In this section
Head trauma can refer to any injury to
the head from a superficial graze, through superficial haematoma to skull
fracture, and life threatening intracranial injury. Traumatic Brain Injury (TBI) refers
more specifically to disruption of the brain tissue by an external mechanical
force. This may lead to a range of
presentations from minimally impaired mental status, with no neurological
deficit, to profound and sustained loss of consciousness.
Coma scale 
has been used to classify severity of traumatic brain injury. This score designates patients as suffering
from mild (GCS 13-15), moderate (GCS 9-12) or severe traumatic brain injury
(GCS <8). Although originally
designed for adults, the Glasgow Coma Scale has been adapted to include
children and infants.[2, 3]. Other criteria used in the various
classifications of head injury severity include presence of post traumatic
amnesia, duration of loss of consciousness, presence of neurological changes,
presence of skull fracture or intracranial lesions.
injury in children is common. Traumatic
brain injury is a leading cause of long-term disability and mortality in
children. Children under 3 have the
highest rates of head injury. Most are
trivial or mild head injuries due to falls - around 90% will be discharged from
The majority of head injury in young children is the result of accidental
injury, however in children less than 2 years old, 80% or more of deaths from
head injury are due to non-accidental trauma. 
is a second peak in head injuries during adolescence. This group has a greater proportion of fatal injuries, where
mechanism is more commonly motor vehicle accident related. In one analysis of children presenting to the
Royal Children's Hospital, Melbourne, 24% of patients
with head injuries had an injury to one or more other body regions and 20 % of all children with severe head injury
had an accompanying cervical spine injury.
Children sustain different patterns of head injury compared to
adults due to their relevant anatomical, physiological and biomechanical
properties. In particular, the following
differences are important:
Outcomes from head injuries
depend on both the severity of the initial injury (primary brain injury), as
well as the extent of subsequent complications and how these are managed
(secondary brain injury). A holistic approach to the management of paediatric
head injury therefore includes identification of risks so that primary injuries
can be prevented. This includes maintaining
an increased awareness of inflicted injury, and advocating for the use of
protective devices - such as seat belts, bike helmets or netting around
trampolines which lessen the number of, or decrease the severity of injury
following accidents. This advocacy also identifies and informs parents of those
sports/activities which carry increased risks of head injuries - for example
quad-biking, Aussie rules football, and horse-riding.
Once a primary injury has
occurred, hospital management is directed toward the prevention, identification
and treatment of the secondary injuries.
Outcomes from head injuries
depend on the severity of the initial injury (primary injury) and the extent of
subsequent damage from oedema, ischaemia and inflammation (secondary
initial stage of TBI is due to mechanical tissue damage from shearing or
tearing forces on the neurons, glia and blood vessels. In many cases there is direct neural cell
loss and necrotic cell death. The
primary injury triggers secondary biochemical, metabolic and cellular
changes. These include:
Primary intracranial injuries include:
refers to the injury to brain cells after the original insult. It is a major contributor to overall morbidity
and mortality in traumatic brain injuries - and occurs over hours to weeks
following a primary injury to the brain.
Not all of this secondary brain injury is preventable. Nevertheless, the goals of patient management
are aimed at:
achieve these goals, it is important to understand cerebral haemodynamics.
There are two major principles to consider in order to understand cerebral haemodynamics - the Munro-Kellie hypothesis and autoregulation.
This hypothesis states that the
skull is a rigid compartment filled with essentially non-compressible contents
- the brain, intravascular blood and CSF.
An increase in volume of one of the contents should lead to a decrease
in the volume of another. This can occur
through displacement of CSF to the spinal subarachnoid space, or through
displacement of blood by compression of the venous system. However, the degree of this compensation is
limited, and once it is reached, intra-cranial pressure (ICP) can rise.
ICP rise can lead to:
Cerebral perfusion pressure (CPP) is dependent on mean arterial
pressure (MAP) and intracranial pressure (ICP). The uninjured brain is able to
regulate blood flow through a range of blood pressures through autoregulation
of cerebral vascular resistance. Various
conditions such as hypercapnia and acidosis lead to dilation of cerebral
arteries. Alkalosis, hypocapnia and
hypertension lead to cerebral arterial constriction . The injured brain may lose the normal
homeostatic mechanisms for blood flow and when this occurs, blood flow is
dependent on the CPP.
