Scalp Hematoma Research Articles

Trauma Infant Neurologic Score Predicts the Outcome of Traumatic Brain Injury in Infants

To investigate the clinical features of infancy traumatic brain injury (TBI) and the prognostic value of the Trauma Infant Neurologic Score (TINS), infants <2 years of age with TBI who were admitted from 2000 to 2007 were retrospectively studied. Fifty-six patients with a mean age of 13.3 ± 6.5 months (range = 2–24) were identified. The clinical diagnoses, in terms of the severest injury, included scalp hematomas (n = 2), skull bone fractures (n = 3), epidural hematomas (n = 21), subdural hematomas (n = 14), cerebral contusion and laceration (n = 4), intracerebral hematomas (n = 7), traumatic subarachnoid hemorrhage (n = 2), diffuse axonal injury (n = 2) and diffuse brain swelling (n = 1). The most common clinical presentations were vomiting (66.1%), paleness (55.4%), irritability (37.3%), pupillary abnormalities (35.7%) and altered consciousness (32.1%). The mechanism of injury included falls (n = 41), vehicle accident (n = 9), abuse (n = 4) and unknown (n = 2). The TINS score ranged from 1 to 10 with a mean of 3.6 (SD = 2.4) in the whole patient cohort. The Children’s Coma Scores (CCS) on admission were 13–15 (n = 31), 9–12 (n = 7) and 3–8 (n = 18). Thirty-nine of the infants were operated on and the other 17 infants were treated nonsurgically. Forty-eight patients (86%) were followed up for a period of 1–8 years (mean = 4.4) after discharge. In the followed-up patient cohort, the mean TINS score at admission was 3.8 ± 2.5. The total clinical outcome, according to the Glasgow Outcome Scale (GOS), was: 37 (77.1%) good recovery, 4 (8.3%) moderately disabled, 1 (2.1%) vegetative and 6 (12.5%) dead. For those who were operated on the outcome was: 25 (78.1%) good recovery, 4 (12.5%) moderately disabled and 3 (9.4%) dead, and for those who were not operated on: 12 (75.0%) good recovery, 1 (6.3%) vegetative and 3 (25.0%) dead. At two years of follow-up, the GOS included 34 (73.9%) good recovery, 3 (6.5%) moderately disabled, 2 (4.3%) severely disabled, 1 (2.2%) vegetative and 6 (13.0%) dead. Statistical tests revealed that the TINS scores were highly associated with the GOS. Higher TINS scores resulted in worse clinical outcome. The CCS scores were also to some degree associated with the GOS score. However, the CCS score on admission was not as discriminating as TINS, predicting only the best and worst outcome in our series. Our study showed that the clinical features of TBI in infants were different from those seen in adults regarding both the distribution of the pathology type and the clinical presenting symptoms. We found that the TINS scoring system is useful for predicting prognosis and outcome in infancy TBI and suggest that it could be routinely used in the infantile population.

Validation of a Clinical Score to Predict Skull Fracture in Head-Injured Infants

To validate a previously derived clinical score that uses clinical signs to determine which head-injured infants are at risk of skull fracture. The clinical score is calculated on the basis of the patient's age, the scalp hematoma size, and the location of the hematoma, with a total value between 0 and 8. We performed a prospective observational study of children younger than 2 years with blunt head trauma presenting to an urban pediatric emergency department. Among subjects who had head imaging performed (validation set), we assessed the utility of our clinical score to detect skull fracture and intracranial injury. In the 203 patients with imaging, 51 (25%) were diagnosed with skull fracture and 29 (14%) with intracranial injury. A clinical score of 4 or greater identified 90% (46/51) of patients with skull fracture with a sensitivity of 0.90 (95% confidence interval [CI], 0.78-0.96) and a specificity of 0.78 (95% CI, 0.70-0.84). A clinical score of 3 or greater identified 93% (27/29) of those with an intracranial injury with a sensitivity of 0.93 (95% CI, 0.76-0.99) and a specificity of 0.42 (95% CI, 0.35-0.50). A score of 3 or greater identified 100% of intracranial injury among asymptomatic patients. We have validated our clinical scoring system as an accurate way of determining an infant's risk of skull fracture. Whereas a clinical score of 4 or greater maximizes the trade-off between sensitivity and specificity for identifying skull fracture, a clinical score of 3 or greater may be preferable for detecting intracranial injury.

