Home > Diagnoses & Conditions > Traumatic Brain Injury > Initial Diagnosis
Traumatic Brain Injury - Initial Diagnosis
Overview
Because the initial evaluation and management of the injury is generally accomplished in the inpatient setting and the diagnosis is rarely in question, this page will focus on the initial assessment of the child with traumatic brain injury (TBI) in the Medical Home. The approach to this assessment will vary depending on the severity of injury and its sequelae, the age of the child, and the presence of pre-existing conditions.Pearls And Alerts
Although it is difficult to predict the extent of recovery in a child soon after sustaining a TBI, the Glascow Coma Scale (GCS) in the first 24 hours after injury is correlated with eventual outcome. GCS scores range from 3 to 15, with 3 being the lowest (worst) possible score and 15 the highest (best). [Catroppa: 2008]
Over the last few years, it has become evident that successive concussions, even with recovery between events, and repeated injuries to the head that do not meet criteria for concussion, may be more deleterious than previously suspected. See [Congeni: 2009], [McCrory: 2009], and [Miller: 2009].
Practice Guidelines
Society of Critical Care Medicine.
Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents.
Crit Care Med.
2003;31(6 Suppl):S407-91.
PubMed abstract
History And Examination
Medical History
Background: explore pre-existing problems and family functioning. A history of previous brain injury and/or seizures is particularly important. Did the child have developmental delay, psychiatric or behavioral problems, or cognitive problems before the injury?Related to the acute injury, the following details may help you understand the injury and its impact on the child and family:
- What were the circumstances surrounding the trauma?
- What was the nature of the injury?
- Was the injury witnessed?
- Did the child lose consciousness, for how long?
- What was initial Glascow Coma Scale?
- What, if any, other injuries did the patient suffer?
- Did the patient have any seizures at the time of injury?
- What treatment was given post injury?
- Was a CAT scan or MRI performed?
- Were C-spine films done?
- Was the child admitted to an ICU? If so, for how long?
- Did the patient receive inpatient rehabilitation? If so, for how long?
- What was the child's status upon discharge from rehabilitation?
- By what percentage has the child returned to pre-injury status?
- Are there contributing factors, other than the injury, that have kept the child from returning to pre-injury status?
- Has the child experienced headaches, nausea, vomiting, confusion or irritability?
- What medications is the child currently taking?
- Eating; is the patient having difficulty maintaining or gaining weight?
- Bathing
- Dressing
- Bowel/bladder function
- Fine and gross motor skills
- Communication and comprehension
- School and developmental milestones
- Are symptoms of depression, anxiety, attention deficit, or irritability present?
Developmental and Educational History
What grade was the child attending in school? Prior to this injury, did the patient have any physical, emotional, or learning challenges? Before the injury, did the patient require any special services in school or have any problems with academic performance?Maturation History
Assessment of pubertal status is important, particularly for understanding the social impact of any resulting disabilities.Social and Family History
Before the injury, did the child and/or family have difficulty functioning in the community? Is there a history of depression, alcoholism, etc. in the child or family that might hamper recovery? Psychiatric disorders after TBI are correlated with preinury family functioning, family socio-economic class and functioning, and a family history of psychiatric problems. [Max: 1998] How much family support is there currently? Potentially?Physical Exam
General
Assess mental status, including wakefulness, alertness, interaction, ability to follow commands in an age-appropriate manner, attention span for age, and memory. Assess speech and language: Are expressions of wants and needs and response to circumstances age appropriate?Testing
Imaging and EEG
Imaging: Review scans that have been done. Although a non-contrast CT scan indicates the presence of hemorrhage or edema, MRI provides a much clearer picture and shows subtle changes. Imaging doesn't need repeating unless the patient has acute changes in mental status. Note: In general, imaging results will not alter the treatment plan. A normal MRI or CT scan does not necessarily mean that a child will not have long-term difficulties post injury.EEG: if seizures are suspected after the first week post-injury (note, the longer the patient goes without a seizure, the less likely he/she is to develop post-traumatic seizures).
Subspecialist Collaborations and Other Resources
Pediatric Physical Medicine & Rehab (see Services below for relevant providers)
often helpful in monitoring physical, emotional, behavioral issues, spasticity and generally key to devising and implementing a rehabilitation plan
Pediatric Neurology (see Services below for relevant providers)
as needed for the treatment of seizures
Pediatric Orthopedics (see Services below for relevant providers)
as needed for orthopedic issues relating to spasticity or injuries
Pediatric Gastroenterology (see Services below for relevant providers)
as needed for problems related to feeding
Speech/Language Therapy (see Services below for relevant providers)
to evaluate language, content, memory, speech, and feeding-related functions
Occupational Therapy (see Services below for relevant providers)
to evaluate visual perception and processing, hand writing, upper extremity strength and coordination, activities of daily living and fine motor skills.