The relationship between ICP and
CPP is shown below:
CPP = MAP - ICP
In injury, a fall in blood
pressure (systemic hypotension) or a rise in ICP will lead to a reduction in
the CPP. A reduction in CPP leads to
cerebral ischaemia (that is a reduction in cerebral blood flow) - which leads
to further neuronal death and cerebral oedema - further increasing ICP and
contributing to a vicious cycle of escalating secondary brain injury.
order to prevent cerebral ischaemia, the ICP and MAP must ideally be maintained
within normal limits. In healthy children, a normal ICP is typically less than 10-15
mmHg. In the head injured child, it is
typical to aim to keep ICP below 20mmHg.
The target MAP varies with age - but is typically kept >50-60mmHg. The goal is to achieve a CPP 40-50mmHg with
infants within the lower range and adolescents in the higher range. 
Given the concepts outlined above, the general management of
traumatic brain injury focuses on minimising factors that contribute to raised
intracranial pressure, cerebral edema and cerebral ischaemia. This is achieved
In all aspects of trauma management the primary
survey is the first priority. This
should all take less than 1 minute .
(see Cervical spine injury)
(see Primary and secondary survey)
(see Breathing management)
D Assess level of disability
in-line cervical stabilisation at all times
central stimuli – such as sternal pressure or pinching the trapezius
muscle – to ascertain the child’s response to pain.
The primary survey can help guide initial management steps:
Ensure an AMPLE history has been taken (see How children are different). Also ensure to ask about the following:
Perform a complete secondary survey. In
all cases of head injury, pay particular attention to:
(see also Primary and secondary survey)
A general trauma panel is recommended including:
Infants are more at risk of skull
fractures than older children due to their thinner craniums. The presence or
absence of a skull fracture however, does not always correlate with the severity of
the underlying brain injury.
of the CT scan should only be undertaken when the patient is stable enough to
be transferred to the CT scanner. They must be fully monitored and accompanied
at all times. Indications for a CT head
Whilst it should not interfere with emergency management
documenting history and findings both descriptively and with photography and
preserving clothing or other “evidence” appropriately can help the care of the
child both in elucidating the nature of the mechanism particularly in the case
of inflicted injury and non-verbal children.
The scalp, being highly vascularized,
can be a source of significant bleeding. In young infants, scalp lacerations,
in particular a subgaleal haematoma, can lead to haemorrhagic shock.  All wounds should be explored to check for underlying skull
fractures are most common in the first year of life. They may occur in the presence or absence of
external clinical signs - i.e a boggy haematoma, as these may take some time to
Types of skull fractures include:
Mild TBI and
concussion are interchangeable terms. Sports concussion is a subtype of mild
TBI. According to
The WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury, mild
TBI is defined as:
The Task Force also
states the manifestations cannot be due to a penetrating head injury.  Others have
restricted mild TBI to those with GCS 14-15 as patients with GCS 13 have a risk
of intracranial lesion like those with moderate TBI.  In general,
mild TBI does not result in in head CT or MRI changes. This finding however is
not universally agreed upon and may change as new neuroimaging modalities are
risk to patients with apparent mild
TBI is the delayed onset of an intracranial haematoma or brain swelling. Both
are the most common causes of avoidable death in this subset of patients. The
decision to perform a head CT or not in a child with apparent mild TBI is therefore
are a number of clinical decision tools, with high sensitivity and external
validity, to help determine the need for a head CT in children (PECARN, CATCH, CHALICE[KA1] /NICE).
(see Radiology). According to the 2014 National Institute for Health and Care
Excellence (NICE) Guidelines (UK), factors that would prompt a head CT in
children include: 
Any one of:
Or, in the
absence of any of the above, two or more of:
hospital, for a minimum of four hours is advised where there is there is only
one of the latter set of conditions. Home
observation is another option for patients with normal mental status, normal
neurological exam and the availability of a reliable adult parent/carer. Of
note, it can be difficult to have a reliable neurological exam in infants and a
higher degree of suspicion is required.
