Compared with older children, those younger than two years are at higher risk for injury following head trauma. However, it would not be reasonable to obtain skull radiographs and computed tomographic (CT) scans for every child of that age with a head injury. Schutzman and colleagues reviewed the literature on head trauma in younger children and proposed a set of guidelines for assessing and managing these children.
Minor head trauma is defined as blunt trauma to the scalp, skull, or brain in which the person remains alert or awakens easily. The authors did not include children who had a history of head injury or in whom abuse was suspected.
The study panel reviewed 404 published articles about head trauma in children that were identified through a MEDLINE search. The expert panel that was assembled for the study included four pediatric emergency medicine physicians, one emergency medicine physician with experience in pediatric head trauma, two pediatric neurosurgeons, one pediatric neuroradiologist, and one general pediatrician. Each of these panel members was a full-time academic faculty member and a nationally recognized expert in pediatric head trauma. Data were reviewed to determine a consensus management strategy; if there were insufficient data, expert consensus was used.
Acute intracranial injury can usually be diagnosed with the aid of a CT scan. In young children with minor head trauma, the incidence of intracranial injury (hematoma, cerebral contusion, or cerebral edema) is no more than 6 percent. Skull fracture, change in mental status, focal findings, scalp swelling, younger age, and inflicted injury are all more likely to be associated with intracranial injury. Vomiting and loss of consciousness have not been shown to predict intracranial injury, however. The younger the child, the more likely that intracranial injury will be asymptomatic. Of the above signs and symptoms, skull fracture is the best predictor of intracranial injury in young children with minor head trauma. Skull fractures can be predicted by the presence of scalp hematoma (sensitivity: 80 to 100 percent) and younger age. In children with a skull fracture, an intracranial injury was present in 15 to 30 percent of patients. If a child with minor head trauma had a normal CT scan, the incidence for late deterioration was zero percent.
The authors conclude that (1) the threshold for obtaining skull radiographs or CT scans should be lower in younger children than in older children, (2) the more associated signs and symptoms are present, the more likely an imaging study should be obtained, and (3) the greater the force of the injury and the more prominent the physical findings, the more likely an intracranial injury is to have occurred.
Patients at high risk (age younger than three months, depressed mental status, focal neurologic findings, depressed or basilar skull fracture, acute skull fracture, bulging fontanel, or irritability) should be evaluated with a CT scan. Expert opinion held that children with seizures, worsening vomiting, or loss of consciousness should also have a CT scan, although the literature did not show that these factors were independently associated with a higher risk of intracranial injury.
Patients in the intermediate risk group can be evaluated with CT scan or by observation, and those in the low-risk group should be observed for signs and symptoms indicative of intracranial injury. The intermediate category would include children with three or four episodes of vomiting (more would place them in the high-risk category), transient loss of consciousness, resolved irritability, behavior that is not normal for the child, or the presence of a skull fracture that is more than 24 hours old. If a CT scan is not obtained, the child should be observed for at least four to six hours. Development of signs or symptoms should prompt a CT examination. Skull radiographs are not necessary unless there is suspicion of abuse or neglect.
Another intermediate category includes children who, after physical examination, are thought to have a skull fracture or whose mechanism of injury is unknown. These children may need observation, skull radiographs, CT scan, or all of these evaluative methods. If symptoms develop in these children, a CT scan should be obtained. The proposed guidelines are summarized in an algorithm found in the original article.