Physical Therapy (see Services below for relevant providers)
to evaluate gross motor function, balance, lower extremity strength and coordination
Educational Advocacy (see Services below for relevant providers)
to assess learning disabilities and develop a plan for re-integration into school
Neuropsychology (see Services below for relevant providers)
to assess cognitive abilities. Sometimes available during initial hospitalization, often not done until 3 to 6 months post traumatic brain injury and repeated every 2 to 3 years as needed.
Resources
Information & Support
For Professionals
Traumatic Brain Injury (CDC)
Overview, information, and links about TBI and its prevention, from the Centers for Disease Control and Prevention.
National Resource Center for Traumatic Brain Injury
Offering assessment tools, training program, publications, etc. for professionals and consumers. From the Virginia Commonwealth
University Health System.
The Traumatic Brain Injury Networking Team Resource Network
A resource for teachers, clinicians, parents and students. This is a great website with information for both families and
professionals, with some info specific to Colorado. It offers a Traumatic Brain Injury Identification and Intervention Protocol
as well as helpful documents that can be downloaded from the website. A complete manual is coming soon.
Diagnosing Pediatric Post-Injury Behavior
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36 KB)
The Brain Injury Association of Washington provides information and resources about brain injury in general as well as for
children aged birth to four. Diagnosing Pediatric Post-Injury behavior is found under the Children’s Resource list.
Traumatic Brain Injury in Young Children: In Harm's Way
Brain Injury Awareness for Head Start Providers. This documentary presentation was created by New Mexico’s Aging and Long-Term
Services Department to educate early childhood providers about TBI in young children. It is located with their permission
on the Brainline Kids website.
TBI and Memory webcast
This webcast is designed to increase understanding of TBI and its impact on memory as well as provide research-based strategies
proven effective in supporting children with TBI. Includes a training module (ppt) for parents and educators of children
who have experienced a TBI. From the Wisconsin Dept of Public Instruction.
CBIRT: Center on Brain Injury Research & Training
Established in 1993 at the Teaching Research Institute, a division of Western Oregon University, CBIRT conducts research and
training to improve the lives of children and adults with traumatic brain injury (TBI).
Project BRAIN: Effects of TBI on Students
Project BRAIN is a resource and training network for educators, families, and health care professionals who support students
in Tennessee with traumatic brain injury. This webpage focuses on physical, cognitive and psychosocial/behavioral functioning.
HRSA Federal TBI Program
Do you know someone who's had a Traumatic Brain Injury? Chances are you do...
For Parents and Patients
Support
Brain Injury Association of America
National Organization whose site provides information, links to resources, publications, and information about policy/legislation
and state chapters.
Brain Injury Association of Utah
A non-profit organization dedicated to education and support for the prevention and recovery of brain injury. The site lists
services (support groups, helpline, community education, conferences, legislative liaisons) and offers family education (simple
definitions, a map of the brain with explanations of function, consequences of injury and more).
General
Traumatic Brain Injury (MedlinePlus)
from the National Library of Medicine and National Institutes of Health; offers an overview and an extensive compilation of
links to reliable web sites and organizations related to TBI.
Traumatic Brain Injury (NINDS)
from the National Institute of Neurological Disorders and Stroke, provides an overview and links to publications and relevant
organizations; not pediatric-specific.
Traumatic Brain Injury (NICHCY)
From the National Dissemination Center for Children with Disabilities; parent-focused page about TBI, includes information
about education.
Brain Injury: The ABC Years
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90 KB)
According to the Centers for Disease Control and Prevention (CDC), an estimated 5.3 million Americans currently live with
disabilities resulting from brain injuries. A publication of the Brain Injury Association of America.
Brainline Kids – Helping Kids with Brain Injury
BrainLine Kids, a feature of Brainline.org, provides information about children ages birth through 22 years who are affected
by Traumatic Brain Injury. Children aged 0 to 4 years and older adolescents aged 15 to 19 years are among the groups most
likely to sustain a TBI.
Abusive Head Trauma (Shaken Baby Syndrome)
Abusive head trauma/inflicted traumatic brain injury — also called shaken baby/shaken impact syndrome (or SBS) — is a form
of inflicted head trauma.
Infant Head Injury
Any kind of head injury can be scary, but when the injured is a young child or baby, it becomes even harder to assess the
damage.
CDC: Traumatic Brain Injury
Educational initiatives and campaigns from the CDC for clinicians, parents, educators, coaches, and individuals including
children with TBI. Free, downloadable materials and fact sheets.
