Journal of Child Neurology
Original Article
Head Trauma in Children, Part 1:
Admission, Diagnostics, and Findings
Thomas Kapapa, MD, Kathrin König, MD, Ulrike Pfister, MD,
Michael Sasse, MD, Dieter Woischneck, MD, PhD, Hans Heissler, and
Eckhard Rickels, MD, PhD
The objective of this study is to describe and to determine the
preclinical situation and early in-clinical situation, diagnostic
findings, and factors influencing the outcome of severe head
trauma in children. Records of 48 children (0-16 years) were
analyzed during a 3-year interval. Correlations with the out-
come (Glasgow Outcome Scale) were determined by focusing
on different scales, clinical findings, biochemistry, and
clinical course features. The initial shock index had a major
relevance (P ¼ .0089). Systolic blood pressure (P ¼ .0002)
and bradycardia (P ¼ .035) were important factors. Assessing
C
hildren’s severe head trauma and traumatic brain
injury are global challenges with local differ-
ences. A French population of 9 million had 671
children with severe traumatic brain injury with need of
intensive care.1 Based on population counts for children
(0-14 years) from 2001 in the United Kingdom and Eire
(N ¼ 22 210 476), the prevalence of severe traumatic
brain injury (February 2001 to August 2003) was 1246
children with admittance to an intensive care ward.2 The
incidence of traumatic head trauma and brain injury
among children (0-14 years) in the United States has esti-
mated to be 475 000 injuries each year (1995-2001).3
Even when there has been a decrease of incidences, the
Received October 31, 2008. Received revised January 12, 2009. Accepted
for publication January 12, 2009.
From the Department of Neurosurgery, University of Ulm, Ulm, Germany
(TK, DW, ER), Department of Neurosurgery, Krankenhaus Nordstadt,
Hannover, Germany (KK), Department of Pediatric Medicine,
Clementine Hospital, Frankfurt am Main, Germany (UP), Department
of Pediatric Medicine, Intensive Care Unit (MS), and Department of
Neurosurgery (HH), Medizinische Hochschule Hannover, Hannover,
Germany.
The authors have no conflicts of interest to disclose with regard to this
article.
Address correspondence to: Thomas Kapapa, Universitätsklinik Ulm,
Neurochirurgische Klinik, Steinhövelstraße 9, 89075 Ulm, Germany;
e-mail: Thomas.Kapapa@uniklinik-ulm.de.
Kapapa T, König K, Pfister U, Sasse M, Woischneck D, Heissler H,
Rickels E. Head trauma in children, part 1: admission, diagnostics, and
findings. J Child Neurol. 2010;25:146-156.
146
Volume 25 Number 2
February 2010 146-156
# 2010 The Author(s)
10.1177/0883073809332698
http://jcn.sagepub.com
the severity of trauma according to the Glasgow Coma Score,
the most accurate parameter for outcome is based on the
detailed quality of ‘‘eye opening’’ (P ¼ .0155). Pupillary
motoricity at the accident site (P ¼ .002) and emergency
room (P ¼ .0004) are strong predictors. Preclinical measure-
ments of stabilization and oxygenation have the same impact
as the in-clinical management.
Keywords: head trauma; outcome; prognostic factor; cere-
bral perfusion pressure
number of children with severe head trauma is still high
as stated in a prolonged study from Denmark.4
As stated by the German Federal Statistical Office, the
incidence of head injuries in children younger than
15 years rose from 2001 to 2006 with 773/100 000 to
817/100 000. The incidence of intracranial injuries
remained constant with 568/100 000 in 2001 and 570/
100 000 in 2006.5 Head trauma is one of the major diag-
noses after accidents in young patients younger than 15 years
old. In 1999, 86 497 children up to 15 years old were
admitted and treated for head trauma. In 2001, 158 chil-
dren (98 male, 60 female) died as a result of an accident
and subsequent head trauma. In this regard, traffic acci-
dents (119) are a major cause of death in Germany.6-8
Standards are being sought in the treatment of head
trauma because of varying therapeutic concepts in neurosur-
gery.9 Adapted from the guidelines, we performed and
discussed the cerebral perfusion pressure–guided concept
in the treatment of child head trauma.10-12 Accordingly, all
children with head trauma, a Glasgow Coma Score of 8 (or
lower) at the accident site, and secondary alterations of
consciousness were treated in a standardized manner. The
objective of management is the prevention of secondary brain
damage. Therefore, prevention of increased intracranial
pressure through brain edema as well as maintenance of
reasonable cerebral perfusion has been the highest priority.
Hence, the purpose of this part of our study is to
describe the preclinical and early in-clinical situations and
management in children with severe head trauma. The