Sagittal synostosis and ossified scalp hematoma: cause or consequence?

In this paper, the author presents 2 cases of sagittal synostosis with scaphocephaly that featured ossified scalp hematomas straddling the sagittal suture in the midparietal region. These ossified lesions were originally cephalohematomas. Collection of blood under the pericranium across the midline was possible in these cases because sagittal synostosis had obliterated the sagittal suture and its dense attachment to overlying periosteum. Scaphocephaly very likely exacerbated the difficulty of the deliveries and contributed to the causation of the scalp hemorrhages. The alternative hypothesis, that ossification of a scalp hematoma immobilized the suture and caused synostosis, is not tenable for reasons that are reviewed. Sagittal synostosis in these 2 instances was not a complication of birth trauma.

Head Trauma: When Is a CT Not Indicated?

Head Trauma: When Is a CT Not Indicated?

Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study

CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary. We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission >or=2 nights). We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0) and sensitivity of 25/25 (100%, 86.3-100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99.95%, 99.81-99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations. These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated. The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.

Images in trauma: An unusual cause of airway obstruction

1. Unusual cause of upper airway obstruction1.1. PresentationA 55-year-old male with a history of alcoholism presented tothe trauma bay after being found unconscious. On arrival, he washaemodynamically stable with an oxygen saturation of 100%. Hewas able to phonate, and had clear breath sounds bilaterally. Hisexam was also notable for an occipital scalp haematoma andbilateral periorbital swelling. Rapid sequence intubation wasinitiated secondary to agitation and inability to cooperate withfurther assessment. After administration of a paralytic agent, thepatient quickly desaturated. The patient could not be intubatedsecondary to an object visibly obstructing the posterior pharynx.Bag-valve mask ventilation was also unsuccessful, thereforeemergent cricothyrotomy was performed at the bedside. Thepatient was then taken to radiology for computed tomography torule out traumatic injury.1.2. DiagnosisCoronal reconstructions of the cervical spine revealed a foreignbody in the posterior pharynx (Fig. 1). The cricothyroidotomy wasrevised to a tracheostomy in the operating room, at which time a12 cm pine cone was removed from the patient’s upper airway(Fig. 2). Creation of an emergent surgical airway is indicated in thepatient who cannot be intubated or oxygenated.

Management of scalp hematomas and compilations in infants

Objective To investigate the management of scalp hematomas and complications in infants. Method 99 infants with scalp hematoma and intracranial complications,or both diagnosed by CT from Jan. 2004 to Jun. 2006 were reviewed. The scalp hematomas were naturally absorbed in 16 cases,and punctured in 44 cases. Hard lumps of scalp hematomas were resected in 39 cases. Results None of the series had infection and rebleeding after the puncture of hemtomas and the resection of cranial hard lumps. Normal shape of the cranium had recovered. Intracranial complications were managed by combining therapy, and the curative effect was good. Conclusions The scalp hematomas and complications in infants should be diagnosed and treated early and the result is satisfactory. Key words: Infant; Hematoma; Scalp; Compliations; Therapy

Forehead Osteoma Excision by Endoscopic Approach

Six cases of frontal osteoma had been operated with assistance of endoscopic surgery. Patient age ranged from 34 to 59 years. The diameter of the masses varies from 8 to 14 mm. The access incision was hidden behind the frontal hairline and the dissection plane went in the subperiosteal layer. The injury of the nerve branch and vessel can be easily avoided and endorsed by manipulating the endoscope. The average length of the procedure was 59.5 minutes. There is no complication such as scalp sensation impairment or hematoma over the forehead or scalp area. The elimination of the forehead osteoma can be executed at the forehead area scarlessly by the assistance of the endoscopic-assisted surgery.

