1
2
3
4
5
6
Eyes
Does not open eyes
Opens eyes to pain
Opens eyes to speech
Opens eyes spontaneously
–
–
Verbal
No verbal response
Inconsolable, agitated
Inconsolable, moans
Cries but consolable
Smiles, orients to sounds, interacts
–
Motor
No motor response
Extension to pain (decerebrate)
Abnormal flexion to pain (decorticate)
Withdraws from pain
Withdraws from touch
Moves spontaneously/purposefully
2.
Traumatic brain injury (TBI):
(a)
TBI is the most common cause of pediatric traumatic death. Incidence increased in children <four-years-old and 15–19-years-old.
(b)
Accounts for approximately 37,000 admissions and 2,500 deaths/year in the USA.
(c)
Concussion: mild traumatic brain injury. An alteration of consciousness as a result of non-penetrating traumatic injury to the brain. Findings observed are a vacant stare, delayed verbal or motor responses, difficulty focusing, memory deficits, and irritability. CT is negative or significant for mild swelling only.
(d)
Severity: minor (GCS 15), mild (GCS 14), moderate (GCS 9–13), severe (GCS 5–8), critical (GCS 3–4).
3.
Types of TBI:
(a)
Epidural hematoma (EDH): almost always associated with an overlying skull fracture most commonly in temporal and parietal lobes.
(b)
Subdural hematoma (SDH):
(i)
More common in infants than toddlers and adolescents.
(ii)
Large SDH with significant midline shift must be evacuated.
(c)
Intracerebral hematoma (ICH):
(i)
Due to coup/countercoup injuries from rapid acceleration and deceleration.
(ii)
Most commonly in frontal and temporal lobes due to contact of the brain with skull base bony protuberances.
(d)
Subarachnoid and Intraventricular hemorrhages (SAH, IVH)
(e)
Diffuse multi-lobar injury:
(i)
Angular acceleration and deceleration. Shearing injury of axons most commonly at the gray-white matter junction, corpus callosum, and brain stem.
(ii)
Can range from minor concussion to severe Diffuse Axonal Injury (DAI) with severe impairment of neurologic function.
(iii)
MRI findings: range from normal to deep white matter, corpus callosum or brain stem punctate hemorrhages most evident on gradient-ECHO sequences.
(f)
Non-accidental Head injury (NAHI)/Abusive head injury/Shaken-baby syndrome.
(i)
Most victims are <3 years old.
(ii)
Common acute, subacute, chronic or mixed SDHs and subarachnoid hemorrhages (SAH).
(iii)
Best prognosticator factor is the initial patient presentation (GCS).
4.
In general for hematomas: small and asymptomatic can be observed; larger ones, especially those causing significant mass effect and or midline shift require surgical evacuation.
5.
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Skull fractures:
(a)
Linear fractures are the most common: most heal on their own and require no treatment.
(b)
Closed depressed skull fractures: surgical indications can include cosmetic defects, opened air sinus, compression of dural sinus, presence of dural laceration, compression of eloquent brain area with impaired function.
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