second part of our study will present benefits and limita-
tions of the cerebral perfusion pressure–guided manage-
ment after severe head trauma.
Patients and Methods
The primary objective was to select factors that would predict a
child’s outcome after severe head trauma. To achieve this
objective, 48 children who had suffered a head trauma, which
required intensive care, were evaluated retrospectively. Treat-
ment was administered according to a protocol established in
1998 (Figure 1). This protocol called for early monitoring of
intracranial pressure with the presence of correlating symptoms
and cerebral perfusion pressure–guided therapy. The study was
not affected by special drug studies that could have falsified the
results. Medical records were evaluated for hospitalized children
between 0 and 16 years old from January 1998 to January 2001.
Special attention was paid to the assessment of conscious-
ness and vital functions so that secondary brain damage due to
hypoxia and hypotension could be prevented with appropriate
treatment.
The severity of head trauma was evaluated according to the
Glasgow Coma Score at the accident site. A Glasgow Coma
Score  8 following trauma described a severe head trauma. The
children were examined from the perspective of traumatology
and neurology. Tests performed after arriving at the emergency
room included an ultrasound of the abdomen, and radiographs
of the chest, cervical spine, and extremities. If indicated, a trauma
scan (computer tomography [CT] of the neurocranium, spine,
chest, and abdomen in children with a Glasgow Coma Score of
8 was also ordered. The clinical examination, radiograph, CT,
and ultrasound were used to determine the pattern of injury. The
number of injuries and their localization were assessed.
During intensive care, important parameters were moni-
tored. If continual sedation was administered, the intracranial
pressure was monitored by inserting an intracranial pressure
transducer (intrapernchymal). If intracranial pressure measure-
ment was not necessary and the patient was neurologically asses-
sable, a CT was frequently taken. Additionally, the children’s
intensive care unit also had access to transcranial ultrasound,
Doppler ultrasound of the intracranial vessels, and electroence-
phalogram. Microdialysis was used to determine tissue biochem-
istry (eg, metabolic factors such as glucose, lactate, pyruvate,
glutamate, or glycerol). A scheme of therapeutical management
is shown in Figure 1.
Demographic and organizational data were collected
retrospectively and are shown in Table 1. The values for mean
arterial pressure, central venous pressure, heart rate, and cerebral
perfusion pressure were matched for age groups to facilitate a bet-
ter comparison. This was also done for the outcome (Glasgow
Outcome Scale). Classification into Glasgow Coma Score and
Glasgow Outcome Scale was performed accordingly (Tables 2-4).
Univariant, multivariant, and mainly the regression analysis
with different scale values were used. Especially binary logistic
regression, t test, or 2 test was applied. Level of significance was
defined to P  .05. The study was approved by an ethics
committee.
Head Trauma in Children Part 1 / Kapapa et al 147
Results
Between January 1998 and January 2001, 48 children
were treated at an intensive care unit for severe head
trauma. There were 16 (33.3%) female and 32 (66.7%)
male patients. Age ranged from 19 days to 14.5 years.
Mean age was 5.9 years. Because of the different levels
of maturation, groups were created according to age
(Table 5). The height ranged from 49 to 165 cm; mean
height was 110 cm. The minimum weight was 4.4 kg and
the maximum weight was 55 kg with the mean calculated
at 22.5 kg.
Accident Site, Transport, and Emergency Room
Frequencies in accident causes, interval without therapy
(between the accident and the administration of first aid
by paramedics or an emergency physician), and lifesaving
measures are given in Table 6.
Severity of Trauma According to Glasgow Coma
Scores
Eleven (22.9%) children were evaluated as having a
Glasgow Coma Score of >8. A total of 37 children
(77.1%) had a severe head trauma (Glasgow Coma Score
8). Comparing the Glasgow Coma Score with the
Glasgow Outcome Scale, a poor outcome is mainly found
in patients with a Glasgow Coma Score  8. The lower the
Glasgow Coma Score, the higher the probability of a poor
outcome (P ¼ .0151). The most accurately calculated
parameter for a poor or good outcome is based on detailed
qualities such as ‘‘eye opening’’ (P ¼ .0155) and ‘‘best
motor response’’ (P ¼ .0159).
Level of Consciousness
The majority of patients were found unconscious (n ¼ 31;
64.6%). Twelve children (25%) had a moderately dis-
turbed level of consciousness and 5 (10.4%) were fully
oriented. Every fully oriented child who was admitted was
discharged with a good outcome (Glasgow Outcome Scale
Group II; Table 4). This also applied to the majority of
children with a moderately disturbed level of conscious-
ness. The prognosis could not be calculated based on the
level of consciousness at the accident site. Only 1 of those
admitted in poor condition had a poor outcome. The
better the level of consciousness, the more likely that it
will be correlated to a good outcome (P ¼ .0152).
Pupillary Reflex
Although checking the pupillary motoricity is a standar-
dized examination in head trauma, the pupillary reflex was
148 Journal of Child Neurology / Vol. 25, No. 2, February 2010