Practice Guidelines
Society of Critical Care Medicine.
Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents.
Crit Care Med.
2003;31(6 Suppl):S407-91.
PubMed abstract
Tools
Heads Up: Brain Injury in Your Practice
CDC, in collaboration with an expert work group, has recently updated and revised the "Heads Up: Brain Injury in Your Practice"
tool kit. This tool kit contains practical, easy-to-use clinical information and tools.
Services
Early Intervention Programs
See all Early Intervention Programs services providers (36) in our database.
Educational Advocacy
Children's Education Services,
more info...
100 N Mario Capecchi Drive
Salt Lake City, UT 84113
Phone: 801-662-4914
http://intermountainhealthcare.org/xp/public/documents/pcmc/school.pdf
See all Educational Advocacy services providers (25) in our database.
Pediatric Gastroenterology
See all Pediatric Gastroenterology services providers (2) in our database.
Pediatric Physical Medicine & Rehab
See all Pediatric Physical Medicine & Rehab services providers (6) in our database.
For other services related to this condition, browse our Services categories or search our database.
Studies
Brain Injuries in Children (clinicaltrials.gov)
A listing of clinical trials related to brain injuries in children, from ClinicalTrials.gov.
Helpful Articles
PubMed search on traumatic brain injury: articles over the past 2 years
Martin C, Falcone RA Jr.
Pediatric traumatic brain injury: an update of research to understand and improve outcomes.
Curr Opin Pediatr.
2008;20(3):294-9.
PubMed abstract
Orliaguet GA, Meyer PG, Baugnon T.
Management of critically ill children with traumatic brain injury.
Paediatr Anaesth.
2008;18(6):455-61.
PubMed abstract
Atabaki SM.
Pediatric head injury.
Pediatr Rev.
2007;28(6):215-24.
PubMed abstract
Giza CC, Mink RB, Madikians A.
Pediatric traumatic brain injury: not just little adults.
Curr Opin Crit Care.
2007;13(2):143-52.
PubMed abstract
V Anderson, PhD, C Catroppa, PhD, S Morse, BAppSci, F Haritou, BAppSci, J Rosenfeld, FRACS.
Functional Plasticity or Vulnerability After Early Brain Injury?
.
Pediatrics.
2005;116(No. 6): pp. 1374-1382.
/ Full Text
Traumatic brain injury (TBI) is a common, acquired, childhood disability. Recent research suggests that such early insults
may have a profound impact on development.
Liesemer K, Bratton SL, Zebrack CM, Brockmeyer D, Statler KD.
Early post-traumatic seizures in moderate to severe pediatric traumatic brain injury: rates, risk factors, and clinical features.
J Neurotrauma.
2011;28(5):755-62.
PubMed abstract
A retrospective, observational study at a level I pediatric trauma center of children with moderate-to-severe traumatic brain
injury (TBI) to identify clinical and radiographic risk factors for early post-traumatic seizures (EPTS).
DeMatteo CA, Hanna SE, Mahoney WJ, Hollenberg RD, Scott LA, Law MC, Newman A, Lin CY, Xu L.
"My child doesn't have a brain injury, he only has a concussion".
Pediatrics.
2010;125(2):327-34.
PubMed abstract / Full Text
Children with mild traumatic brain injuries have an increased frequency of receiving the concussion label, although the label
may also be applied to children with more-severe injuries. The concussion diagnosis is associated with important clinical
outcomes. Clinicians may use the concussion label because it is less alarming to parents than the term mild brain injury,
with the intent of implying that the injury is transient with no significant long-term health consequences.
Page Bibliography
Catroppa C, Anderson VA, Morse SA, Haritou F, Rosenfeld JV.
Outcome and predictors of functional recovery 5 years following pediatric traumatic brain injury (TBI).
J Pediatr Psychol.
2008;33(7):707-18.
PubMed abstract
Congeni J.
Management of the adolescent concussion victim.
Adolesc Med State Art Rev.
2009;20(1):41-56, viii.
PubMed abstract
Max JE, Robin DA, Lindgren SD, Smith WL Jr, Sato Y, Mattheis PJ, Stierwalt JA, Castillo CS.
Traumatic brain injury in children and adolescents: psychiatric disorders at one year.
J Neuropsychiatry Clin Neurosci.
1998;10(3):290-7.
PubMed abstract
McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R.
Consensus statement on concussion in sport - The 3rd international conference on concussion in sport held in Zurich, November
2008.
PM R.
2009;1(5):406-20.
PubMed abstract
Miller G.
Neuropathology. A late hit for pro football players.
Science.
2009;325(5941):670-2.
PubMed abstract