Interobserver Agreement in Assessment of Clinical Variables in Children with Blunt Head Trauma

To be useful in development of clinical decision rules, clinical variables must demonstrate acceptable agreement when assessed by different observers. The objective was to determine the interobserver agreement in the assessment of historical and physical examination findings of children undergoing emergency department (ED) evaluation for blunt head trauma. This was a prospective cohort study of children younger than 18 years evaluated for blunt head trauma at one of 25 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). Patients were excluded if injury occurred more than 24 hours prior to evaluation, if neuroimaging was obtained at another hospital prior to evaluation, or if the patient had a clinically trivial mechanism of injury. Two clinicians independently completed a standardized clinical assessment on a templated data form. Assessments were performed within 60 minutes of each other and prior to clinician review of any neuroimaging (if obtained). Agreement between the two observers beyond that expected by chance was calculated for each clinical variable, using the kappa (kappa) statistic for categorical variables and weighted kappa for ordinal variables. Variables with a lower 95% confidence limit (LCL) of kappa > 0.4 were considered to have acceptable agreement, Fifteen-hundred pairs of observations were obtained. Acceptable agreement was achieved in 27 of the 32 variables studied (84%). Mechanism of injury (low, medium, or high risk) had kappa = 0.83. For subjective symptoms, kappa ranged from 0.47 (dizziness) to 0.93 (frequency of vomiting); all had 95% LCL > 0.4. Of the physical examination findings, kappa ranged from 0.22 (agitated) to 0.89 (Glasgow Coma Scale [GCS] score). The 95% LCL for kappa was < 0.4 for four individual signs of altered mental status and for quality (i.e., boggy or firm) of scalp hematoma if present. Both subjective and objective clinical variables in children with blunt head trauma can be assessed by different observers with acceptable agreement, making these variables suitable candidates for clinical decision rules.

Bleeding Diathesis in Patients (pts) with Chronic Myelogenous Leukemia Receiving Dasatinib Therapy.

