Infants with intracranial injuries may have limited neurologic findings and appear asymptomatic Clinical assessment of infants may be challenging Index of suspicion for nonaccidental trauma should be low Goal of Treatment The primary goal in the evaluation of any patient who has sustained a blunt head injury is to determine the severity of the injury and identify ciTBI As with all trauma evaluations, the initial goal of treatment is immediate stabilization Current Evidence Neurotrauma is one of the most common reasons for ED evaluation with more than 800,000 annual visits by children ED visits for younger children up to years of age have increased significantly in the past several years Common mechanisms of injury include falls, being unintentionally struck by or against an object, motor vehicle collisions either as a passenger or pedestrian struck by, bicycle accidents, sportsrelated, assaults, and nonaccidental trauma A detailed description of anatomy, pathophysiology, and causes of increased intracranial pressure (ICP) is included in Chapter 41 Injury: Head Briefly, the spectrum of traumatic brain injury (TBI) patterns range from minor head injury, concussion, skull fracture, pneumocephalus, intracranial hematoma, cerebral edema, diffuse axonal injury (DAI), cerebral herniation to death Cerebral hematomas may be extra-axial, occurring in the epidural or subdural space or intra-axial, occurring within the parenchyma of the brain Most recent studies have separated intracranial injury from ciTBI The definition of ciTBI includes the presence of a depressed skull fracture necessitating surgical elevation, neurosurgical intervention including, but not limited to, invasive ICP monitoring, ventriculostomy, hematoma evacuation and/or decompressive craniectomy, endotracheal intubation for more than 24 hours, hospital admission for 48 hours or more, and death Utilizing this definition, the overall incidence of ciTBI ranges from 0.02% to 4.4% TBI is the leading cause of acquired disability in children Neurologic and cognitive deficits are related to patient age at time of injury, severity of injury, and degree of structural injury Unique considerations should be given to children with shunt-dependent hydrocephalus and bleeding diatheses or platelet disorders, such as hemophilia Clinical Considerations (See Also Chapter 41 Injury: Head ) Clinical Recognition The historical and physical features of TBI encompass a wide spectrum of signs and symptoms For a detailed review of signs and symptoms, please review Chapter 41 The presentation of infants may be nonspecific and include poor feeding, vomiting, irritability, a bulging anterior fontanelle, altered mental status defined as a Pediatric Glasgow Coma Score of less than or equal to 14 ( Table 113.1 ), lethargy, seizure and presence of scalp hematoma and/or depression Typical complaints in children include headache, progression of headache with increasing severity, vomiting, confusion, altered mental status defined as a Glasgow Coma Scale (GCS) of less than or equal to 14 ( Table 113.1 ), seizure, lethargy, focal neurologic abnormality, obtundation, or signs of a basilar skull fracture, such as Battle sign, periorbital ecchymosis hemotympanum, and cerebral spinal fluid (CSF) otorrhea or rhinorrhea Signs of impending cerebral herniation include altered mental status, pupillary changes, bradycardia, hypertension, and respiratory depression Recent clinical decision rules to assist in the determination for emergent radiography have stratified ciTBI risk based on key historical and physical examination features The clinical decision rules are applied to two separate patient populations, children less than years of age and children years of age and greater Children less than years of age provide a unique challenge to the clinician as they commonly present after minor trauma but may be asymptomatic or clinical assessment may be difficult Additionally, the clinician must always have a low index of suspicion for nonaccidental trauma, as the incidence of child abuse in this age group is high Head injury accounts for the highest mortality in nonaccidental or intentional injury For a detailed review of inflicted injuries, please refer to Chapter 87 Child Abuse/Assault The features that place children less than years of age at higher risk of ciTBI include altered mental status, especially if the parent is concerned the child is acting abnormally, parietal, temporal, or occipital scalp hematoma, loss of consciousness >5 seconds, evidence of depressed or basilar skull fracture, bulging anterior fontanelle, persistent vomiting, posttraumatic seizure, focal neurologic examination findings, or suspicion of nonaccidental trauma The features that place children years of age and greater at higher risk of ciTBI include altered mental status, evidence of depressed or basilar skull fracture, posttraumatic seizure, prolonged loss of consciousness, worsening severe headache, and focal neurologic examination findings See Table 113.2 Emergent neuroimaging should be performed for any child with one or more of these features Just as certain features dictate the use of radiographic imaging, the absence of these features should allow the clinician to spare the patient unnecessary radiation exposure Children less than the age of who have a normal mental status with normal behavior, lack a scalp hematoma or have a frontal scalp hematoma, without evidence of skull fracture and a normal neurologic examination should not undergo radiographic imaging; nor should older children who have a normal mental status, no loss of consciousness, no vomiting, no severe headache, without evidence of a skull fracture, and a normal neurologic examination The diagnostically challenging patient population are the children in the intermediate-risk category These are the children who may have isolated features indicative of ciTBI with resolution or improvement of symptoms and a normal neurologic examination Observation for to hours after the injury may offer an alternative to emergent neuroimaging TABLE 113.1 GLASGOW COMA SCALE AND PEDIATRIC GLASGOW COMA SCALE ... feeding, vomiting, irritability, a bulging anterior fontanelle, altered mental status defined as a Pediatric Glasgow Coma Score of less than or equal to 14 ( Table 113.1 ), lethargy, seizure and... the injury may offer an alternative to emergent neuroimaging TABLE 113.1 GLASGOW COMA SCALE AND PEDIATRIC GLASGOW COMA SCALE