FROM THE CANADIAN PAEDIATRIC SOCIETY

SOCIETE CANADIENNE DE PEDIATRIE COMMUNIQUE

Management of children with head trauma

Emergency Paediatrics Section,* Canadian Paediatric Society

H ead trauma is common among children and
results in a significant number of visits to
emergency departments and physicians' of-
fices. Even though most patients have mild to
moderate trauma, appropriate evaluation and thera-
py require considerable clinical judgement and are
the most challenging problems confronting pediatri-
cians and emergency physicians.
Essential for successful management of children
with head trauma are a proper clinical assessment of
the primary injury and an appreciation of the
potential for intracranial complications. Indeed, the
need for immediate care, investigations and hospital
admission should be determined on the basis of
these factors. Although most patients will not require
hospital admission or diagnostic procedures those at
risk must be identified and observed closely.
Fear of underlying brain injury and medicolegal
reprisal, parental pressure and the difficulty in evalu-
ating the patient may result in unnecessary investiga-
tions and prolonged periods of observation. These
outcomes should be avoided without putting the
child at increased risk of post-traumatic disability
and death. Despite numerous clinical studies of
various management strategies there is no unani-
mous opinion about the indications for skull radiog-
raphy, computed tomography (CT), observation and
further neurologic consultation.'-3
Generalization of the experience with adults to
children is inappropriate because of the differences
in anatomy and physiologic response to cerebral
trauma.4 Children are more predisposed than adults
to head injury because their head:body ratio is
greater, their brains are less myelinated and thus
more prone to injury, and their cranial bones are
thinner. Although children have a lower incidence of
mass lesions than adults they are more likely to
suffer from a unique form of brain injury called
"malignant brain edema".' In addition, children
may lose relatively large amounts of blood from
scalp lacerations and subgaleal hematomas and pres-
ent in hemorrhagic shock.
This statement was prepared to assist physicians
in the management of children brought to the
emergency department with head trauma. It is in-
tended to (a) suggest management priorities, (b)
provide a rapid and safe method of screening for the
presence or risk of intracranial injury and of assign-
ing an index of severity, (c) provide triage guidelines
according to the severity of the injury and the
availability of resources and (d) give guidelines to
determine the need for radiographic studies.
Management priorities
Assessment of airway, breathing and circulation
The airway, breathing and circulation must be
assessed before detailed history-taking or neurologic
examination. Instability of the cardiorespiratory sys-
tem may be due to severe intracranial injury, intra-
cranial hypertension or injury to other areas such as
the thorax or the abdomen. Whatever the cause,
prompt ventilatory support and treatment of shock
is mandatory since these factors, if left uncorrected,
will result in secondary intracranial insults.5 6

*Members: Drs. Dorothi' M. Anna Jarvis (chairman), Emergencv Medicine, Hospital for Sick Children, Toronto; Marilvn Li
(vice-chairman), head, Emergency Services, Children 's Hospital of Eastern Ontario, Ottawa; Donald K. Clogg (past chairman), director,
Emergency Department, Alberta Children's Hospital, Calgarv; Robert Thivierge (secretarvy), Emergencv Departmnent, h6pital
Sainte-Justine, Montreal; and Niranjan Kissoon (member-at-large and principal author), director, Emergency Department, Children's
Hospital of Western Ontario, London. Canadian Paediatric Society Accident Prevention Committee representative: Dr. Heather Onvett,
Department ofPediatrics, Queen 's Universitv, Kingston, Ont.
Reprint requests to: Emergencv Paediatrics Section, Canadian Paediatric Societv, Children's Hospital of Eastern Ontario, 401 Smnvth Rd.,
Ottawa, Ont. KJH 8LI