Dasatinib (Sprycel®, Bristol-Myers Squibb) is an oral potent ATP-competitive multikinase inhibitor active against BCR-ABL and SRC family kinases (SFKs). Dasatinib is approximately 300-fold more potent than imatinib against BCR-ABL and is active against a wide array of imatinib-resistant BCR-ABL kinase mutants at clinically achievable concentrations. Dasatinib has demonstrated high efficacy and safety in patients (pts) with chronic myelogenous leukemia (CML). The most frequent non-hematologic side effects associated with dasatinib therapy are gastrointestinal, rash, and fluid retention syndromes. In addition, dasatinib therapy may be associated with increased risk of bleeding in some pts. We evaluated the incidence of bleeding episodes associated with dasatinib therapy among 138 consecutive pts (69 female) with CML treated at our institution between November 2003 and January 2006 after failure or resistance to imatinib. The median age for the entire cohort was 57 years (range, 15 to 81 years). Among 50 pts treated in the phase I study, 23 (46%) were in chronic (CP), 7 (14%) in accelerated (AP), and 20 (40%) in blastic phase (BP) at the time of dasatinib start, whereas 88 pts, 43 (49%) in CP, 25 (28%) in AP, and 20 (23%) in BP, received dasatinib in phase II studies. Fifteen (11%) pts started dasatinib at a dose <100 mg, 22 (16%) at 100 mg, 92 (67%) at 140 mg, and 9 (6%) at >140 mg daily. The median time on dasatinib therapy for the study group was 42 weeks (range, 4–120): 69 weeks (range, 18–120) for pts in the phase I study and 34 weeks (range, 4–61) for those in phase II studies. Thirty-seven bleeding episodes occurred in 32 (23%) pts, 11 (22%) treated in the phase I study and 21 (24%) in the phase II studies. Seven (5%) pts had grade 1, 16 (12%) grade 2, and 9 (7%) grade 3 bleeding. No grade 4–5 bleeding episodes were observed. The median time to development of bleeding was 6 weeks (range, 0.5–38), occurring within the first 3 months of therapy in 22 (69%) pts. Most bleeding episodes occurred in the gastrointestinal tract (81%) (lower gastrointestinal bleed [LGIB; n=22]; upper gastrointestinal bleeding [UGIB; n=8]. Other bleeding types included: gingival (n=4), vaginal (n=2), and epistaxis (n=1). Six (19%) pts experienced >1 concomitant bleeding type: 4 with LGIB and UGIB, 1 with LGIB, gingival bleeding, and scalp hematoma, and 1 with gingival and vaginal bleeding. In addition, 12 (37%) pts (5 CP, 2 AP, and 5 BP) had recurrent bleeding episodes: 8 LGIB (in 2 separate occasions in 3 of them), 1 UGIB, 2 gingival bleeding, and 1 vaginal bleed. Bleeding led to transient dasatinib interruptions in 15 (47%) pts, 8 with LGIB (2 of them also with UGIB), 6 with UGIB (2 of them also with LGIB), 2 with gingival bleeding, and 1 with vaginal bleeding. Bleeding episodes were observed in 12% of pts treated in CP, 31% in AP, and 35% in BP (p=0.02) and were more frequent among pts treated at daily doses ≥140 mg compared to those treated at ≤100 mg (84% vs 16%; p=0.001). Fifty-one percent of bleeding episodes were observed in pts with platelet counts ≥30×109/L, including 37% in pts with platelet counts >100×109/L. Basic coagulation studies (PT, aPTT, fibrinogen, D-Dimer) were normal in all but 1 BP patient. In conclusion, bleeding diathesis is a relatively frequent complication of dasatinib therapy, particularly among pts with advanced CML receiving dasatinib ≥140 mg. Early identification, transient dasatinib interruption, and dasatinib dose reduction are required to adequately manage pts with this complication.

Neuroimaging for paediatric minor closed head injuries

It is clear that paediatric minor head injuries are common and that most cases may be observed without neuroimaging. However, with easier access to computed tomography scans, there has been an increase in its use. In the present article, clinical decision rules for neuroimaging of paediatric minor head injuries, such as the Child and Adolescent Trial for Cardiovascular Health (CATCH) study, will be discussed. Risk factors that should trigger concern are persistently low Glasgow coma scale, suspected open or basilar skull fracture, worsening headache, irritability, large and boggy scalp hematomas and dangerous mechanism of injury. An update on recent recommendations and evidence-based changes are provided.

Pediatric Head Injury

Pediatric Head Injury

Pediatric Head Injury

1. Shireen M. Atabaki, MD, MPH* 1. *Attending Physician, Division of Emergency Medicine, Children's National Medical Center; Assistant Professor of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC After completing this article, readers should be able to: 1. Describe the clinical features and management of epidural hematoma. 2. Recognize that the syndrome of inappropriate antidiuretic hormone secretion is possible following head injury. 3. Know the association of cervical cord injury with head trauma. 4. Discuss the long-term cognitive/behavioral consequences of head trauma. Head injury is a leading cause of morbidity and mortality in childhood. More than 1.5 million head injuries occur annually in the United States, resulting in approximately 300,000 pediatric hospitalizations, with males twice as likely as females to sustain a head injury. Overall, up to 90% of injury-related deaths among children are associated with head trauma. Motor vehicle collisions are the most common cause of pediatric head injury, followed by falls. Football is the most common cause of sports-related head injury, with 75% of fatal head injuries occurring in high school students and 74% of football-related head injury fatalities associated with subdural hematomas. Head trauma injuries include scalp hematoma and laceration, skull fracture, intracranial hemorrhage, cerebral contusion, and diffuse axonal injury (DAI). Most children sustaining blunt head trauma have minor traumatic brain injury. The American Association of Neurologic Surgeons defines traumatic brain injury (TBI) as a blow or jolt to the head or penetrating head injury that disrupts the normal function of the brain. Mild TBI may result in a brief change in mental state or consciousness; severe TBI may result in prolonged unconsciousness, coma, or death. Any blow to the head can transfer energy from the skin, through the skull and meninges, to the brain. When evaluating head trauma, the clinician should remember the anatomic layers of the head that may be affected: the skin, galea aponeurotica, periosteum, cranial bone, epidural space, dura mater, subdural space, arachnoid mater, subarachnoid space, and brain (Fig. 1). Figure 1. Layers of the scalp …

