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Heads up!: Head trauma
Case presentation
A 7-month-old child presents to the Emergency Department after rolling off a couch. The child’s mother, who is visibly distraught and is worried that “her child’s brain is ruined,” reports that the child fell off the couch and struck the hardwood floor. The distance of the fall is approximately 2–3 feet. The child immediately cried and since the event, which occurred about 1 hour ago, has been at her baseline. There is no report of emesis.
The physical examination reveals age-appropriate vital signs. The child is alert, interactive, and smiling. There is a 3-cm right frontal hematoma with some ecchymoses but no step-off or laceration. The child is moving her neck well. There is no apparent abdominal or spine tenderness. The child is moving all of her extremities well and there is no other swelling, tenderness, or deformity.
Imaging considerations
The majority of children with minor head trauma do not require neuroimaging. Injuries such as small nondepressed skull fractures are not clinically significant and would not lead to harm if they are unidentified. Rather, the decision to pursue radiological imaging should be made when history or physical examination findings lead to a high suspicion for clinically important traumatic brain injury that would require hospitalization or surgical intervention. Clinical prediction rules have been published to help determine which patients may or may not require neuroimaging, the most commonly used being those put forth by the Pediatric Emergency Care Applied Research Network (PECARN).
Plain radiography
The utility of plain radiographs in pediatric head trauma is limited. Skull radiographs can help diagnose fractures and delineate if a fracture is depressed but cannot detect intracranial injury. This is important for patient management, since there is often significant brain injury present without an associated skull fracture. As such, most experts recommend forgoing plain radiography in favor of computed tomography (CT) scanning for patients with suspected head injury, as CT can identify intracranial injuries requiring surgical intervention. ,
Ultrasound (US)
US may be useful in diagnosing skull fracture in children presenting with head trauma. Several studies have shown that US has high sensitivity and specificity in identifying skull fractures when compared to CT scan. The advantage of US is that it may be performed at the bedside, without sedation, often by an emergency physician. A major limitation of US, similar to plain radiography, is the inability to identify clinically important intracranial injuries that may or may not be associated with skull fracture. US for this indication is also operator dependent.
Computed tomography
CT without contrast is the first-line imaging modality for diagnosing clinically important traumatic brain injuries. , It is relatively inexpensive and generally easily accessible and can quickly diagnose injuries that might require emergent intervention. CT can detect subarachnoid hemorrhage, subdural and epidural hematomas, pneumocephalus, ischemia, cerebral edema, midline shift, and signs of herniation, as well as scalp injuries and foreign bodies. However, subtle findings such as small hemorrhages or early cerebral edema may be difficult to detect, and study quality may be limited by motion artifact if patients are not completely still. The benefits of the information obtained from a head CT must be weighed against the potential risk of cancer mortality from the radiation required to perform the study. The estimated lifetime risk due to radiation-induced malignancy from one head CT is approximately 1 in 1500 in a 1-year-old child and approximately 1 in 5000 in a 10-year-old child, with risk decreasing as patients get older. This exposure risk can be mitigated by the implementation of pediatric-specific imaging protocols that adhere to the American College of Radiology radiation imaging dose guidelines.
Angiography is utilized in patients with increased risk for injury to major vessels due to penetrating trauma to the head, but in practice, venography is typically done if the fracture crosses the expected location of the dural venous sinus. Children with facial or orbital entry wounds, transdural trajectory of penetration, or accompanying intracranial hemorrhage are more likely to have aneurysm development.
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