Assessment & Clinical Manifestations
Initial Assessment
- Pediatric Glasgow Coma Scale (PGCS): Modified version of the adult GCS that accounts for developmental differences in verbal and motor responses. Scores range from 3-15, with scores ≤8 indicating severe injury.
- Vital Signs: Monitor for Cushing's triad (hypertension, bradycardia, and irregular respirations), which indicates increased intracranial pressure. In children, hypotension is a late sign of shock and indicates decompensation.
- Pupillary Response: Assess size, symmetry, and reactivity to light. Fixed and dilated pupils or unequal pupils may indicate increased intracranial pressure or herniation.
- Fontanelle Assessment: In infants, a bulging fontanelle suggests increased intracranial pressure, while a sunken fontanelle may indicate dehydration.
Key Points
- The pediatric GCS must be adjusted for developmental stage, especially for pre-verbal children.
- Hypotension is rarely due to isolated head injury—search for other sources of bleeding if present.
- Serial assessments are more valuable than single evaluations for detecting deterioration.
Clinical Scenario: Infant with Head Injury
A 10-month-old is brought to the ED after falling from a changing table. The infant is irritable, has a bulging fontanelle, and vomited twice. Vital signs show HR 100, RR 30, BP 90/60. The right pupil is slightly larger than the left but both react to light.
Priority Assessment: This presentation suggests increased ICP. Immediate priorities include stabilizing the airway, preventing secondary injury, and preparing for rapid neuroimaging. The bulging fontanelle and pupillary changes are concerning for developing intracranial hemorrhage.
Age-Specific Signs & Symptoms
- Infants (0-12 months): May present with irritability, poor feeding, altered cry, bulging fontanelle, seizures, or decreased responsiveness. Inability to console an infant is a significant red flag.
- Toddlers (1-3 years): May display regression in developmental milestones, unsteady gait, vomiting, altered sleep patterns, or behavior changes. Limited verbal skills make assessment challenging.
- School-Age Children (4-12 years): Can report headache, visual disturbances, confusion, memory problems, or difficulty concentrating. May show personality changes or declining school performance.
- Adolescents (13-18 years): Similar to adults but may minimize symptoms to avoid activity restrictions. Watch for subtle cognitive changes, mood alterations, or academic difficulties.
Key Points
- Symptoms in preverbal children are often behavioral rather than reported complaints.
- Persistent vomiting, especially projectile vomiting, is a concerning sign in all pediatric age groups.
- Post-traumatic seizures occur more frequently in children than adults and may be immediate or delayed.
Red Flags Requiring Immediate Intervention
- Altered Level of Consciousness: Any deterioration in mental status, including increased sleepiness, confusion, or agitation requires immediate assessment.
- Focal Neurological Deficits: New onset weakness, sensory changes, or cranial nerve abnormalities may indicate a focal lesion requiring urgent imaging.
- Seizure Activity: Post-traumatic seizures may indicate significant brain injury. Status epilepticus requires emergency management.
- Signs of Increased ICP: Headache that worsens with lying flat, persistent vomiting, visual changes, altered vital signs, or papilledema require immediate intervention.
- Battle's Sign and Raccoon Eyes: Bruising behind the ears or periorbital ecchymosis developing hours after injury suggests basilar skull fracture.
Key Points
- Deterioration after initial improvement (the "talk and die" phenomenon) may indicate an expanding hematoma requiring emergency intervention.
- CSF rhinorrhea or otorrhea (clear fluid from nose or ears) indicates a basilar skull fracture with dural tear and risk of meningitis.
- Cushing's triad is a late sign of increased ICP and indicates impending herniation requiring immediate intervention.
Diagnostic Evaluation
Neuroimaging
- CT Scan: First-line imaging for acute head trauma due to rapid acquisition and availability. Identifies fractures, hemorrhages, midline shift, and hydrocephalus but exposes the child to radiation.
- MRI: Provides superior detail of brain tissue, white matter tracts, and subtle injuries not visible on CT. Used for follow-up or when clinical suspicion is high despite normal CT findings.
- Ultrasound: May be used in infants with open fontanelles to assess for intracranial hemorrhage or increased ICP without radiation exposure. Limited in scope compared to CT/MRI.
- X-ray: Limited utility in head trauma but may be used to identify skull fractures in low-risk scenarios. Not recommended as a standalone assessment tool.
Key Points
- PECARN (Pediatric Emergency Care Applied Research Network) criteria help determine which children need CT scans after head trauma, reducing unnecessary radiation exposure.
- Children under 2 years have different PECARN criteria than older children, reflecting developmental differences.
- Consider the radiation risks of CT scans in children, whose developing tissues are more sensitive to radiation effects.
Laboratory Studies
- Complete Blood Count: Evaluates for anemia if blood loss is suspected. Elevated white blood cell count may indicate stress response or infection.
- Coagulation Studies (PT/PTT/INR): Essential if there is bleeding or if anticoagulant therapy is being considered. Also important to rule out coagulopathies that may worsen intracranial bleeding.
