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Head injury in the infant and toddler. Coma scoring and outcome scale
Insights
Young children (1-36 months) with closed-head injuries had poorer outcomes, especially those under one year. Ocular coma scores and hemiparesis strongly indicated poor outcomes in pediatric head trauma.
Area of Science:
- Pediatric Neurology
- Trauma Surgery
- Neurocritical Care
Background:
- Closed-head injuries in young children (1-36 months) present a significant clinical challenge.
- Understanding prognostic indicators is crucial for managing pediatric head trauma.
Purpose of the Study:
- To analyze outcomes of closed-head injured children aged 1-36 months.
- To identify clinical factors correlating with outcomes in pediatric head trauma.
- To evaluate a newly devised coma scoring system for pediatric head injury.
Main Methods:
- Retrospective review of 1-36 month old children with closed-head injuries admitted between 1959-1978.
- Correlation analysis of neurological signs, fontanelle status, retinal hemorrhages, seizures, and skull fractures with age and outcome.
- Application of a devised coma scoring system (ocular, motor, verbal) to assess consciousness levels.
Main Results:
- Children under one year had poorer outcomes, except in the deepest coma grades.
- Ocular coma scores were the most consistent indicator of neurological damage.
- Subdural hematomas, primarily in infants, significantly worsened outcomes.
- Hemiparesis, tense fontanelle, and bilateral/depressed skull fractures correlated with poor outcomes.
- Bilateral retinal hemorrhages were strongly associated with subdural hematomas.
Conclusions:
- Age is a critical factor in pediatric head injury outcomes, with younger infants facing higher risks.
- Specific clinical signs like hemiparesis and ocular coma scores are vital prognosticators.
- Early identification of subdural hematomas and associated findings like bilateral retinal hemorrhages is essential for improved management in pediatric head trauma.
Abstract:
This is a retrospective review of all closed-head injured children, ages 1-36 months, admitted to the Children's Memorial Hospital from 1959 to 1978. Injuries ranged from trivial to those producing deep coma. A coma scoring system (to correlate level of consciousness with age and outcome) was devised. Lateralizing neurological signs, fontanelle status, retinal hemorrhages, seizures, and skull fractures were correlated with age, outcome, and late onset of seizures. Children of 1 year and younger were more prone to have a poor outcome in all coma grades except the deepest, where the trend apparently reversed. Of the three components of the coma score (ocular, motor, verbal) the ocular score more constantly reflected neurological damage. Subdural hematomas, which were largely responsible for poorer outcomes in infants, occurred almost exclusively in children under 1 year of age. Lateralizing neurological signs, which were not found to correlate directly with a poor outcome, were unilateral Babinski, ataxia, and the combination of ocular deviation and hemiparesis (which is probably a seizure variant). Hemiparesis alone, however, did correlate directly with a poor outcome, as did full, and especially tense, fontanelle, and split sutures or diastatic fractures. Linear fractures, when unilateral, were not associated with a poor outcome, although bilateral linear and depressed fractures were. Bilateral retinal hemorrhages were found to be both quantitatively and qualitatively different from unilateral retinal hemorrhages, and to be statistically more often associated with subdural hematoma.