Blunt traumatic brain injury (TBI) is a disruption in the normal function of the brain caused by a mechanical impact to the head. TBI ranges from mild to severe and/or fatal. TBI can be conceptualized as a primary event occurring at the moment of impact, followed by secondary damage due to edema and elevated intracranial pressure. Early identification and management of traumatic brain injury are crucial in halting the progression of the primary insult and preventing or reducing secondary brain injury. TBI is typically classified as mild, moderate or severe, based on the Glasgow coma scale (GCS). Patients with a GCS of 14 to 15 are considered to have mild TBI, while patients with a GCS of 9 to 13 have moderate TBI, and those with a GCS of 3 to 8 have severe TBI. Initial symptoms of moderate-severe TBI in children are similar to adults, but the ultimate functional impact in children who survive TBI becomes more apparent as the child ages and faces increased challenges in processing information, reasoning, and impaired judgment.
The most common cause of TBI in children are falls and sports/recreation-related injuries. Falls (striking the head) are more common in very young children because of their under-developed ambulatory skills combined with disproportionately large heads, a shifted center of gravity, and immature neck muscles. Less common, but more severe etiologies of TBI include non-accidental trauma and motor vehicle-related injuries including pedestrians struck by a vehicle.
Each year, pediatric TBI results in over 500,000 emergency department visits and about 60,000 hospitalizations in the United States. Fatal TBI in children is primarily caused by non-accidental trauma and motor vehicle-related injuries (including pedestrians struck by a vehicle). Falls and sports/recreation-related TBI rarely lead to fatal injuries but can cause post-concussive symptoms in up to 30% of patients. Falls are more common in children in the 0 to 4 year age group, while sports and recreation-related injuries are more common in the 5 to 14 year age group. Across all age groups, males are more likely to present with TBI.
Most patients with moderate-to-severe TBI have a combination of intracranial injuries. Diffuse axonal injury (DAI) is thought to be present to some degree in the majority of patients with moderate-to-severe TBI. DAI is typically caused by a rapid rotational or deceleration force that causes stretching and tearing of neurons, leading to focal areas of hemorrhage and edema that are not always detected on the initial CT scan. Subarachnoid hemorrhage (SAH) due to tearing of pial vessels is considered a marker of severity, present in almost half of pediatric patients with severe TBI. Subdural and epidural hematomas are the most frequent type of mass lesion identified in TBI. Cerebral contusions occur in about one-third of patients with moderate-to-severe TBI, caused by a direct impact or acceleration-deceleration forces that cause the brain to strike the frontal or temporal regions of the skull. Intracerebral bleeding or hematoma, caused by coalescence of contusions or a tear in a parenchymal vessel, occurs in up to one-third of patients with moderate-to-severe TBI.
The initial resuscitation should proceed in a step-wise fashion to identify all injuries, as well as optimize cerebral perfusion by maintaining hemodynamic stabilization and oxygenation. The initial survey should also include a brief, focused neurological examination with attention to the GCS, pupillary examination, and motor function.
The pediatric GCS is similar to the adult GCS, but the main difference is in the verbal response in which the pediatric GCS assigns a normal verbal score of 5 for babbling, cooing, or smiling appropriately, while subtracting 1 point if crying but consolable, subtracting 2 points for inconsolable crying, subtracting 3 points for moaning or grunting, and subtracting 4 points for no verbal response.
After addressing any airway or circulatory deficits, a thorough head-to-toe physical examination must be performed with vigilance for occult injuries and careful attention to detect any of the following warning signs:
Non-accidental trauma (NAT) should be suspected if the patients present with classical features like:
Non-contrast cranial computed tomography (CT) is the imaging modality of choice for patients with TBI and an abnormal GCS. CT findings associated with a poor outcome in TBI include midline shift, subarachnoid hemorrhage into the verticals, and compression of the basal cisterns. MRI may be indicated when the clinical picture remains unclear after a CT to identify more subtle lesions. Several clinical decision guidelines have been validated and can be applied to determine which children with a normal or near-normal GCS can safely avoid CT.
Fundoscopy is needed to look for the presence of retinal hemorrhages in cases suspected with NAT. Abusive head trauma (shaken baby syndrome) is the most common cause of death in patients sustaining NAT.
Airway adjuncts are indicated in patients not able to maintain an open airway, or not able to maintain greater than 90% oxygen saturation with supplementary oxygen. Oxygenation parameters should be monitored using continuous pulse oximetry with a target of greater than 90% oxygen saturation. Ventilation should be monitored with continuous capnography with an end-tidal pCO2 target of 35 to 40 mm Hg. Placement of a definitive airway is recommended in a patient with a GCS of less than 9.
Systemic hypotension negatively impacts the outcome in the setting of TBI, and current studies have demonstrated improved outcomes in patients with a systolic BP = 120 mm Hg. Isotonic crystalloids should be used to prevent and correct hypotension; colloidal solutions have not been shown to improve outcomes.
