Head injury in the infant and toddler. Coma scoring and outcome scale.

Abstract

This is a retrospective review of all closed-head injured children, ages 1-36 months, admitted to the Children's Memorial Hospital from 1959 to 1978. Injuries ranged from trivial to those producing deep coma. A coma scoring system (to correlate level of consciousness with age and outcome) was devised. Lateralizing neurological signs, fontanelle status, retinal hemorrhages, seizures, and skull fractures were correlated with age, outcome, and late onset of seizures. Children of 1 year and younger were more prone to have a poor outcome in all coma grades except the deepest, where the trend apparently reversed. Of the three components of the coma score (ocular, motor, verbal) the ocular score more constantly reflected neurological damage. Subdural hematomas, which were largely responsible for poorer outcomes in infants, occurred almost exclusively in children under 1 year of age. Lateralizing neurological signs, which were not found to correlate directly with a poor outcome, were unilateral Babinski, ataxia, and the combination of ocular deviation and hemiparesis (which is probably a seizure variant). Hemiparesis alone, however, did correlate directly with a poor outcome, as did full, and especially tense, fontanelle, and split sutures or diastatic fractures. Linear fractures, when unilateral, were not associated with a poor outcome, although bilateral linear and depressed fractures were. Bilateral retinal hemorrhages were found to be both quantitatively and qualitatively different from unilateral retinal hemorrhages, and to be statistically more often associated with subdural hematoma.