Figure 1. Management of children with severe head trauma at emergency room and intensive care ward. CVP, Central venous pressure; CPP,
Cerebral perfusion pressure; CT, Computed tomography; EEG, Electroencephalogram; GCS, Glasgow Coma Score; GOS, Glasgow Outcome Scale;
ICP, Intracerebral/-cranial pressure; MAP, Mean arterial pressure.
 Head Trauma in Children Part 1 / Kapapa et al 149

Table 1. Overview of the Collected Data

Admission Accident Emergency Room Various Data

Data of birth Date Cardiovascular system Imaging diagnostics

Gender Time Aeration Pattern of injuries
Height Mechanism Body temperature Scores
Weight Aeration Consciousness Drugs
Body surface Reanimation Duration of reanimation Neurostatus
Date and time of admission Parameters of cardiovascular system Need and time of intubation Laboratory parameters
Age at admission Glasgow Coma Score Glasgow Coma Score of first six days
Date of transfer to Time without therapy or treatment Movements of different extremities Pattern of artificial ventilation
the normal ward Aspiration Status of pupils Glasgow Outcome Scale
Date of discharge Need and time of intubations Brain stem reflexes Circumstances of surgical
Date of admission and Movements of different extremities treatments
discharge from rehabilitation Consciousness
Circumstances of fatality Status of pupils
Brain stem reflexes

Table 2. Normal Mean Arterial Pressure, Central Table 3. Normal Cerebral Perfusion Pressure According
Venous Pressure, and Heart Rate According to Age to Age

Mean Arterial Age Group Cerebral Perfusion Pressure

Pressure Central Venous Heart Rate
Up to 1 month >40
Age Group (mm Hg) Pressure (mm Hg) (BPM)
2 months up to 1 year >45
Up to 1 month 40-70 2-10 80-210 1 year up to 7 years >50
2 months up to 1 year 50-80 2-10 75-200 From year 7 onward >55-60
1 year up to 7 years 55-90 2-10 65-170
From year 7 onward 60-100 2-10 50-160
Note: BPM, beats per minute.

effect on the outcome (P ¼ .0001). One half of the patients

documented in only 34 patients at the accident site and in
45 patients in the emergency room. Both the pupillary
motoricity at the accident site (P ¼ .002) and in the
emergency room (P ¼ .0004) significantly influenced the
outcome. The more pathological the pupillary reflex
(anisochoria, mydriasis, and fixed pupils), the higher the
probability of a poor outcome.
Cardiopulmonary Status
Initial shock index at the accident site was significantly
associated with a poor outcome (P ¼ .0089). A systolic
blood pressure (P ¼ .0002) and bradycardia (P ¼ .035)
under age-adjusted normal values were important factors
indicating a poor outcome. Furthermore, a low systolic
blood pressure in the emergency room (P ¼ .035) was
associated with a poor outcome. The diastolic blood pres-
sure, heart rate, and shock index in the emergency room
were not significantly related to outcome.
with initial body temperatures below 35 C (95 F) were
finally discharged with a poor outcome.
Stabilization Procedures at the Accident Site
Eight children (16.7%) required advanced procedures to
stabilize their cardiopulmonary status when the emer-
gency physician arrived. One case required repeated
resuscitation attempts in the emergency room. Overall,
10 (20.8%) children required stabilization procedures
(accident site or emergency room). The necessity of
resuscitation correlates significantly with the outcome
(P ¼ .0003). All patients survived the acute stabilization
procedures. The first fatality occurred 1 day after stabili-
zation. With regard to stabilization and subsequent
outcome, 6 patients died, 1 patient remained in a persis-
tent vegetative state (Glasgow Outcome Scale Group I:
N ¼ 7; 70%), and 3 patients achieved a favorable outcome
(Glasgow Outcome Scale Group II: N ¼ 3; 30%).

