Conditions with Cerebral Dysfunction in the Pediatric Patient

Head injuries involve trauma to the brain and its surrounding structures that are the result of an external force, and can include injuries like lacerations, skull fractures, and concussions.

Alright, so, lacerations are tears of the scalp typically caused by blunt trauma or penetration with a foreign object. Skull fractures are breaks in the skull bone, and include linear fractures, which cause a crack in the skull bone that does not cross suture lines; comminuted fractures, which consist of multiple linear fractures; depressed fractures, where pieces of skull bone push inward, causing hematomas, which is a pooling of blood outside a blood vessel, or lacerations of the brain tissue; and basilar fractures, which occur at the base of the skull.

Then, there are mild traumatic brain injuries, or concussions, which cause a transient disruption in normal neurologic function resulting in an alteration in mental status and sometimes a temporary loss of consciousness.

Now, head injuries can be caused by several mechanisms, like contact head injuries, acceleration-deceleration injuries, and penetrating injuries.

Contact head injuries occur when a child hits their head on a hard surface, like when falling down the stairs; or when they receive a violent blow or jolt to the head, like when a child is tackled during a football game.

On the other hand, acceleration-deceleration injuries happen when the brain bounces around inside the skull, like in a car accident, or if a child is repeatedly shaken, like with shaken baby syndrome.

The bouncing of the brain inside the skull causes a contusion, or bruising of the brain, at the site of impact, called coup injury.

Then, the recoil force directs the brain the other way to strike the opposite side of the skull, resulting in a contusion on the other side of the brain, called contrecoup injury.

Lastly, head injuries can also be caused by penetrating injuries, like knife or gunshot wounds. Risk factors for head injuries include playing contact sports, child abuse, and being younger than one year old.

Also, children's heads often respond differently to an external force because their heads tend to be relatively heavy, they are larger compared to the rest of their body, and they have weaker musculoskeletal support for their head.

Head injuries can lead to complications like infection, bleeding, cerebrospinal fluid leaks, seizures, cerebral edema, and increased intracranial pressure, or ICP, due to the swelling of the brain tissue or when there’s bleeding inside the cranium.

Clinical manifestations of head injuries vary depending on the type of injury and degree of severity. Visible signs of trauma, such as scalp lacerations may present with surface wounds, like shallow cuts, abrasions, and bruises.

And because the scalp is very vascular, even a small injury to the scalp can cause profuse bleeding. Skull fractures will often present with scalp hematoma and symptoms of underlying brain tissue damage, including headache, altered level of consciousness, nausea, vomiting, pupillary changes, and altered vision or speech.

Confusion or irritability may also be present. Specific findings of basilar fractures include leakage of cerebrospinal fluid from the nose, known as rhinorrhea, or ear, known as otorrhea.

After 24 to 48 hours, basilar fractures can also present with periorbital ecchymosis, sometimes referred to as racoon eyes, as well as subcutaneous bleeding behind the ear over the mastoid process, referred to as Battle sign.

Diagnosis of head injuries begins with a patient history and physical examination. The child’s level of consciousness is assessed using the pediatric version of the Glasgow coma scale, or GCS, which evaluates eye-opening responses, verbal, motor and related to the child’s age.

Diagnostic imaging may include an X-ray, CT scan, or MRI. Treatment of head injuries depends on the type and severity of the injury.

Scalp lacerations and superficial injuries are cleansed and sutured, but if they’re deeper, surgical repair is required.

Minor head injuries are treated with brain or cognitive rest, along with physical rest, as well as analgesic medications like acetaminophen.

Some skull fractures will require surgery to remove bony fragments. Antibiotics can be given to prevent infections and antiepileptics are used to prevent or treat seizures.

All patients who have had a head injury should be closely observed for neurologic deterioration. Alright, when caring for your pediatric patient with a head injury, begin by obtaining a baseline neurologic assessment, including their GCS score and vital signs.

Take steps to avoid increasing ICP by instituting bed rest, keeping their head and neck midline, elevating the head of the bed to 30 degrees, and decreasing stimulation by dimming bright lights, maintaining a quiet environment, and clustering your care.

Watch them closely for indications of increased ICP, like decreased level of consciousness and pupillary changes, as well as signs of infection, like fever, and keep a close eye on their vital signs to ensure hemodynamic stability and adequate cerebral perfusion.

Also, administer the prescribed antiemetics and analgesics, as needed. When your patient is ready for discharge, teach caregivers to monitor their child closely; and instruct them to seek emergency medical treatment immediately for a worsening headache; vomiting; changes in behavior, like confusion; difficulty walking or talking; visual changes; or seizures.

Also, review ways they can prevent future injuries through supervision, using car seats, fastening seat belts in strollers and feeding chairs, wearing helmets when riding a bicycle and using protective equipment when playing sports.

Alright, as a quick recap …. Head injuries involve trauma to the brain and its surrounding structures that are the result of an external force, and can include lacerations, skull fractures, and concussions.

They can be caused by direct contact, acceleration-deceleration forces, or penetration, and can present with clinical manifestations like surface scalp wounds, bleeding, and altered level consciousness.

Treatment typically involves rest, observation, and analgesics. Nursing care includes monitoring neurologic status, preventing complications, and providing patient and caregiver education.