Head Injury in Children: Essential Assessment Skills for Healthcare Professionals

Head injuries in children are a common concern in pediatric medicine. Due to the developing nature of a child's brain, prompt and accurate assessment of head injuries is crucial to prevent long-term consequences. This guide aims to provide medical students and healthcare professionals with a detailed approach to assessing head injuries in children. The information is designed to be practical, evidence-based, and applicable in various clinical settings.

1. Understanding Head Injuries in Children

Head injuries in children can range from minor bumps and bruises to severe traumatic brain injuries (TBIs). The mechanisms of injury often include falls, sports-related injuries, and motor vehicle accidents. Unlike adults, children's heads are proportionally larger compared to their bodies, making them more susceptible to head injuries. Additionally, the skull bones in children are thinner, and the brain is still developing, which increases the risk of damage from even relatively minor trauma.

Types of Head Injuries:

• Scalp Injuries: Includes lacerations, abrasions, and hematomas. Scalp injuries often appear worse than they are due to the rich blood supply in this area.
• Skull Fractures: Can be linear, depressed, or basilar. Linear fractures are the most common in children.
• Concussions: A type of mild traumatic brain injury caused by a blow to the head, leading to temporary disruption of brain function.
• Intracranial Hemorrhages: Includes epidural hematoma, subdural hematoma, and subarachnoid hemorrhage. These are serious conditions that require immediate medical attention.

2. Initial Assessment: The ABCs Approach

The initial assessment of a child with a head injury should follow the ABCs of resuscitation: Airway, Breathing, and Circulation. This is a critical first step to ensure that the child is stable before moving on to a more focused neurological examination.

• Airway: Ensure the airway is patent. Consider cervical spine injury in cases of trauma; immobilize the spine if necessary.
• Breathing: Assess the child’s respiratory rate, effort, and oxygen saturation. Look for signs of respiratory distress or failure.
• Circulation: Check the child’s heart rate, blood pressure, and capillary refill time. Look for signs of shock, which may indicate significant blood loss or severe injury.

Once the child is stable, proceed with a focused neurological assessment.

3. Focused Neurological Assessment

A thorough neurological examination is essential in assessing the severity of a head injury. The examination should include the following components:

Glasgow Coma Scale (GCS):
The GCS is a widely used tool to assess the level of consciousness in children with head injuries. It evaluates three aspects: eye response, verbal response, and motor response. The score ranges from 3 (indicating deep unconsciousness) to 15 (normal consciousness). Pediatric modifications of the GCS are available for younger children.

• Eye Opening (E):
  • 4: Spontaneous
  • 3: To speech
  • 2: To pain
  • 1: No response
• Verbal Response (V):
  • 5: Oriented
  • 4: Confused conversation, able to answer questions
  • 3: Inappropriate responses, words discernible
  • 2: Incomprehensible sounds or speech
  • 1: No response
• Motor Response (M):
  • 6: Obeys commands
  • 5: Localizes pain
  • 4: Withdraws from pain
  • 3: Flexion response to pain (decorticate posturing)
  • 2: Extension response to pain (decerebrate posturing)
  • 1: No response

Pupil Examination:
Assess the size, shape, and reactivity of the pupils. Anisocoria (unequal pupil size) can be a sign of increased intracranial pressure or a significant brain injury, such as a third nerve palsy. Fixed and dilated pupils are ominous signs indicating potential brain herniation.

Cranial Nerve Examination:
Examine all cranial nerves for abnormalities. Specific attention should be given to cranial nerves III, IV, and VI, which control eye movements, and cranial nerve VII, which controls facial movements. Abnormalities in these nerves can indicate a more severe injury.

Motor and Sensory Examination:
Assess the child’s motor strength, tone, and coordination. Look for any asymmetry in movement, which could indicate focal brain injury. A sensory examination should include light touch, pain, and proprioception.

Cerebellar Function:
Check for signs of ataxia by assessing the child’s gait, coordination, and ability to perform rapid alternating movements. Cerebellar dysfunction may result from a posterior fossa injury.