Body Temperature Status at Admission and Outcome

Bladder catheter or external body temperature measured in To compare the status at admission and the outcome
the emergency room and intensive care unit had a significant according to age, patients were assigned to groups of
150 Journal of Child Neurology / Vol. 25, No. 2, February 2010
Table 4. Classification According to Glasgow Outcome
Scale, Dichotomization of Glasgow Outcome Scale, and
Glasgow Coma Score
Poor Outcome Good Outcome
Glasgow Outcome Glasgow Outcome Scale Group II
Scale Group I
Glasgow Outcome Glasgow Outcome Scores 3, 4, and 5
Scores 1 and 2
Score Translation Statistics
Glasgow Coma Poor admission Glasgow Coma Score  8
Score 3 to 8
Glasgow Coma Good admission Glasgow Coma Score > 8
Score 9 to 15
Glasgow Outcome Poor outcome Glasgow Outcome
Scale 1 and 2 Scale Group I
Glasgow Outcome Good outcome Glasgow Outcome
Scale 3 to 5 Scale Group II
Glasgow Outcome Scale 1 and 2 ¼ Glasgow Outcome
Scale Group I and Glasgow Outcome Scale 3-5 ¼ Glasgow
Outcome Scale Group II (Table 4). There was no instance
of a good admission (Glasgow Coma Score > 8) and a sub-
sequent poor outcome (Glasgow Outcome Scale Group I).
The age group ‘‘up to year 1’’ had 5 patients (71.4%) with a
poor admission (Glasgow Coma Score  8) and a subse-
quent good outcome (Glasgow Outcome Scale Group II).
The age group in ‘‘year 1 to year 7’’ had 5 (20%) patients and
the age group ‘‘from year 7 onward’’ had 4 (25%) patients
with the identical course (Figure 2, Table 7).
Children with a poor status on admission (Glasgow
Coma Score  8) and a good outcome (Glasgow Outcome
Scale Group II) are mainly found in the age group ‘‘year 1
to year 7’’ which contains 13 (52%) patients (Table 7). The
age group ‘‘from year 7 onward’’ had 10 (62%) patients and
the age group ‘‘up to year 1’’ had 1 (14.3%) patient with
this course. Overall, the results showed a good outcome
(Glasgow Outcome Scale Group II) after a good admission
(Glasgow Coma Score > 8). The majority of patients (N ¼
34, 70.8%) could be discharged in good condition accord-
ing to the Glasgow Outcome Scale (Figure 2).
In 27 survivors (56.3%) with a Glasgow Coma Score of
8, 14 patients (29.2%) could be transferred to rehabilita-
tion. They exhibited paresis, plegia, paresis of the cranial
nerves, speech disorders, mental and coordination disor-
ders, and organic psychological problems. Only 1 partici-
pant suffered from seizures. Headaches and sensory
disorders were rare. Results for the precarious preschool
age of 1 to 3 years and 3 to 7 years are given in Table 7.
Morbidity and Mortality
Head trauma resulted in 10 fatal cases (20.8%). The
majority died during the first 4 days in the intensive care
unit; 2 patients died on day 6, and 9 after admission.
Table 5. Classification According to Age
Group Age N
Group 1 Up to the year 1 7 (14.6%)
Group 2 Year 1 to year 7 25 (52.1%)
1-3 years 6 (24%)
3-7 years 19 (76%)
Group 3 From year 7 onward 16 (33.3%)
Four patients (8.3%) remained in a persistent vegeta-
tive state (Glasgow Outcome Scale 2). They were
transferred directly to clinical rehabilitation. Severe
impairments (Glasgow Outcome Scale 3) could be found
in 8 (16.7%) patients after treatment in the intensive care
unit; 5 were transferred directly to clinical rehabilitation.
Of the 5 patients (10.4%) with moderate impairment
(Glasgow Outcome Scale 4) and 21 (43.8%) patients
without any impairment (Glasgow Outcome Scale 5),
5 patients participated in a brief period of rehabilitation
following inpatient treatment.
Imaging Diagnostics
Cranial CT. Cranial CT was performed on 44 patients
on the day of admission. Only 4 patients exhibited moder-
ate or light head trauma. In these patients, cranial CT was
performed 1 day later. Twelve (25%) of 48 patients had no
pathological findings in the cranial CT. The remaining
results can be seen in Table 8. Significant correlations
of imaging results and outcome were found only if
cofactors such as hypoxia (P ¼ .0011) and brain edema
(P ¼ .0001). Twenty-two children (71%) suffered from
severe brain edema accompanied by compression of the
subarachnoid space and basal cisterns. Because of this,
12 (38.7%) patients were discharged with a poor outcome
and 10 (32.3%) patients with a good outcome. One patient
died as a result of cerebral herniation. Of the 8 patients
(25.8%) with moderate brain swelling, 1 patient died.
Chest radiograph and ultrasound. In 17 patients (35.4%),
the routine chest radiograph was deemed to be unremark-
able in the emergency room. Other results are shown in
Table 9. Neither rib fractures nor lung pathology corre-
lated significantly with the outcome.
Ultrasound detected blunt abdominal trauma and
intra-abdominal bleeding in 2 cases as well as perirenal
bleeding in 1 case. These injuries were not correlated to
the outcome.
Pattern of Injuries
Head trauma had the greatest impact in 21 children.
Fifteen (31.3%) of those were discharged with a favorable
outcome (Glasgow Outcome Scale Group II) and 6
 Head Trauma in Children Part 1 / Kapapa et al 151

Table 6. Accident Causes, Interval Without Therapy, and Lifesaving Measures

Interval Without Therapy
Accident Causes N (S ¼ 43 Minutes; Table 4) Minutes Lifesaving Measures N

Traffic accident 26 (54.2%) Glasgow Outcome Scale Group I 15 Helicopter 13 (27.1%)

Fall 14 (29.2%) Glasgow Outcome Scale Group II 9.5 Paramedics and emergency physician 30 (62.5%)
Other (falling objects, kicked 8 (16.7%) Paramedic alone 3 (6.3%)
by horse, and confrontations) Parents 2 (4.2%)
No statistical relationship between Difference is not statistically No relationship between the
the accident mechanism and the outcome significant measures and the outcome