- Electrolytes and Glucose: Abnormalities can mimic or exacerbate neurological symptoms. Hypoglycemia, in particular, can cause altered mental status that may be confused with TBI effects.
- Blood Gas Analysis: Helps assess for hypoxemia or acid-base disturbances that may contribute to secondary brain injury.
- Toxicology Screen: Consider in adolescents or when the mechanism of injury is unclear, as substance use may contribute to injuries or complicate assessment.
Key Points
- Biomarkers like S100B protein and neuron-specific enolase are being studied for TBI but are not yet standard in pediatric practice.
- Hypoglycemia can mimic symptoms of head injury and should always be ruled out during initial assessment.
- Consider non-accidental trauma workup (including skeletal survey and ophthalmologic exam) when the history is inconsistent with the injury pattern.
PECARN Criteria for CT Decision-Making in Pediatric Head Trauma
| Children < 2 Years |
Children ≥ 2 Years |
| GCS ≤ 14 or altered mental status |
GCS ≤ 14 or altered mental status |
| Palpable skull fracture |
Signs of basilar skull fracture |
| Occipital, temporal, or parietal scalp hematoma |
History of loss of consciousness |
| Loss of consciousness ≥ 5 seconds |
Severe mechanism of injury |
| Severe mechanism of injury |
Severe headache |
| Not acting normally per parent |
Vomiting |
Note: CT is recommended if any of the above criteria are present. Observation may be appropriate for children with isolated findings.
Nursing Management
Acute Care Interventions
- Airway Management: Maintain cervical spine immobilization while ensuring patent airway. Position to prevent aspiration while avoiding neck flexion or extension.
- Oxygenation: Administer supplemental oxygen to maintain SpO2 > 94%. Intubation may be necessary for GCS ≤ 8 or inability to protect airway.
- Circulation: Establish IV access for fluid resuscitation and medication administration. Treat hypotension promptly with isotonic fluids.
- ICP Management: Elevate head of bed 30° (if no spinal concerns), maintain normothermia, prevent pain and agitation, and avoid unnecessary stimulation.
- Seizure Prophylaxis: Administer anticonvulsants as ordered for patients at high risk of post-traumatic seizures.
- Neurological Monitoring: Perform frequent neurological assessments (q1h for severe injuries) using age-appropriate scales.
Key Points
- Maintain normothermia, normoglycemia, and normocapnia to prevent secondary brain injury.
- Avoid hypotonic fluids which can worsen cerebral edema; use isotonic solutions like normal saline.
- Document pupil size, reactivity, and symmetry with each neurological assessment.
Important Alert: Preventing Secondary Brain Injury
The "6 H-bombs" that worsen secondary brain injury must be prevented:
- Hypoxemia (maintain PaO2 > 80 mmHg)
- Hypotension (maintain age-appropriate SBP)
- Hypercarbia (maintain normocapnia, PaCO2 35-40 mmHg)
- Hyperthermia (maintain normothermia)
- Hyperglycemia (maintain normoglycemia)
- Hyponatremia (avoid hypotonic fluids)
Medication Management
- Analgesics: Acetaminophen for mild pain; opioids may be used cautiously for moderate to severe pain, recognizing they can mask neurological changes.
- Anticonvulsants: Levetiracetam (Keppra) or fosphenytoin for seizure prophylaxis in high-risk patients or treatment of post-traumatic seizures.
- Sedatives: May be required for intubated patients or those with agitation. Propofol, midazolam, or dexmedetomidine are commonly used, with careful monitoring of neurological status.
- Hyperosmolar Therapy: Mannitol (0.25-1 g/kg) or 3% hypertonic saline for increased ICP. Requires careful monitoring of serum osmolality and electrolytes.
- Corticosteroids: Not routinely recommended for traumatic brain injury as evidence suggests they may be harmful.
Key Points
- Calculate pediatric medication doses based on weight to prevent medication errors.
- Monitor for side effects of anticonvulsants, including drowsiness, ataxia, and behavioral changes.
- Avoid routine use of prophylactic anticonvulsants beyond 7 days post-injury unless seizures have occurred.
Family-Centered Care
- Education: Provide age-appropriate explanations to the child and comprehensive information to parents about the injury, treatment plan, and expected outcomes.
- Emotional Support: Acknowledge the family's anxiety and fear while providing realistic reassurance. Connect families with support services as needed.
- Participation in Care: Encourage parents to participate in care activities appropriate to their comfort level and the child's condition.
- Discharge Planning: Begin early to address potential needs for rehabilitation, home modifications, or follow-up care.
Key Points
- Provide written discharge instructions with clear return precautions and follow-up information.
- Educate families about the potential for delayed symptoms or complications, particularly with concussions.
- Address siblings' needs and concerns, as they may experience fear, guilt, or confusion about the injured child.
Memory Aid: AVPU Scale for Quick Neurological Assessment
- A - Alert: Child is awake, interactive, and age-appropriately oriented
- V - Voice responsive: Responds to verbal stimuli but may be confused
- P - Pain responsive: Responds only to painful stimuli
- U - Unresponsive: No response to any stimuli
A drop in AVPU status requires immediate physician notification and reassessment.