The overwhelming majority of pediatric head injuries are not
severe, with 85% of injuries classified as “mild.”5 Although
minor head injury (MHI) in children presenting to the ED accounts
for only 1% to 2% of all pediatric ED visits,1 this
represents almost 400,000 ED visits each year, with children 0 to
4 years of age most commonly affected. Of all children with MHI
coming to the ED, it is estimated that <5% have intracranial injury,2 and
<1% of those with intracranial injury require neurosurgical intervention.3,4
Given the large number of children with MHI and the small number
requiring intervention, the diagnostic challenge facing ED physicians
is to distinguish those children with MHI who require urgent identification and
treatment to avoid serious morbidity or mortality. Because radiation exposure
from CT scans puts the developing brain of children at risk and often
requires sedation, which includes additional risk, imaging decisions
require a careful consideration of the risks and benefits.
Concussion can be associated with any degree of head trauma,
including seemingly trivial injury, and the identification of concussion
has profound implications for both the ED and outpatient management
of children with MHI. Recent consensus statements from international
experts highlight a growing appreciation of the need for careful
surveillance for concussion and close longitudinal outpatient monitoring
and management of the concussed child. This chapter reviews the
contemporary ED diagnosis and management of MHI in children. The
chapter concludes with a discussion of the evolving concept of the
evaluation and management of concussion in children.
The literature uses a variety of definitions for “minor” or “mild” head
injury. The basic elements of the definition require a history identifying
a mechanism of injury or trauma to the head, or findings on physical
examination of possible head injury, including both external cranial
findings and neurologic deficits.
The Glasgow Coma Scale (GCS; Table 132-1),
or its derivative for younger, preverbal infants and toddlers, is
the method most often used to determine the severity of head injury. In
this chapter, head injuries resulting in a GCS score of ≤8 are considered
severe, those associated with scores ranging from 9 to 13 are considered
moderate. Although no universally agreed upon definition for MHI
exists, those with GCS scores ranging from 13 to 15 (usually 15),
and a normal neurologic examination and mental status are considered
to have MHI (see Decision Rules below).6 Some
studies define MHI as a GCS score of 15 only and others as score
of 13 to 15 on the GCS.7 Current pediatric resuscitation
training materials also define MHI as a score of 13 to 15 on the
GCS.8 The American Academy of Pediatrics
defines children with MHI as “those who have normal mental
status at the initial examination, who have no abnormal or focal findings
on neurologic (including funduscopic) examination, and who have
no physical evidence of skull fracture.”9
Table 132-1 Glasgow
Coma Scale Score for Adults ...
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