Discussion

From year 7 onward

Despite the brief period of investigation, the number
of participants is useful. Because of this, the distribu-
tion according to age and severity of head trauma was
inhomogeneous. Thus, a normal age distribution had
Year 1 to year 7 to be generated according to circulation and chemical
parameters as well as the cerebral perfusion pressure.
This provided comparability. All children were given
Up to year 1
optimal care with the consequence that there is no
control group when comparing intracranial pressure
therapy or surgical treatment. This complicates a
20% 40% 60% 80% 100% direct comparison.
GCS ≤ 8; GOS Group I (= GOS 1 and 2)
GCS ≤ 8; GOS Group II (= GOS 3-5)
GCS > 8; GOS group II ( = GOS 3-5)

Epidemiology
Figure 2. Admission and outcome according to age.
Age and Sex

(12.5%) with a poor outcome. A more complex injury pat-
tern involving head trauma was found in 27 patients.
However, the head trauma was the predominant injury.
Of those patients suffering from multiple trauma, 19
(39.6%) could be discharged in good condition (Glasgow
Outcome Scale group II) and 8 (16.7%) with a poor out-
come. A comparison of patients with isolated head trauma
and patients with multiple traumas revealed no significant
differences.
Scores
Scores from the Glasgow Outcome Scale (Glasgow
Outcome Scale), Pediatric Risk of Mortality Score, Version
III, Abbreviated Injury Score, and Injury Severity Score
were determined retrospectively based on patient medical
records. The Pediatric Risk of Mortality Score correlates
significantly with the outcome (P ¼ .0006). Abbreviated
Injury Score and Injury Severity Score were focused on only
those patients who were classified as a polytrauma, accord-
ing to the definition of Injury Severity Score, N ¼ 11 (Injury
Severity Score > 16).13 These scores did not correlate.
Age ranged between 0 and 15 years. The mean age was
5.9 years. The majority of patients were male 3 (66%).
These results are comparable to other epidemiological
findings.1-3,7,10-12,14-16
A comparison of age groups revealed that children
up to year 1 with severe head trauma (Glasgow Coma
Score  8) composed the majority in poor outcome
(83%). The proportion of poor outcome within the other
age groups was 29%. This finding is also comparable to
other studies.1,17
According to the traumatic coma data bank, Levin
et al18 have described a poor outcome in children less than
4 years. This is the result of high mortality (62%) during
the first year. Subdural hematomas (20%) and hypoten-
sion (32%) dominated the cases. The best outcome was
found in children between 5 and 10 years old. Of these,
66% could be discharged with a favorable outcome. A sig-
nificant correlation between age and outcome could not
be confirmed by Bruce et al and Ong et al.19,20 Gruskin
and Schutzman21 and Engberg and Teasdale4 described
a higher risk for skull fractures and intracranial injury in
children younger than 12 months (29%) compared to
children aged 13 to 24 months (4%; P < .001).
152 Journal of Child Neurology / Vol. 25, No. 2, February 2010

Table 7. Preclinical, In-hospital Conditions, CT Findings, Intracranial Pressure Decision, and Outcome in Preschool Age
Children (With Abbreviations)

GCS at
Accident Consciousness at Status at Admission Morbidity and ICP
25 Children in 3 to 7 years Site Accident Site and Outcome (GOS) Mortality CT Measurement

1-3 years, N ¼ 6; Falls: > 8; N ¼ 1 Full orientated; In GCS > 8, out GOS Death; N ¼ 2 (8%; Diffuse injuries; Yes;N ¼ 3
N ¼ 4, Traffic accident: (4%) N ¼ 1 (4%) II N ¼ 1 (4%) Herniation) N ¼ 2 (8%) (12%)
N¼2 Disturbed In GCS 8, out GOS Persistent vegetative Severe intracerebral
consciousness; II; N ¼ 2 (8%) state N ¼ 0 (0%) lesions; N ¼ 3
N ¼ 1 (4%) (12%)
8; N ¼ 5 Unconscious; In GCS > 8, out GOS Severe impaired; Brain edema and/or No; N ¼ 3
(20%) N ¼ 4 (16%) I; N ¼ 0 (0%) N ¼ 1 (4%) brain shift; (12%)
N ¼ 4 (16%)
In GCS  8, out GOS No impairments; Fracture; N ¼ 3 (12%)
I; N ¼ 3 (12%) N ¼ 3 (12%)
3-7 years, N ¼ 19; >8; N ¼ 5 Full orientated; In GCS > 8, out GOS Death Diffuse injuries; Yes; N ¼ 3
Falls: N ¼ 5; (20%) N ¼ 1 (4%) II; N ¼ 5 (20%) N ¼ 1 (4%) N ¼ 10 (40%) (12%)
Hit/Kick by Horse: N ¼ 3; disturbed In GCS  8, out GOS Persistent vegetative Severe lesions;
Traffic accident: N ¼ 11 consciousness; II; N ¼ 11 (44%) state; N ¼ 2 (12%) N ¼ 9 (36%)
N ¼ 7 (28%)
8; N ¼ 14 Unconscious; In GCS > 8, out GOS Severe impaired; Brain edema; brain No; N ¼ 16
(56%) N ¼ 11 (44%) I; N ¼ 0 (0%) N ¼ 2 (8%) shift; N ¼ 9 (36%) (64%)
In GCS  8, out GOS No impairments; Fracture; N ¼ 7 (28%)
I; N ¼ 3 (12%) N ¼ 14 (56%)
Note: CT, computer tomography; GCS, Glasgow Coma Scores; ICP, intracerebral/-cranial pressure.