Evaluation of a Modified Prediction Instrument to Identify Significant Pediatric Intracranial Injury After Blunt Head Trauma

We evaluate the effect of a modification of the University of California-Davis Pediatric Head Injury Rule on the ability of the decision instrument for pediatric head injury to predict clinically important intracranial injury in an external cohort. We analyzed data prospectively recorded in 1,666 pediatric patients enrolled in the derivation set of the National Emergency X-Radiography Utilization Study II (NEXUS II). Treating physicians at 21 emergency departments recorded the presence or absence of clinical predictors on all patients who received a head computed tomography (CT) scan after experiencing blunt head trauma. Predictors included 3 exact elements of the University of California-Davis Rule (abnormal mental status, signs of skull fracture, and scalp hematoma in children < or = 2 years of age), some with different wording, and 2 modified elements with new definitions (the presence of high-risk vomiting or severe headache, rather than any vomiting or headache). A significant intracranial injury was identified by CT in 138 (8.3%) patients. Sensitivity of the modified instrument to detect significant intracranial injury was 90.4% (95% confidence interval [CI] 85.4% to 95.4%); 13 children with such an injury were misclassified as low risk. Specificity of the modified instrument was 42.7% (95% CI 40.1% to 45.3%). In the NEXUS II cohort, a modified version of the University of California-Davis Rule misclassified a substantial proportion of pediatric patients with clinically important blunt head injury. Although we cannot evaluate the exact University of California-Davis Rule, we demonstrate that using stricter definitions of "headache" and "vomiting" and different wording than in the original study may have unintended or negative consequences. We emphasize the importance of careful attention to precise definitions of clinical predictors when a decision instrument is used.

Infected Scalp Hematoma Presenting With Low-Grade Fever and Significant Weight Loss

Infected Scalp Hematoma Presenting With Low-Grade Fever and Significant Weight Loss

Developing a Decision Instrument to Guide Computed Tomographic Imaging of Blunt Head Injury Patients

Computed tomographic (CT) head scanning of blunt trauma patients is expensive, delays care, and necessitates radiation exposure, while detecting intracranial injuries in a minority of patients. Clinical characteristics may be able reliably identify patients who do not have intracranial injuries and consequently, do no require imaging. Physicians assessed blunt trauma patients undergoing imaging for the presence or absence of specific criteria. Recursive partitioning was used to identify criteria that predict intracranial injuries with high sensitivity. Intracranial injuries were found in 917 of 13,728 enrolled patients (6.7%). Injuries were rare among patients under age 65 who had no evidence of skull fracture, scalp hematoma, neurologic deficit, abnormal alertness, abnormal behavior, coagulopathy, or persistent vomiting. These characteristics would have identified 901 injury cases (sensitivity 98.3% [CI: 97.2-99.0]), while classifying 1,752 patients (12.8%) as "low risk." Clinical characteristics can reliably identify patients who are unlikely to have intracranial injuries and who do not require CT imaging.

