, such as brain tumors or preexisting neurologic disorders, warrant separate consideration. Finally, children with ventriculoperitoneal (VP) shunts and bleeding disorders may have a higher risk of serious injury than otherwise healthy children, or may have intracranial bleeding with a less severe mechanism of injury.
12
What are the PECARN criteria by which children qualify as low risk for serious injury?
Table 26.1 describes the criteria for children who qualify as low risk based on the PECARN guidelines.
| Children <2 years | Children ≥2 years |
|---|---|
| Acting normally per parents | Normal mental status (GCS ≥14) |
| Known, low-risk mechanism | Known, low-risk mechanism |
| No loss of consciousness | No loss of consciousness |
| No nonfrontal scalp hematoma | No vomiting |
| No signs of basilar skull fracture | No signs of basilar skull fracture |
| No concern for abuse | No complaints of severe headache |
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