- For prescribing information see page 1007 CAN MED ASSOC J 1990; 142 (9) 949

Control of increased intracranial pressure
Table 1 outlines the emergency therapy for
increased intracranial pressure, which is common
among children who have severe head injury with or
without a mass lesion. Since the risk of death
increases with an intracranial pressure greater than
20 mm Hg prompt, aggressive treatment in suspect-
ed cases is warranted.
History-taking and physical and neurologic
assessment
These procedures are invaluable to (a) deter-
mine the severity of the intracranial injury and
identify those at risk for secondary injury and (b)
identify injuries to other regions that may contribute
to illness and death.
Events surrounding the injury, such as the
mechanism of injury, the time and the loss or
presence of consciousness, should be obtained. How-
ever, reports may be inconsistent and hence unreli-
able. Fortunately the progression of symptoms pro-
vides invaluable information to assist the physician
in clinical decision-making. A brief seizure at the
time of injury may not be clinically significant and
may not necessitate therapy. However, one or more
prolonged seizures associated with cardiorespiratory
compromise necessitates prompt treatment. Many
.. . .. - if the child cries after stimulation.9 The rest of the
11 :.. ..
f' ;.!
950 CAN MED) ASSOCJ 1990: 142 (9)
.M
children will vomit two to three times after even a
minor head injury.7 However, protracted vomiting
and retching associated with other symptoms or
signs indicate a more severe head injury. Amnesia,
irritability, lethargy, pallor or agitation may also
indicate severe injury.
The child's medical history must be obtained;
evidence of such conditions as a predisposition to
seizures or a bleeding diathesis is important and
would further dictate clinical management.
Table 2 outlines the salient points in a physical
and neurologic examination. Bradycardia with hy-
pertension (a Cushing response) is usually a late
response in children with increased intracranial pres-
sure and therefore not very reliable.4 Early clues to
increased intracranial pressure include a decrease in
the Glasgow Coma Scale score of 2 points or more,
abnormality or changes in pupillary size and reaction
to light, respiratory abnormalities and development
of paresis in absence of shock, hypoxia or seizures.
Because a rapid pulse often signifies blood loss,
other injuries should be sought. The child with
severe head injury should be kept in a normothermic
state since increased cerebral metabolism may cause
secondary brain injury.
The Glasgow Coma Scale (Table 3) is an impor-
tant tool that influences treatment decisions and
outcome.6" Although coma scales for children have
not been validated, the Glasgow scale may be used
for children less than 2 years of age, who have
limited verbal skills, by assigning a full verbal score
neurologic examination helps to determine the pres-
ence of focal neurologic signs that may signify an
intracranial mass lesion or impending cerebral her-
niation from increased pressure.
..
 cranial pressure treated before any triage or trans-
In all cases the physician should palpate scalp cranial pressure treated before any triage or trans-
hematomas and contusions for underlying depres- portation decisions are made.
sions, which signify a depressed skull fracture, and
explore all full-thickness skull lacerations to ensure Mild injury
that the underlying bone is intact before suturing.
Injuries to other areas such as the thorax or the Children with mild intracranial injury may be
abdomen should be sought and treated promptly discharged home. An instruction sheet should be
since they may contribute to illness and death. given to the parents or caregiver concerning observa-
tion and precautions (Table 5). These patients com-
Classification of the severity of head injury monly do not pose a major therapeutic or diagnostic
dilemma.
Table 4 classifies the severity of intracranial
injuries on the basis of the child's history and the Moderate injury
findings at physical and neurologic examination. The
categories are similar to those used previously' but Close observation for at least 6 hours after
have been adapted to reflect the unique characterist-injury is warranted. If the condition progressively
ics of children with head trauma. The inclusion of improves during that time the child may be dis-
the Glasgow Coma Scale provides more information charged home. A reliable caregiver should be in
to assist in triage, treatment and prediction of charge at home and be given an instruction sheet for
outcome. observation and precautions. If any of these criteria
are not met the observation period in hospital
Triage guidelines should be extended to 24 hours. CT scanning and
neurosurgical consultation may be necessary if
Triage and referral guidelines should be based the child's condition does not improve or deteri-
on the severity of the intracranial injury, the need orates. The decision to provide care in a community
for immediate therapy and the availability of re- hospital may best be made after careful clinical
sources at the treating hospital. Cardiorespiratory evaluation and assessment of the possible adverse
instability should be corrected and increased intra- outcomes and the available resources to treat them.
If physicians are in doubt, they should consult with a
neurosurgeon or a critical care specialist at a referral
Table 4: Classification of severity of intracranial injury centre.
Mild Severe injury
Asymptomatic
Mild headache
Three or fewer episodes of vomiting Children with severe injury should be admitted
Glasgow Coma Scale score of 15 to a tertiary care facility and be seen by a neurosur-
Loss of consciousness for less than 5 minutes geon. However, cardiorespiratory stabilization and
Moderate treatment of increased intracranial pressure are more
Loss of consciousness for 5 minutes or more
Progressive lethargy important than referral and should be started imme-
Progressive headache diately. If the child is brought to a nontertiary care
Vomiting protracted (more than three times) or centre the physician should consult with a neurosur-
associated with other symptoms geon or a critical care specialist at the referral centre
Post-traumatic amnesia before the patient is transferred.
Post-traumatic seizure
Multiple trauma
Serious facial injury Table 5: Instructions to parents or caregivers for
Signs of basal skull fracture observation at home of children with head trauma
Possible penetrating injury or depressed skull
fracture Bring child immediately to emergency department if
Suspected child abuse any of the following signs and symptoms appear
Glasgow Coma Scale score of 1 1 to 14 within the first 72 hours after discharge
Severe
Glasgow Coma Scale score of 10 or less or Any unusual behaviour
decrease of 2 points or more not clearly caused by Disorientation as to name and place
seizures, drugs, decreased cerebral perfusion or Inability to wake child from sleep
metabolic factors Increasing headache
Focal neurologic signs Seizures
Penetrating skull injury Unsteadiness on feet
Palpable depressed skull fracture Unusual drowsiness and sleepiness
Compound skull fracture Vomiting more than two to three times

CAN MED ASSOC J 1990; 142 (9) 951

Use of radiography
Radiography plays no appreciable role in the
evaluation and management of head trauma."' How-
ever, in some cases it serves as an adjunct to
history-taking and physical and neurologic examina-
tion in the detection of skull fracture and thus
enhances the care of the patient.
The suggested indications for skull radiography
are (a) possible penetration, (b) possible depressed
fracture, (c) compound fracture, (d) previous crani-
otomy with indwelling shunt, (e) child less than 2
years of age with "boggy" scalp hematoma and
(f) suspected child abuse. The presence or absence of
a fracture may not correlate with the degree of
underlying brain injury. For example, patients with
severe injury may have no fracture, whereas those
with linear fractures may show no neurologic dam-
age.' 4 The correct management of a noncomplicated
linear skull fracture is controversial; however, we
suggest observation in hospital for 24 hours.
Head trauma and child abuse
Head trauma may be due to child abuse or
serious neglect by a parent or caregiver. In all cases a
thorough history should be obtained of past injuries
and of circumstances surrounding the present injury.
It may be impractical to review old records of all
patients with head injuries, but in suspicious cases
all records must be reviewed and appropriate follow-
up arranged. Readers are referred to excellent re-
views for further information on the subject." ->
The committee gratefully acknowledges the assistance of
Dr. Manjit Singh Walia, Children's Hospital of Western
Ontario, London, in the preparation of this statement.
952 CAN MED ASSOC J 1990; 142 (9)
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For prescribing information see page 972