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Doug - It is my understanding that when deciding when to perform a CT scan of
the head in minor head trauma  patients with a GCS of 15, that many textbooks
(and journal articles)  use an age < 2 years as a high risk factor indicating a
lower threshold for performing a CT scan of the head. I personally think that an
inability to assess a child's alertness and social  functioniong is mainly a
problem in children < 6 months of age, and I think that it would not be critical
to differentiate between a GCS of 13, 14 or 15 if one is going to perform a CT
scan in children < 6 months of age anyway - based on age as a high risk
criteriae.
 
I personally do not think that hypoxia or hypotension are confounding variables
because those variables are rarely present in most of the minor head injury
children with a GCS of 15. They probably only occcur with multiple trauma (high
fall or MVA) and I would imagine that these hypoxic/hypotensive kids will have
sufficient other reasons to warrant a CT scan of the head even if they have a
GCS of 14/15 at presentation eg. distracting pain or injuries, which is also a
high risk factor.
 
I cannot understand why " frontal position of the skull injury" should be a
relevant factor. The GCS is tailored toward looking for diffuse brain injury and
signs of increased ICP and is not geared towards looking for isolated brain
injury. However, I do think that there are independent variables that warrant a
CT scan of the head irrespective of the GCS - depressed skull fracture, basal
skull fracture, penetrating skull injury, isolated blow to the head imparted
with considerable force eg. baseball bat injury, and skull fracture picked up
clinically or by incidental skull (or C-spine) X-ray.
 
As regards site of injury - I think that small, slowly expanding bleeds in the
infratentorial region are the most difficult to clinically diagnose because they
may have no early altered LOC or focal neuro signs, and the patients  may
suddenly develop increased ICP and sudden death without progressing through the
rostro-caudal progression of brainstem signs, which may be seen in supratenrial
bleeds.
 
Jeff
 
"Douglas W. Ragland, M.D., J.D." wrote:
 
> Jeff & Jay, one of the problems I have encountered with children (especially
> pre-verbal children) is the difficulty in obtaining an accurate GCS rating.
>
> It is also my impression that GCS rating system may not be as valid in
> children with head trauma as it is in adults - even if the GCS rating is
> accurate.
>
> GCS ratings are reasonably accurate and reproducible for separating severe
> head injury (GCS 8-) from "less than severe" head injury (GCS 9+).  The
> distinction between "minor head injury" (GCS 15? GCS 14-15?  GCS 13-15?) and
> "moderate head injury" (GCS 9-13?9-14?) is much more arbitrary and
> subjective, however.
>
> The GCS rating is not accurate or predictive in the presence of hypoxia,
> hypotension or intoxication.  While intoxication should (generally?) not be
> a confounding variable pediatric head trauma, the others certainly can be.
>
> Finally it has been my anecdotal impression from personal experience that
> pts (both adult & pediatric) with frontal lobe head trauma preserve their
> GCS rating much better than other areas of the brain despite rather severe
> head trauma.  I find myself factoring in more often "location of head
> trauma" and "mechanism of injury" when assessing the severity of head
> trauma.
>
> Has your experience been similar or different from mine?
>
 
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