Cause of Accidents if treatment is started in the intensive care unit. In adults,

The majority of authors mention traffic accidents as the
main cause of head trauma in children. Traffic accidents
were followed by falls.7,8,15,22 Our study confirmed traffic
accidents (54.2%) as the major cause of severe head trauma.
Falls were responsible for 29.2% of the head trauma cases in
children. There was no statistical relationship between the
causes of an accident and the final outcome.
Mortality
According to the German Federal Statistics Office,
86 497 children were admitted and subsequently treated
for head trauma in 1999.8 This includes children who
were admitted for a 24-hour period of monitoring.
A direct comparison of data from different countries is
virtually impossible because of the markedly different study
designs and the differences in measures and scales. For the
United Kingdom, a mortality rate up to 23% for severe head
trauma is reported.2,14 For the United States, a rate of up to
35% was reported in various studies.3,17,23,24 The annual
death rate from head trauma was reported at 22 per
10 000 in France (region of Aquitaine).25
In a previous study, we reported a mortality rate of 22%
in children with severe traumatic brain injury after admis-
sion.7 These results were supported by new study results
that yielded a mortality of 20.8%. This proportion changes
to a value of 27% if the mortality rate is based only on
children with a Glasgow Coma Score  8 at admission and
the fatality rate is specified at 35% to 45%.17,23
Evaluation of Consciousness and Severity of
Head Trauma
The physical examination of children with head trauma
must be quick and safe to evaluate the severity. There is
a great variety of neurotrauma pediatric scales.26-32 They
manage the assessment of neurological status according
children’s age, cognitive abilities such as speech and obey-
ing, motor function, papillary reflexes, and consciousness.
They are also considering causation of trauma. In addition
to these tests, the Trauma-Infant-Neurological-Score is
increasingly used.26
In our study, the Glasgow Coma Score is an important
predictive factor. To evaluate the initial severity of head
trauma, the Glasgow Coma Score is widely used.33,34 This
is a reliable and comparable classification system.
Furthermore, the Glasgow Coma Scores exhibit predictive
qualities with respect to the outcome.15,19,35,36
In the medical literature, traits such as the ‘‘best motor
response’’ appear to have a notable impact on predicting
the outcome, because they can be more readily evaluated
in children than activities such as ‘‘eye opening’’ and ‘‘best
verbal response.’’17,37,38
Ong et al20 calculated a predictive value that is 2 to
4 times higher at the limits of Glasgow Coma Score  8
in the presence of hypoxia. Our study showed the use of
sedative drugs at the accident site in 54.2% of the cases.
 Head Trauma in Children Part 1 / Kapapa et al 153

Table 8. Results of Cranial Computed Tomography Table 9. Results of Radiography Investigations

