1. Minimal Traumatic brain Injury in children
Dr vijay warad

2. Head trauma occurs commonly in childhood
 Head trauma occurs commonly in childhood. Most head trauma in children is minor and not associated with brain injury or long-term sequelae. However, a small number of children who appear to be at low risk after minor head trauma may have a clinically important traumatic brain (ciTBI) injury.
The clinical challenge for evaluating minor head trauma in pediatric patients is to identify those infants and children with ciTBI while limiting unnecessary radiographic imaging and radiation exposure.

3. Minor head trauma in these patients as a history or physical signs of blunt trauma to the scalp, skull, or brain in an infant or child who is alert or awakens to voice or light touch.
GCS of 14 or 15 at the initial examination
•No abnormal or focal findings on neurologic examination
•No physical evidence of skull fracture (eg, no palpable skull defect and no signs of basilar skull fracture such as hemotympanum, CSF oto- or rhinorrhea, or periocular or posterior auricular hematomas.
 Mild traumatic brain injury (TBI) is generally associated with symptoms, such as a brief loss of consciousness, disorientation, or vomiting. scalp hematoma, irritability,Seizures and headache

4.  Brain injury can occur following a minor head trauma because rotational acceleration-deceleration of the head generates shearing forces that cause mechanical disruption of nerve fibers, resulting in diffuse axonal injury.
Most children with isolated scalp hematomas and no other clinical symptoms do not have ciTBI (eg, injuries resulting in death or requiring hospitalization for >2 days, endotracheal intubation for >24 hours, or neurosurgery). However, hematomas can be an important indicator of potential TBI when they appear in younger infants, are larger (eg, >3 cm), and are located in nonfrontal regions

5. ciTBI is more likely in children who have vomiting and other findings associated with ciTBI (eg, severe mechanism of injury, loss of consciousness, or altered mental status.
Vomiting two or more times after head trauma was associated with an approximately 37 percent increase in traumatic brain injury.
findings of skull fracture include a palpable skull defect, cerebrospinal fluid rhinorrhea or otorrhea, posterior auricular hematoma (Battle’s sign), hemotympanum, and periorbital hematomas (“raccoon eyes”).
 The priority for the evaluation of children with apparently minor head trauma is to identify those patients with traumatic brain injury (TBI) who may require immediate intervention (eg, an expanding epidural hematoma), admission for monitoring (eg, small stable epidural hematomas or cerebral contusions) or close follow-up (eg, skull fracture without intracranial injury),.

6. Historical features that may suggest an increased risk of clinically important traumatic brain include the following:
●Caregiver concern that a child younger than two years of age is not acting normally
●Seizure, confusion, or loss of consciousness
●Severe or worsening headache
●Vomiting
●High-risk mechanism, such as a fall from greater than 3 to 5 feet (depending on age), significant motor vehicle collision, penetrating injury, inflicted injury, or unknown mechanism (which may represent inflicted injury)
●Preexisting conditions that place the child at risk for intracranial hemorrhage, such as arteriovenous malformation or a bleeding disorder
The presence of the following specific findings is significant:High Risk:-
●Scalp abnormalities, such as hematoma, tenderness, or depression
●In infants, bulging anterior fontanelle
●Abnormal mental status
●Focal neurologic abnormality
●Signs of basilar skull fracture (periorbital ecchymosis, Battle's sign, hemotympanum , cerebral spinal fluid [CSF] otorrhea, or CSF rhinorrhea).
Intermediate risk – Variable significance has been reported for each of the following findings.
•Seizures
•Loss of consciousne ss
•Amnesia
•Vomiting
•Age less than two years
•Nonfrontal scalp hematoma in children younger than one year of age
•Persistent or worsening headache
•Significant trauma mechanism (eg, bicycle-related injury, falls from >0.9 to 1.5 m [3 to 5 feet], serious motor vehicle collision)
●Low risk – Patients with none of the above findings (low mechanism of injury, normal exam except frontal hematoma, no symptoms) are considered low risk and should typically not undergo neuroimaging.
Neuroimaging:- Infants and children younger than two years of age with high risk for intracranial injury or with suspected skull fracture should have a head CT