Head Injuries in Children: Epidemiology, Classifications, Pathophysiology, and Management, Slides of Pediatrics

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Head Injuries

Epidemiology:

• Head trauma is one of the most frequent reasons for an acute visit to physicians & the leading cause of death and disability in children, accounting for more than 50% of the deaths in the pediatric population.
• The incidence peaks early in childhood again in mid to late adolescence.

Definitions:

• A concussion is defined as a minor head trauma that causes confusion or loss of consciousness less than 1 minutes.

•A contusion is an area of focal cortical injury,result from:

1. Direct trauma from external contact force.
   2. Brain contacting surfaces with acceleration & deceleration trauma.

Classifications:

1. Head trauma classified based on neurologic status using the GCS into: Mild, moderate, severe.
2. Intracranial hemorrhage :

• Epidural hge: Middle meningeal artery. Middle meningeal vein. Dural sinuses.
• Subdural hge: Bridging veins tearing which is divided into acute,subacute, & chronic.

Pathophysiology

• A traumatic forces produce strain & distortion within the brain that disrupt axons & small blood vessels causing brain edema.
• Factors that determine degree of brain edema :

1. The number of axons injured, less severe axonal injury is reversible but more severe ones can be permanent.
2. A significant increase in ICP impairs cerebral blood flow & inducing ischemia & further brain edema.

3. Traumatic injury begins a cascade of cellular responses that impair metabolism after blood flow & worsen the cerebral swelling.
4. Abnormal permeability of BBB increase brain edema.
5. Free radical formation.
6. Inflammation.

Management of mild head trauma

• The child who has normal findings on physical and neurologic examinations requires no further evaluation. CT is not indicated however the child must be observed for evidence of neurologic deterioration.
• If there is acute changes the child should be retained to medical attention for a repeat full evaluation that most likely include CT.

• The child who has persistent and significant symptoms following mild head injury requires CT because there is an increased risk of intra-cranial injury.
• Children whose symptoms are worsening require repeat CT to show intra-cranial pathology.
• The child who has symptoms but normal findings on CT maybe discharged from the hospital with appropriate instructions for observation and returned to medical care if there is any change in status.

Moderate and Severe Head Injury

• The priority in managing the patient who has moderate GCS (9-12) or severe GCS (≤8) head injury is to minimize secondary brain injury with evaluation and treatment simultaneously.
• Maintenance of adequate hemodynamics and oxygenation are of most important.
• Endotracheal intubation and mechanical ventilation should be performed in patient who have modified GCS 8 or less.

• The neurologic status of the patient must

be followed during the period of

resuscitation using the GCS to evaluate the

response to therapy.

• All children require brain CT.
• In patients whose mental status is altered

there is a significant possibility of a spinal

cord injury that requires appropriate

immobilization.

• |Pediatric ICU admission if GCS less than

• Monitoring of intra-cranial pressure is required to manage increased intra-cranial pressure properly and to assist in the management of traumatic brain injury that involves cerebral swelling.
• The ideal method of monitoring pressure is through the use of an intra-ventricular catheter because it can be used to measure pressure and drain CSF to reduce pressure.
• Other methods of monitoring include intra- parenchymal fibroptic monitoring which is inserted easily but does not allow for drainage of CSF.

• Sedation is used in head injured patients to

reduce intra-cranial pressure and cerebral

oxygen demand.

• Osmolar therapy by mannitol is an

important in patients who have elevated

intra-cranial pressure, its diuretic action

may be result in reduced intravascular

volume and cerebral perfusion therefore

hemodynamics must be monitored

carefully when using mannitol.

• Generally injury in infancy and early childhood result in greater morbidity than seen in later childhood this is believed to be the luck of myelination and developmental stage of CNS.
• Fewer than 24 hours of coma rarely is associated with permanent neurologic abnormalities.
• Coma lasting more than 3 weeks result in impaired intelligence that worsens as the time in the coma is extended.
• Improvement in function can continue for up to one year following head injury specially in the older children and adolescent.