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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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