Distinguishing Abusive from Accidental Head Trauma

Source: Bechtel K, Stoessel K, Leventhal JM, et al. Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma. Pediatrics. 2004;114:165–168.A majority of children under the age of 2 who have serious or fatal head trauma have been victims of abuse.1,2 Nevertheless, major head injuries may occur in this same age group from accidental causes. These authors present a prospective study of children less than 2 years of age who were hospitalized at Yale-New Haven Children’s Hospital, Conn, with a diagnosis of head injury and who had computed tomography of the head performed as part of their evaluation. The children were classified as victims of inflicted or accidental head trauma based upon predetermined criteria that did not include the presence or absence of retinal hemorrhages. All patients in the study underwent a dilated ophthalmologic examination by a pediatric ophthalmologist.The 67 children in the “accidental injury” group included 65 who fell (of these, 47 fell ≤4 feet), 1 child whose head was run over by a car, and 1 passenger in a motor vehicle crash. The 15 children in the “inflicted injury” group included 12 for whom no mechanism of injury was provided by the caretakers, 1 who was reported to have fallen 4 inches, 1 who was reported to have hit himself in the head with a piece of wood, and 1 child whose father admitted to shaking the child 48 hours prior to hospitalization.There were no differences between the 2 groups with regard to mean age, gender, or ethnicity. Significantly more patients in the “abusive injury” group had subdural hemorrhage (SDH) (80% versus 27%), retinal hemorrhage (RH) (60% versus 10%), seizures (53% versus 6%), and abnormal mental status at presentation (53% versus 10%). Among children with RH, those due to abuse were significantly more likely to be bilateral (6/9 versus 1/7); extend to the periphery of the retina (4/9 versus 0/7); and include pre-retinal hemorrhage (5/9 versus 0/7), premacular hemorrhage (3/9 versus 0/7), or vitreous hemorrhage (2/9 versus 0/7). Accidentally injured children were significantly more likely than abused children to have a skull fracture (60% versus 27%) or scalp hematoma (51% versus 7%).In recent years, a small but vocal segment of the medical community has charged that the conventional understanding of findings attributed to abusive head trauma are the result of circular reasoning.3–5 Certain findings, eg RH, have been linked with abuse,6 and so, if a child comes in and has RH, we conclude that the child has been abused. Critics assert that adequate controlled trials to test this hypothesis have not been done, and that no attempt has been made to establish whether certain patterns of RH are indicative of abuse.3–5 This study addresses those concerns. Most importantly, the allocation of children to the “inflicted injury” or “accidental injury” groups was based upon findings and considerations other than those being analyzed.We can conclude from the data presented in this article that RH may occur in some accidental injuries, although with far less frequency than they are seen in abused children. When RH does occur in accidental head trauma, it is not likely to present with the findings most typical of the abused child with head trauma, ie, multilayer, bilateral hemorrhages that extend to the periphery of the retina.This study contains important information for the pediatrician who faces the quandary of when to suspect child abuse in the head-injured child. While the authors did not present likelihood ratios, they can be readily calculated from the data they present. While positive likelihood ratios (+LR) for certain history and examination findings cannot conclusively confirm the diagnosis of child abuse (RH, +LR = 6.0 [95% CI, 3.9–9.1]; seizure, +LR = 8.3 [95% CI, 5.2–13.4]; and mental status decrease, +LR = 5.3 [95% CI, 3.3–8.6]), any combination of 2 of these findings virtually rules in a diagnosis of child abuse based on the prevalence of child abuse in head injury that has been previously reported.1

Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma.

