PEM GUIDE - HEAD TRAUMA
INTRODUCTION
The term “head trauma” is used to describe a spectrum of injuries, from minor
mishaps to severe injury. The clinician must decide which patients are at risk of
intracranial injury (i.e. hemorrhage, diffuse axonal injury, cerebral edema, and
increased ICP) and therefore require a CT scan. While there are guidelines to
assist in clinical decision-making, no guideline is perfect, and the topic remains
controversial.
DIAGNOSIS
The diagnosis of head trauma is based on the mechanism of injury, patient
symptoms and associated physical exam findings. In the patient at increased risk
for intracranial injury, the use of neuroimaging is warranted. Diffuse axonal injury
is the most common finding in pediatric head trauma. A multi-center study of
pediatric head trauma by the Pediatric Emergency Care Applied Research
Network (PECARN) was recently completed (see the article)
SIGNS AND SYMPTOMS SUGGESTIVE OF INTRACRANIAL INJURY
C Coagulopathy
F Focal neurologic deficit
L LOC > 1 minute
A Altered mental status
P Persistent vomiting
P Persistent/worsening headache
S Signs of skull fracture
S Seizure (some contact seizures may be excluded)
S Scalp hematoma in a child < 2 y.o.
SIGNS OF INCREASED ICP
Headache
Depressed consciousness
3rd cranial nerve compression (fixed, dilated pupil)
Papilledema
Hemiparesis
Decorticate posturing
Cushing triad (bradycardia, hypertension, irregular respirations
SIGNS OF BASILAR SKULL FRACTURE
Battle sign (bruising over the mastoid)
Raccoon eyes
Hemotympanum
Hearing loss
Facial paralysis
CSF otorrhea or rhinorrhea
