Pediatric Trauma
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Pediatric trauma is injury to the brain or head during birth, infancy, or childhood. Most instances of trauma require only observation, rest, and ice. However, for more serious head trauma, treatment may consist of surgically implanting a device to monitor brain swelling and performing open surgery to control brain swelling or bleeding and repair injury.
From the time a child is born and begins developing, he or she is subject to various types of head trauma. Most often, the injuries are accidental, and most often, surgical treatment is not needed. Generally, the types of injuries during infancy and childhood include the following. These are known as primary injuries because they are the initial trauma to the head or brain:
- Scalp laceration
- Cerebral contusion
- Skull fracture
- Intracerebral hemorrhage
- Intracranial hematoma
- Diffuse axonal injury
- Concussion
A primary injury triggers inflammation of brain tissue and cerebral edema, which are both appropriate reactions to injury. However, inflammation and cerebral edema can cause secondary injury to the brain. The reason secondary injury occurs is that the brain is enclosed in the skull with little unoccupied space. When the brain swells, its delicate tissue is forced against the inside of the skull, producing additional harm.
Fortunately, an infant’s skull has open sutures and the fontanelle, allowing the skull to expand ever so slightly to accommodate the swelling. Despite this, brain swelling is serious and must be detected and treated. Therefore, intracranial pressure may need to be monitored for a few days after serious head trauma.
Birth
On very rare occasions, babies undergo head trauma as they pass through the birth canal. Most injuries are benign and do not require surgical treatment. For instance, contusion on the scalp, small skull fractures and cephalohematoma can occur during delivery and all usually resolve on their own.
Another possible injury during delivery is brachial plexus injury. This injury arises from the stretching of the nerves as the baby is being delivered, and the injury may range from subtle weakness to complete loss of use of the arm. For most babies, the injury improves spontaneously or with physical therapy, but under rare circumstances, surgery may be required if arm function does not return.
Infancy
During infancy, a baby can accidentally topple over, or off a surface, such as a changing table, and hit his or her head. The types of injuries associated with such falls are primarily contusions on the scalp, and only rarely do skull fractures orintracerebral hemorrhagesoccur. If the baby quickly returns to normal activity, then usually he or she is fine and does not need to be taken to a physician.
It is difficult to say how far a child must fall to suffer a more substantial injury, but a general guideline is that falls of about four feet or less are tolerated well. Of course, the type of floor and how the head hits the floor are also important factors; it is possible to fall shorter distances and sustain serious injuries under unusual circumstances. If a parent or caregiver is not sure whether to be concerned after a fall, he or she may wish to call a physician.
Childhood
As children grow up and start to ride bikes and play on swings and gym sets, the types of head injuries they sustain are more like those of adults. These include skull fracture, intracranial hematoma, concussion, contusion, and intracerebral hemorrhage. Some require surgery and others can be observed without any need for an operation. The best advice for parents is to minimize the risk for these injuries. Strategies to minimize risk include ensuring that children wear bike helmets and seat belts, supervising play and exercising good judgment.
Adolescence
During adolescence, teens are exposed to an array of activities that could lead to accidental head trauma. Such activities include driving, sports, skateboarding, and riding a bicycle. Injuries commonly sustained include concussion, skull fracture, intracranial hematoma, contusion, and intracerebral hemorrhage. Although head trauma is most often accidental, parents can encourage certain behaviors to minimize a teen’s risk. For instance, parents should make sure their teen knows:
- Bicycle safety, such as wearing a helmet and crossing streets appropriately
- Sports safety, such was wearing protective equipment (helmet, pads, mouthguard)
- Driving safety, such as wearing a seatbelt and driving responsibly
Most important though, if a head injury is sustained, parents should take extra precautions to prevent an additional injury before the first has healed because a second injury can cause an injury worse than the first. Precautions that should be taken include not allowing a teen to play sports or participate in any activities that could risk a second head injury. The teen’s doctor will advise when he or she can resume normal activities.
Other forms of trauma
Trauma can come in many forms and be the result of many causes. Although this page describes only the more common types and situations that may result in pediatric trauma, our neurosurgeons are highly experienced in all types and prepared for all situations.