Serial neurological examinations allow for early identification of patients with elevated intracranial pressure (ICP), and subsequent implementation of primary bedside interventions to improve venous outflow and reduce metabolic demands. Mortality in TBI is due to elevated ICP.
Initial bedside approaches to increased ICP include:
A thorough head-to-toe physical examination must be performed with vigilance for occult injuries.
Glutaric aciduria type I patients may present with macrocephaly and bilateral subdural hemorrhages which can be mistaken for NAT.
Complications depend on the severity of the head injury. It can vary from mild cognitive impairment to seizures, neurological deficits, and even death.
Parents of a kid who sustains a head injury should be aware of the warning symptoms of raised ICP. Informed consent including all the likely complications (including the long-term ones) should be obtained if the kid is being planned for any surgical intervention.
The management of pediatric head trauma is done by an interprofessional team that consists of a pediatric neurosurgeon, emergency department physician, nurse practitioner, pediatrician, and a radiologist. Most children with mild head trauma are discharged. However, patients discharged after a head injury or concussion should be instructed to return to physical activities in a step-wise approach. The initial step is a period of physical and cognitive rest for no more than 2 to 3 days followed by scheduled increases in activities with close monitoring for recurrence of symptoms. Any recurrence of symptoms indicates the need for further limitation of activities. Recommendations for return-to-activities continue to change as new studies are published, and the CDC website is a helpful source for up-to-date guidelines.
|||Gelineau-Morel RN,Zinkus TP,Le Pichon JB, Pediatric Head Trauma: A Review and Update. Pediatrics in review. 2019 Sep [PubMed PMID: 31477589]|
|||Chen C,Peng J,Sribnick EA,Zhu M,Xiang H, Trend of Age-Adjusted Rates of Pediatric Traumatic Brain Injury in U.S. Emergency Departments from 2006 to 2013. International journal of environmental research and public health. 2018 Jun 5 [PubMed PMID: 29874782]|
|||M Das J,Munakomi S, Raccoon Sign 2020 Jan; [PubMed PMID: 31194384]|
|||Babl FE,Borland ML,Phillips N,Kochar A,Dalton S,McCaskill M,Cheek JA,Gilhotra Y,Furyk J,Neutze J,Lyttle MD,Bressan S,Donath S,Molesworth C,Jachno K,Ward B,Williams A,Baylis A,Crowe L,Oakley E,Dalziel SR, Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. Lancet (London, England). 2017 Jun 17 [PubMed PMID: 28410792]|
|||Paul AR,Adamo MA, Non-accidental trauma in pediatric patients: a review of epidemiology, pathophysiology, diagnosis and treatment. Translational pediatrics. 2014 Jul [PubMed PMID: 26835337]|
|||Araki T,Yokota H,Morita A, Pediatric Traumatic Brain Injury: Characteristic Features, Diagnosis, and Management. Neurologia medico-chirurgica. 2017 Feb 15 [PubMed PMID: 28111406]|
|||Kochanek PM,Carney N,Adelson PD,Ashwal S,Bell MJ,Bratton S,Carson S,Chesnut RM,Ghajar J,Goldstein B,Grant GA,Kissoon N,Peterson K,Selden NR,Tasker RC,Tong KA,Vavilala MS,Wainwright MS,Warden CR, Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. 2012 Jan [PubMed PMID: 22217782]|
|||Kukreti V,Mohseni-Bod H,Drake J, Management of raised intracranial pressure in children with traumatic brain injury. Journal of pediatric neurosciences. 2014 Sep-Dec [PubMed PMID: 25624921]|
|||Das JM,Sapkota R,Shrestha B, Pediatric dural venous sinus thrombosis following closed head injury: an easily overlooked diagnosis with devastating consequences. Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma [PubMed PMID: 29350373]|
|||Adelson PD,Wisniewski SR,Beca J,Brown SD,Bell M,Muizelaar JP,Okada P,Beers SR,Balasubramani GK,Hirtz D, Comparison of hypothermia and normothermia after severe traumatic brain injury in children (Cool Kids): a phase 3, randomised controlled trial. The Lancet. Neurology. 2013 Jun [PubMed PMID: 23664370]|
|||Kuppermann N,Holmes JF,Dayan PS,Hoyle JD Jr,Atabaki SM,Holubkov R,Nadel FM,Monroe D,Stanley RM,Borgialli DA,Badawy MK,Schunk JE,Quayle KS,Mahajan P,Lichenstein R,Lillis KA,Tunik MG,Jacobs ES,Callahan JM,Gorelick MH,Glass TF,Lee LK,Bachman MC,Cooper A,Powell EC,Gerardi MJ,Melville KA,Muizelaar JP,Wisner DH,Zuspan SJ,Dean JM,Wootton-Gorges SL, Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet (London, England). 2009 Oct 3 [PubMed PMID: 19758692]|
|||Choe MC,Gregory AJ,Haegerich TM, What Pediatricians Need to Know About the CDC Guideline on the Diagnosis and Management of mTBI. Frontiers in pediatrics. 2018 [PubMed PMID: 30258835]|