How should we manage children after mild head injury?

Abstract

There are many controversies concerning the management of children after mild head injury. Most of these patients achieve a full recovery without medical or surgical intervention. A small percentage of them deteriorate owing to intracranial complications. The goal of this study was to identify significant factors that might allow the identification of patients at risk of subsequent deterioration. Its secondary goal was to establish a clinical protocol for the management of mild head injuries in children. We retrospectively reviewed the records of 166 children and adolescents with head trauma who had Glasgow Coma Scale (GCS) or Children Coma Scale (CCS) scores of 13-15 at the time of admission. The patients were divided into five age categories: babies younger than 1 year, children 1-3, 4-6, and 7-14 years old, and adolescents 15-17 years of age. The largest age group consisted of children 7-14 years old (83 cases). There was a male predominance (2:1). The main causes of injury were traffic accidents (55 cases) and falls (53 patients). Neurosurgical procedures were required in 93 of the 166 patients (56%). The most common intracranial lesion was subdural and epidural hematoma (60 cases). In 26 children (15.6%) diffuse brain swelling was the only lesion. A skull fracture was found in 103 cases and was accompanied by epidural hematoma (HED) in 19 cases (18%) and by subdural hematoma (HSD) in 12 cases (12%). However, the 63 children without a fracture also included 18 (29%) who had HSD and 11 (17%) who had HED. In our population 165 (99%) of the patients obtained a very good or good result. None was left severely disabled or in a vegetative state. One patient with GCS 13 died of an infection. We concluded that skull X-ray examination is not sufficient to rule out intracranial hematoma. We recommend CT scanning and admission to hospital for 24-h observation for all children with minor head injury, because of the risk of delayed hematoma.