N % Chest Radiograph Radiographic
Findings N % Fracture Findings N %
Diffuse injuries
Cerebral concussion 12 25.0 Pneumothorax 9 18.8 Cervical spine 1 2.1
Contusion of the brain, unilateral 29 60.4 Hemothorax 10 20.8 Scapula 1 2.1
Contusion of the brain, bilateral 6 12.5 Pleural effusion 7 14.6 Clavicle 4 8.3
Severe lesions Pulmonary contusion 4 8.3 Shoulder 1 2.1
Epidural hematoma 9 18.8 Reduced ventilation 30 62.3 Humerus 1 2.1
Subdural hematoma 10 20.8 Pneumonia 3 6.3 Radius/ulna 1 2.1
Subarachnoid hemorrhage 5 10.4 Rib fracture 3 6.3 Finger bones 4 8.3
Contusion of the brain 22 45.8 Femur 2 4.2
Ventricular rupture 5 10.4 Tibia/fibula 1 2.1
Cerebral infarction 4 8.3
Disturbances in circulation of cerebrospinal fluid 4 8.3
Cerebral hypoxia 4 8.3 periodically after head trauma for prognostic evaluation.
Brain edema Taylor et al41 reported a dysfunction of pupil motoricity
Moderate compression of subarachnoid space 8 16.7
after an intracranial pressure > 30 mm Hg due to diffuse
Severe compression of subarachnoid space 22 45.8
Herniation 1 2.1 brain edema. If the elevated intracranial pressure
Brain shift (cm) (>20 mm Hg) is accompanied by a brain shift, it was
1 10 20.8 possible to detect a delay in the pupillary response of up
>1 5 10.4 to 0.6 mm/s on the side of compression.
Lesions of brain stem
Pontine hemorrhage 4 8.3
Fractures Injury Pattern
Fractures of the cranium (unspecified) 6 12.5
Fracture of the roof of the skull/depressed fracture 14 29.2 The likelihood and type of additional injuries in children
Separation of cranial sutures 5 10.4 with head trauma are not equally represented. This is the
Midfacial fracture 3 6.3 result of a different presentation in the severity and pat-
Fracture of the sphenoid bone 2 4.2
Fracture of petrous bone 5 10.4
tern of head trauma. In 43.8% of the patients, multiple
Fracture of the base of the skull 2 4.2 injuries with head trauma occurred. The majority of addi-
Fracture of the orbital floor/cap 6 12.5 tional injuries were thoracic injuries, followed by injuries
Fracture of the zygomatic bone 4 8.3 of the extremities and abdomen. In the medical literature,
Fracture of maxilla/mandible 1 2.1 the incidence of combined injuries was reported at
between 14% and 60% with the main proportion being
accounted for injuries to the extremities.17,40,42 Our study
In 56.3% of the cases, artificial ventilation was required. did not confirm a negative effect of additional injuries on
Before stabilization of the cardiopulmonary system, the outcome like the study of Pfenninger and Santi.40
children were assessed according to the Glasgow Coma However, other studies did.15,20
Score. The preclinical management improved because of
goal-orientated therapy at the accident site and a reduced
Cardiopulmonary Status
rescue time. However, particularly with regard to the
indication of artificial ventilation, drugs are required and A readily available blood supply and a stable status for
this complicates the assessment of consciousness after good gas exchange and stabile circulation determines the
hospital admission.39 prognosis following head trauma in children.43 Circula-
In our study, the Glasgow Coma Score exhibits a tion must guarantee adequate perfusion in all vital organs,
probable correlation to poor outcome at the lower level of most especially the brain.44
Glasgow Coma Score scale. The best calculated likelihood Many studies report the occurrence of hypotension
of outcome is based on detailed qualities such as ‘‘eye open- during shock after severe head trauma in children. There
ing’’ and ‘‘best motor response.’’ Of these qualities, the first is a consensus about what constitutes a sufficient mean
category is mainly associated with a good outcome. arterial blood pressure in children. However, whether and
how this influences the outcome is under dispute.10,17,20
Pigula et al45 reported an increased mortality with a
Pupillary Reflex
systolic blood pressure < 90 mm Hg. Accompanied by
Much is known about the poor outcome associated with hypoxia (PaO2 < 90mm Hg), low systolic blood pressure
bilaterally disturbed pupillary reflexes after head increases secondary brain damage and mortality by up to
trauma.17,23,37,40 We confirm these results. Assessment 4 times.6,7,45 He stated that children with hypoxia and
of pupil motor function is quick and should be performed physiological blood pressure do not exhibit a higher risk
154 Journal of Child Neurology / Vol. 25, No. 2, February 2010
of mortality. He concluded that a physiological blood pres-
sure has a higher impact on the outcome than the arterial
oxygen saturation. The ideal systolic blood pressure was
determined to be 135 mm Hg; there was a gradually
decreasing probability of survival below these levels. Guide-
lines recommend the lower limit of systolic blood pressure
(fifth percentile) for age as 70 mm Hg plus (2 age in
years) and an initial therapy with 100% oxygen.46
We concur with these findings and recommendations
regarding the detrimental effect of decreased initial blood
pressure at the accident site as well as in the emergency
room and a resulting poor outcome. Our study confirms
a poor outcome after ongoing bradycardia following head
trauma, because this could be a sign of severe brain dam-
age. According to Dhellemmes et al,42 bradycardia is an
indication for neuroimaging even without a concomitant
deterioration of the neurological status.
Body Temperature
There is a correlation between initial hypothermia and a poor
outcome. Episodes of hypothermia and hyperthermia during
the following course had no deleterious effect on the out-
come. Some studies indicate that hypothermia has a protec-
tive or intracranial pressure lowering effect.47-49 However,
initial posttraumatic hypothermia which could be the result
of a brainstem lesion is a detrimental prognostic factor.19,50,51
Diagnostics
The cranial CT is one of the fastest and most exact methods
of detecting a brain injury. Although in the United States a
cranial CT is performed even in mild brain injury to avoid
costs associated with inpatient care, in Germany a cranial
CT is performed in children because of the severity of
trauma and the clinical presentation. This limitation holds
to avoid unnecessary radiation exposure in children. There
is agreement that the radiation exposure in a radiograph
and a cranial CT of the infant neurocranium is comparable,
although the radiograph yields less information.52 Never-
theless, a radiograph of the cranium is often performed.
Maier et al52 reported that the detection rate for fractures
with cranial CT was 2 times higher than with a radiograph.
The time point of the initial cranial CT as well as the
period between the first and the second cranial CT is
hardly ever discussed. In a second cranial CT, our study
detects new findings such as hemorrhages (n ¼ 11),
contusions (n ¼ 3), hypoxic changes (n ¼ 5), and diffuse
generalized brain edema (n ¼ 7). The time interval should
be between 12 and 48 hours.53,54 Tabori et al55 noted a
second cranial CT after admission as being important for
children with mild to severe head trauma to obtain more
information about the dynamics of any morphological
changes. This additional examination should only be
performed in children without neurological improvement.
In prior studies, they performed a second cranial CT in
every child. This resulted in no additional surgical conse-
quences, because every child with neurological deteriora-
tion had already received maximum surgical care.
In our study, 34 patients exhibited single hemorrha-
ging in 37.5% of the cases and multiple hemorrhaging in
33.3% of the cases as detected by a cranial CT.
These frequencies are comparable to those mentioned in
the medical literature for intracerebral hemorrhaging
(n ¼ 22), subdural hematomas (n ¼ 10), and epidural
hematomas (n ¼ 9).
Bruce et al19 stated that intracranial hemorrhaging is rarely
found in children but is more frequent in adults. This could
represent a different pathophysiological response of the brain.
Primarily, brain contusions subdural and epidural
hematomas are found in the cranial CT after head trauma;
a subarachnoid hemorrhage occurs rarely.10,53 For a long
time, acute subdural and epidural hemorrhage was
assumed to be associated with a poor or fatal outcome in
neurosurgery.23,24 This was based on complicated diag-
nostics and delayed therapeutic intervention. Especially
in children, there is a latent deterioration of neurological
status or pathology. After an initially rising intracranial
pressure which is compensated, an acute impairment of
consciousness and the neurological situation occurs.42
In our opinion, the varying hematoma volumes
accounted for the absent correlation between removing
the intracranial hematoma and simply leaving it in place.
In 31.3% (n ¼ 15) participants, a midline shift of the
brain was detected by cranial CT. Twelve of these
occurrences had intracerebral hematomas, and all of them
exhibited varying brain edema. We were not able to
determine a significant prognostic effect for the midline
shift. However, other studies reported a detrimental effect
of the midline shift on the outcome in adults.56-58
The literature frequently reports a cumulative appear-
ance of diffuse brain edema after severe head trauma. The
incidence is given at 2 times higher than in adults.59-61 In
this study, the cranial CT detected a brain edema of
varying extent (47.9% severe, 17% mild) in 64.6% of the
patients. In a majority of the patients (77.4%), the diagnosis
already was made with the initial cranial CT, whereas in
22.6% of the cases the brain edema developed during the
subsequent course. The increased susceptibility to edema
and a decreased tolerance for hypoxia exhibited by the
brains of children as well as the elevated rate of the blood
cycle and the metabolic instability of the young organism
are possible causes of frequent brain edema in children.53
Several studies could demonstrate that both hypoxia
and hypotension (especially the combination of both) are
serious complications. They aggravate secondary brain
damage and correlate with a poor outcome.15,20,45 We were
also able to determine a significant effect of hypoxia in cra-
nial CT and a poor outcome; this also holds for arterial
hypotension during posttraumatic shock. With values