Prognosis of mild TBI:
is resolution of confusion within 24 hours. Concussion results in an
inflammatory state of the brain which is then vulnerable to second injury
(second impact syndrome). Clear guidelines on rest, recovery,
return to activity and return to risk activities must be given at discharge. Post-concussion
symptoms are common. These include:
with mild TBI have persistent symptoms or develop neuropsychological deficits
however it is difficult to predict in which patient group this occurs. A
pre-morbid neuropsychiatric disorder is strongly related to persistence of
symptoms for 3 months or longer after injury. Patients with persistent symptoms
for greater than 3 months may benefit from treatment guided by teams
specialized in mild TBI/concussion. 
Sports-related concussion: Post-concussion
symptoms typically resolve within 7-10 days after a first concussion.  Patients should
be counselled to have a gradual return to sport.
Recommendations to families post
Injury Handout’. (end of this chapter)
features can include:
Neurosurgical team and consider CT scan if:
Most patients will initially rapidly
recover from the effects of concussion within a 12-24
hour period. A delay or reversal of recovery suggests haemorrhage, cerebral oedema, or
Clinical features can include:
neurosurgery and intensive care early. Manage
as a multi-trauma patient.
of treatment are:
Optimise cerebral perfusion
Other strategies to minimise secondary injury
Imaging - Arrange urgent head CT.
traumatic seizures are a common event following severe brain injuries. The incidence in this group (i.e. GCS <8) has
been reported as between 19-39%. However,
it is worth noting this risk increases further in those who are young
(<2yrs), have a subdural haematoma, and those who have an inflicted
aggressive management and prevention of seizures in the head injured patient is
required to prevent secondary brain injury.
The mechanisms by which seizures worsen secondary brain injury
post- traumatic seizures have been categorized into either:
However, it has been suggested
that “early post-traumatic seizures” group can be further subdivided into the
factors for early post traumatic seizures include:
treatment of seizures is important to prevent secondary brain injury. Management includes the following:
Any early post traumatic seizure, apart
from a brief (<2min) impact seizure, warrants investigation with imaging (CT
or MRI brain).
of elevated ICP requires invasive monitoring – however, an acute rise in ICP
can be inferred from certain clinical symptoms (described in the cerebral
haemodynamics section above).
Manage in consultation with
neurosurgery and intensive care.
is to minimize ICP while awaiting surgical evaluation. In
addition to the management strategies discussed above, additional therapies
Second tier therapies
Medical management may not
be able to relieve elevated ICP secondary to a large haematoma or severe
cerebral oedema. Emergent surgery may be
required, so early consultation with neurosurgery is necessary.
caused by a direct blow and confined to a focal area of the head. These
injuries may cause:
Initial management is resuscitation, as for severe head injury (see
skull fractures above).
Intracranial haemorrhages will
cause a rise in the ICP with the clinical features discussed above. It is essential
that a neurosurgical consultation occurs as soon as possible, for advice on acute
management and for definitive treatments, such as a surgical evacuation.
This is the most common type of intracranial bleed. It may occur at any age but often seen in infants. Subdural haematomas:
The CT scan above shows a subdural haematoma in the right hemisphere, associated with mass effect as evidenced by midline shift.
Extradural haematomas are often associated with a skull fracture. The haematoma forms a mass and the patient may have an initial
lucid period before a collapse. Typical, extradural haematomas:
Management requires urgent neurosurgical intervention with surgical evacuation of the haematoma and repair of any vessels.
The CT scan above shows an extradural haematoma overlying the right frontal lobe.
Subarachnoid haemorrhages are common in trauma. They arise as a consequence of tearing of the small vessels of the pia mater.
The blood distributes within the subarachnoid space, rarely causing a mass
effect and it may remain relatively focal. Subarachnoid haemorrhages are:
These occur from high-energy
impact, when the cerebral cortex impacts against the sides of the fixed skull
vault. The injuries occur at two points:
are most likely to occur where the brain is less cushioned, i.e less CSF
Effects of cerebral contusions:
RCH has two head injury handouts that can be given to caregivers and older children. The first covers general advice, and the second provides advice on graduated return to school and sport