Management of minor closed head injury in children and adolescents

In order to develop a systematic, evidence-based approach to minor closed head injury (CHI) in the pediatric patient, case records were reviewed of all 2,533 children and adolescents admitted to Cooper Hospital/University Medical Center for minor CHI during the years 1986 to 1992. A survey was taken during a 6-month period of 734 consecutive pediatric patients dischanged from the Emergency Department for minimal CHI (out of a total of 10,276 children during the entire 7 years of the study). Categories of minor CHI derived from studies in adults were used to group data. For each category of minor CHI, the frequency of various complications such as skull fracture, intracranial lesions, and need for neurosurgical intervention was determined. Also reviewed were survival and neurological outcome 6 months following injury. Children with moderate CHI had a 37% incidence of intracranial lesions on computed tomography (CT) scan and 9% of them required intracranial surgery. The incidences of intracranial lesions and surgical intervention in the mild CHI group were 12% and 2.6%, respectively. Children with Glasgow Coma Scale scores of 13 belonged in the moderate rather than the mild CHI group, as evidenced by their higher risk. Skull fracture was not highly correlated with intracranial pathology or the need for surgery. Age had no significant impact on the incidence of lesions, rate of surgery, or outcome. Both intracranial lesions and surgery were extremely rare in the minimal CHI group. We propose three categories of minor CHI based upon relative severity (minimal, mild, and moderate) and offer a simple management scheme for each category. Based on our experience with this approach, we estimate that 80% of children with minor CHI can safely be dischanged from the Emergency Department. Cranial CT scanning will be required in only 7% of cases, but when indicated, will be extremely valuable in guiding further care.