To describe the clinical features that distinguish accidental from abusive head injury in hospitalized children <24 months of age. Prospective study of children <24 months of age hospitalized for head injury between August 1, 2000, and October 31, 2002. During hospitalization, children had computed tomographic scans of the brain, serial neurologic examinations, dilated ophthalmoscopic eye examinations, evaluation by a social worker, and, in some cases, a child abuse specialist. The main outcome measure was the proportion of children in each group with retinal hemorrhages (RHs). Secondary outcome measures were the proportion of children in each group who had vitreous hemorrhage; abnormal mental status on presentation; seizures; scalp hematomas; need for anticonvulsants; and operative procedures such as subdural tap, craniotomy, ventriculostomy, tracheostomy, and gastrostomy. Eighty-seven children were prospectively enrolled. Fifteen children were classified as having abusive head injury, and 72 were classified as having accidental head injury. Five children, all in the accidental head injury group, were excluded from statistical analysis, because they did not have a dilated ophthalmoscopic examination during their hospitalization. Thus 82 children were included in the statistical analysis. There were no significant differences between the 2 groups with respect to mean age, gender, or ethnicity. RHs were more likely to be seen in children with abusive head injury (60% vs 10%) and were more likely to be bilateral (40% vs 1.5%). Pre-RHs were more likely to be seen in children with abusive head injury (30% vs 0%). Premacular RHs and RHs that extended to the periphery of the retina were also more likely to be seen in children with abusive head injury (20% vs 0% and 27% vs 0%, respectively). Of the 7 children with accidental head injury who had RHs, 6 had unilateral RHs. Children with abusive head injury were more likely to have seizures (53% vs 6%) and an abnormal mental status on initial presentation (53% vs 1%). Children with accidental head injury were more likely to have scalp hematomas (6.7% vs 49%). RHs are seen more often in abusive head injury and often are bilateral and involve the preretinal layer. Children with abusive head injury were more likely to have RHs that cover the macula and extend to the periphery of the retina. Unilateral RHs can be seen in children with accidental head injury. Children with abusive head injury were more likely to present with abnormal mental status and seizures, whereas children with accidental head injury were more likely to have scalp hematomas. Such characteristics may be useful to distinguish accidental from abusive head trauma in children <24 months of age.

A decision rule for identifying children at low risk for brain injuries after blunt head trauma

Study objective Computed tomography (CT) is frequently used in evaluating children with blunt head trauma. Routine use of CT, however, has disadvantages. Therefore, we sought to derive a decision rule for identifying children at low risk for traumatic brain injuries. Methods We enrolled children with blunt head trauma at a pediatric trauma center in an observational cohort study between July 1998 and September 2001. We evaluated clinical predictors of traumatic brain injury on CT scan and traumatic brain injury requiring acute intervention, defined by a neurosurgical procedure, antiepileptic medications for more than 1 week, persistent neurologic deficits, or hospitalization for at least 2 nights. We performed recursive partitioning to create clinical decision rules. Results Two thousand forty-three children were enrolled, 1,271 (62%) underwent CT, 98 (7.7%; 95% confidence interval [CI] 6.3% to 9.3%) had traumatic brain injuries on CT scan, and 105 (5.1%; 95% CI 4.2% to 6.2%) had traumatic brain injuries requiring acute intervention. Abnormal mental status, clinical signs of skull fracture, history of vomiting, scalp hematoma (in children ≤2 years of age), or headache identified 97/98 (99%; 95% CI 94% to 100%) of those with traumatic brain injuries on CT scan and 105/105 (100%; 95% CI 97% to 100%) of those with traumatic brain injuries requiring acute intervention. Of the 304 (24%) children undergoing CT who had none of these predictors, only 1 (0.3%; 95% CI 0% to 1.8%) had traumatic brain injury on CT, and that patient was discharged from the ED without complications. Conclusion Important factors for identifying children at low risk for traumatic brain injuries after blunt head trauma included the absence of: abnormal mental status, clinical signs of skull fracture, a history of vomiting, scalp hematoma (in children ≤2 years of age), and headache.

Traumatismes crâniens dits bénins de l'enfant : surveillance clinique ou tomodensitométrie cérébrale systématique ?

In children, minor head trauma is a common injury that can result in intra cranial injury. The 6th ” Conférence de consensus en réanimation et médecine d'urgence” in 1990, then the American Academy of Pediatrics in 1999, published clear guidelines for management of head injured children older than 2 years, specially regarding Xray imaging, while currently no clear guidelines exist regarding children younger than 2 years. Being at higher risk for injuries and more difficult to assess, many authors recommend for these young children a low threshold for Xray imaging. However we believe that many asymptomatic infants older than 3 months of age who have no significant scalp hematoma, no high force mechanism of injury, and no suspicion of child abuse, can be safely managed without Xray imaging.