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 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-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.
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 CO2 target of 35 to 40 mm Hg. Placement of a definitive airway is recommended in the 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 outcome 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.
The management of pediatric head trauma is done by a multidisciplinary team that consists of an emergency department physician, neurologist, 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.
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