ranging between 12.5% and 53%, a generalized brain
edema is usually associated with a poor prognosis.59,61
Pediatric Risk of Mortality Score, Version III
The Pediatric Risk of Mortality Score consists of clinical
findings, cardiopulmonary parameters, and chemical val-
ues. It is widely used in the United States to predict the
outcome of sick or injured children. It appears to be
extremely reliable and is characterized by a high prognos-
tic value for determining case fatality and survival.62 Pol-
lack et al63 proposed the lowest systolic blood pressure, a
pathological pupillary reaction, and a reduced level of con-
sciousness as parameters having the highest predictive
value. Cantais62 reported a significant correlation between
a Pediatric Risk of Mortality Score >35 and mortality. Our
study confirms a correlation between a Pediatric Risk of
Mortality Score >20 and a poor outcome.
Conclusions
The first neurological and clinical assessment at the accident
site is essential for further management in children’s head
trauma. The preclinical cardiopulmonary conditions as well
as the oxygen saturation have the major impact before admis-
sion and emergency room management. Any unconscious
child after head trauma had to be intubated at accident site
to secure sufficient oxygen supply. This reduces the secondary
brain damage, for example, due to brain edema. The necessity
of resuscitation correlates significantly with the outcome.
Children with severe head trauma (Glasgow Coma
Score < 8) and younger than 1 year are at highest risk for
poor outcome. The majority of fatal outcome occurs
within the first 4 days. Significant correlations of imaging
results and outcome were found only if cofactors such as
hypoxia and brain edema were present. In pattern of inju-
ries after multiple injured children, the head trauma had
the greatest impact. Its sufficient diagnoses and manage-
ment in the emergency room is path finding.
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