Signs of Increased Intracranial Pressure (ICP):

• Headache
• Vomiting, especially without nausea
• Altered mental status
• Seizures
• Papilledema (late sign)
• Cushing’s triad (bradycardia, hypertension, and irregular respirations)

4. Imaging and Diagnostic Tests

When to Perform Imaging: Not all head injuries in children require imaging. The decision to perform imaging should be guided by clinical findings and validated criteria such as the Pediatric Emergency Care Applied Research Network (PECARN) rules.

PECARN Criteria for CT Scan:

• For children younger than 2 years:
  • GCS <15
  • Palpable skull fracture
  • Loss of consciousness >5 seconds
  • Severe mechanism of injury (e.g., fall >3 feet)
  • Non-frontal scalp hematoma
• For children 2 years and older:
  • GCS <15
  • Signs of basilar skull fracture
  • Vomiting
  • Severe headache
  • Severe mechanism of injury (e.g., motor vehicle crash)

CT Scan: A head CT is the preferred imaging modality for evaluating acute head trauma. It is fast and effective at detecting skull fractures, intracranial hemorrhages, and other acute injuries. However, it exposes the child to radiation, so its use should be judicious.

MRI: Magnetic Resonance Imaging (MRI) is more sensitive than CT for detecting subtle brain injuries, such as diffuse axonal injury (DAI). It is typically used when CT results are inconclusive or when there are delayed symptoms.

Ultrasound: In infants with open fontanelles, ultrasound can be used to assess for hemorrhage or ventricular dilation.

5. Management and Treatment

Observation vs. Hospital Admission: Children with minor head injuries who are stable and have normal neurological examinations may be observed at home. Parents should be given clear instructions on what to monitor and when to return to the hospital. Observation in the emergency department or hospital is recommended for children with more significant injuries, concerning symptoms, or unreliable home observation.

Managing Concussions: Concussions require physical and cognitive rest. Children should avoid activities that could result in a second injury, such as contact sports, until they are fully recovered. Return to play should follow a stepwise protocol with medical clearance.

Surgical Intervention: Surgery may be required for children with severe head injuries, such as those with depressed skull fractures, large intracranial hemorrhages, or significant mass effect causing midline shift. Neurosurgical consultation should be obtained promptly.

Pharmacological Treatment:

• Pain management: Acetaminophen or ibuprofen can be used to manage pain. Narcotics should be avoided as they can mask neurological symptoms.
• Anti-seizure medications: May be indicated for children with a history of seizures following a head injury.
• Osmotic agents: Mannitol or hypertonic saline may be used in cases of increased ICP.

6. Long-Term Follow-Up and Rehabilitation

Children who suffer from moderate to severe head injuries require long-term follow-up to monitor for cognitive, behavioral, and physical sequelae. Neuropsychological testing may be necessary to assess for learning disabilities or attention deficits. Physical and occupational therapy can help with motor deficits, while speech therapy may be needed for language or communication difficulties.

Post-Concussion Syndrome: Some children may develop post-concussion syndrome, characterized by persistent headaches, dizziness, fatigue, and cognitive difficulties. Treatment is multidisciplinary, often involving neurologists, psychologists, and physical therapists.

Family Support: Head injuries can be distressing for families. Providing education and support is crucial in helping them cope with the challenges of recovery. Parents should be informed about potential long-term effects and the importance of adhering to follow-up appointments.

7. Prevention of Head Injuries

Prevention is the most effective way to reduce the incidence of head injuries in children. Healthcare professionals should educate parents and caregivers on the following preventive measures:

• Proper use of car seats and seat belts: Ensure that children are in the appropriate car seat or booster seat for their age, height, and weight.
• Use of helmets: Encourage the use of helmets during activities like biking, skateboarding, and contact sports.
• Safe home environment: Implement safety measures to prevent falls, such as using safety gates and window guards.
• Supervision: Children, especially younger ones, should be supervised during activities that pose a risk of head injury.