Symptoms
Symptoms of pediatric trauma vary, depending largely on the type and severity of injury. Some common symptoms include:
- Worsening headaches
- Vomiting
- Seizures
- Lethargy
- Loss of consciousness
- Confusion
- Unusual sleepiness
- Irritability
- Change in behavior
- Refusal to nurse or eat
- Persistent crying among infants
Diagnosis
Diagnosis of pediatric trauma starts with a physical examination, during which the physician acquires a complete medical history of the child and asks the child and parent how the injury occurred.
Also, a neurological examination is performed to identify any alterations in brain function and mental status. This exam consists of evaluating hearing, motor function, swallowing, eye movements, sense of smell, sensation, balance, and coordination.
A child’s mental status is assessed according to the Pediatric Glasgow coma scale, a 15-item scoring system, and the score is used to determine whether head trauma was mild, moderate, or severe. The lower the score, the more severe the injury.
Imaging tests are the most important means of diagnosis. For newborns and infants, ultrasonography can be used to image the brain and detect injury or bleeding. For older children, computed tomography (CT) scan or magnetic resonance imaging (MRI) scan can be used. Although MRI is the more sensitive method, CT is superior for emergency situations and allows constant monitoring of a patient’s vitals during the test.
Blood may be drawn or urine collected and sent to a laboratory for testing.
Risk Factors
Pediatric trauma is caused by a direct impact to or vigorous shaking of the body or head. Most often pediatric trauma occurs from motor vehicle accidents, accidental bumps or falls, or recreational activities.
The mechanism by which the brain bruises and tissue becomes damaged is called coup-contrecoup. An impact to the head can cause a bruise at the site of trauma called a coup lesion and a bruise opposite to the site of trauma called a contrecoup lesion. A contrecoup lesion arises when the brain strikes the skull on the opposite side of the site of trauma. The jarring of the brain against the rigid skull can cause shearing of the internal membranes, blood vessels, and tissues, which can possibly lead to bruising, bleeding, or swelling of the brain.
Circumstances that can increase the risk of birth-related head trauma include:
- Breech births
- Cephalopelvic disproportion
- Birth weight of more than 8 pounds, 13 ounces
- Birth before 37 weeks
- Use of forceps during delivery
Treatments
At Columbia, our neurosurgeons use the latest surgical advances and techniques to treat each pediatric trauma, providing the best possible outcome.
The course of treatment depends largely on the severity of the injury and may include:
- Rest
- Ice
- Topical antibiotic ointment and adhesive bandage
- Stitches
- Hospitalization for observation
- Immediate surgical attention
Most children sustain mild injury and thus their physicians require only that they rest, both physically and mentally, until fully recovered.
In rare instances, injury is moderate or severe and requires trauma surgery to control brain swelling and repair the damage. Trauma surgery is typically performed in emergency situations to repair a head injury. Lacerations on the scalp are cleaned and stitched up, and compound and comminuted skull fractures are debrided and repaired. Injury to the brain is repaired by one of two surgical approaches:
- Craniotomy is an operation in which a portion of skull is temporarily removed, providing the neurosurgeon access to the brain to stop a bleeding blood vessel, remove clotted blood or repair another injury.
- When brain swelling is life-threatening, craniectomy may be the best approach; this involves removing a portion of skull to let the brain expand and relieve high pressure. Also, the neurosurgeon now has access to the brain to repair brain injuries.
Before, during, or after trauma surgery, a device may be implanted in the skull to monitor intracranial pressure (ICP) so that, should it increase, immediate action can be taken to bring the pressure back down. Devices that can be surgically implanted include an intraventricular catheter or a fiber optic monitor.
After implantation, the ICP device is attached to a monitor that gives a constant reading of the pressure inside the skull. If the pressure rises, it can be treated right away. While the ICP device is in place, the patient will be given medication to stay comfortable. When the swelling has gone down and there is little chance of more swelling, the device will be removed.
Elevated ICP can be treated with medication to reduce brain swelling or by means of shunt or externalized ventricular drain placement, which involves implanting a catheter in the skull to drain the excess fluid.
For any head injury, avoiding a second head injury, no matter how minor, is essential to having the best recovery possible. The brain is vulnerable, so even a minor second impact to the head can result in an injury worse than the first.
Actions parents can take to prevent head injury for their children include:
- Take precautions to avoid significant falls around your home.
- Make sure your child wears a seatbelt while in a vehicle.
- Don’t drive when you are under the influence of alcohol or drugs.
- Make sure your child wears a helmet while on a bicycle and during contact sports, riding skates or a skateboard, or when batting while playing baseball or softball.
- Keep firearms unloaded and locked away.
