Unconsciousness and Clouding of Consciousness in Pediatric Surgery | |
Mild Closed Head Injury, Minor Head Injury, Cerebral Concussion, Classic and Atypical Cerebral Concussion (there are different synonyms for the term 'Atypical Cerebral Concussion': Syndrome of Cerebral Concussion in Children, Traumatic Stupor, Delayed Encephalopathy, Amaurosis Fugax). | |
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Incidence | |
Minor head injury occurs very frequently in children. | |
Clinical significance | |
1. Very common type of trauma to the head. | |
Etiology | |
Depending on the age, minor head injury results from different causes: | |
Pathophysiology | |
In contrast to the severe head injury, in minor head injury the acute de- and acceleration is of lesser degree and does not occur repeatedly. The resulting cerebral concussion exhibits no long-lasting and irreparable brain damage on conventional histological examination. | |
Clinical presentation (history, findings, clinical skills) | Illustrations |
The diagnosis of a mild traumatic brain injury is a clinical diagnosis and includes:
For practical purposes the following arbitrary definition may be used: The history should find out the mechanism of injury, the child's behavior following the accident, and a possible amnesia. Besides an observed clouding of consciousness, confusion, dizziness, disorientation, apathia, inattention, and inability to solve successive daily tasks may point to a suffered cerebral concussion. At clinical presentation there is no or only a minimal clouding of consciousness (Glasgow coma scale 15 to 13) and the neurological examination is normal. Scalp and facial lacerations, abrasions, hematomas and autonomic nervous signs such as vomiting, paleness and profuse perspiration point to the head injury. In atypical cerebral concussion the clinical signs are more impressive: A short unconsciousness is followed by a long-lasting clouding of consciousness with or without distinct fluctuations of the state of consciousness. In the former situation the children can be awakened for a short time, or sometimes not at all even with a painful stimulus. The described course may also be observed following a latent period with or without an initial unconsciousness. |
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Natural history | |
In the majority of the children there is a complete recovery. A postconcussional syndrome may be observed with neurovegetative and psychoorganic symptoms and schooling problems. | |
Differential diagnosis | Illustrations |
In typical concussion the differential diagnosis is only important if the history of trauma is not known, or if an early epileptic fit occurs. | show details |
Work-up examinations | Illustration |
In suspected fracture of the skull (history of a typical trauma, incidental injury, age 0.6 to 2 years, characteristic findings) skull x-rays in one or two planes, special x-rays and/or CT without/with reconstruction are performed; CT in suspected epidural hematoma or cerebral contusion. | show details |
Therapy | Illustration |
Depending on the history, the clinical findings and the follow-up. | show details |
Prognosis | |
See 'natural history' above.
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