INDIAN JOURNAL OF PEDIATRICS Vol. 42
October, 1975
No. 333
HEAD INJURY IN CHILDREN* K. V. D~VADIO~, Manipal In developed countries, head injury ranks as a major cause of d e a t h in children beyond the first year of life. This subject is of great concern to the parents, family doctors, paediatriclans and neurosurgeons. With rapid industrialization resulting in increased traffic accidents and urbanization leading to problems of housing, there is every indication that head injury would become a major problem in our country too. H e a d injury in children differs from that in adults in its aetiology, its long term effect on personality and behaviour and the possibility of post-traumatic epilepsy. As falls are the main cause of head injuries in children (Calvert 1960, Hendrlck et al. 1964, K a l y a n a r a m a n et al. 1970, Rao 1959, R o w b o t h a m tt al. 1954), there is some scope for the prevention o f head injuries related to fails. T h e present study deals with an analysis of head injuries in children in art urban set up. Material a n d M e t h o d s This is a study of consecutive head injuries admitted to the Irwin Hospital, New Delhi from i962-1964. *From the Department of Neurological Sciences, Kasturba Medical College and Hospital, Manipal-57 6119, South India. Based on M.S. thesis "Clinical study of Head Injury" Delhi University. Received June I0, 1975.
Observations T h e r e was a total of 641 cases, of whom 419 were males and 222 females (Table 1). Only children upto the age of 13 years have been included in this study. T h e incidence of head injury was lowest in infants below one year o f age. T h e main cause of head injury in the present study was a fall. In children below the age o f 4 years, the fall was mainly from the terrace, balcony or staircase. Above this age, the fall mostly occurred while playing. Traffic accidents were responsible for 16 per cent of head injuries (Table 2). 85 per cent of the children on admission were found to be fully conscious or responded to sharp commands and only 5 per cent were deeply unconscious or comatose (Table 3). Vomiting was noted soon or a few hours after the injury in 144 cases. Most of them had bleeding from the nose or mouth. Subgaleal h a e m a t o m a was noted in 137 cases. X - r a y revealed evidence o f a skull fracture in 78 cases. Nearly two-thirds of the patients were hospitalized for less than 2 days and another 25 per cent were discharged within 7 days. Thus less than 10 per cent of the children remained in the hospital for more than 10 days (Table 4).
292
VOL. 42, No. 233
XNDtANJOURNAL OF PEDIATRICS
Table 1, Age in years .
Incidence of head injury
Male .
.
.
.
r,i
Female
~
Total
it
i
Percentage
ii
|ll
i
Under 1 year
7
4
11
1.9
1--2
24
16
40
6.2
2--3
37
21
58
9.0
3--4
46
38
8~
13.1
4--5
50
25
75
11.7
5--6
50
25
75
11.7
6--7
45
20
65
10.1
7--8
28
17
45
7.0
8--9
41
18
59
9.2
9m10
29
8
37
5.8
10--11
24
18
42
6.6
11--12
13
3
16
2.4
12m13
25
9
34
5.3
Total
419
222
641
100.0
Table 2. Aetiology of head injuries. Rowbotham et alo (1954) No.
%
Hendrick et al. (1964) No.
%
Kalyanaraman et al. (1970) No.
%
Present series
No.
%
Fall
207
51.8
2359
52.9
443
59.0
505
78.8
Traffic accidents
147
36.7
1419
31.8
293
39.0
105
16.4
46
11.5
687
15.3
15
2.0
31
4.8
Miscellaneous
293
DEVADIGA-- HEAD INJURY IN CHILDREN
T a b l e 3. Level of consciouness at admission and mortality.
Total number
Percentage
Number of deaths
204
31.8
2
1.0
342
53.4
4
1.1
Responds to painful stimuli
61
9.5
14
22.8
No response
34
5.3
27
79.4
641
100.0
47
7.3
Alert and fullly conscious Responds to sharp commands
Total
T a b l e 4.
Percentage
Length of stay in the hospital by age and sex.
0--5Yr.
6 - - 12 Yr. Total F
Less than 2 days
I39
80
117
52
388
60.5
3 - - 7 days
53
33
63
24
173
27.0
8--10 days
10
7
6
3
26
4.0
12
9
19
14
5t
8.5
214
129
205
93
641
100.0
More than I0 days Total
M
Percentage
M
F
294
VOL. 42, No. 333
INDIANJOURNAL OF PEDIATRICS
There was a total of 47 deaths, with 26 occurring in children below the age of 5 years and the remaining above that age group (Table 5). No significant difference in mortality rate was noted in these two arbitrary age groups. Ten patients died within an hour after admission, another 26 within 24 hours, thus accounting for 36 of 47 deaths within 24 hours of admission.
was noted in 6 and basal fractures in 3. Extradural haemorrhage was present in 3, subdural in 6, subarachnoid haemorrhage in 3, laceration or contusion of the brain in 7 and brain stem haemorrhage in 2, The findings noted at post mortem examination suggested severe brain damage in
O f the remaining 11 patients 8 died within 48 hours and 2 within 72 hours. One patient died on the 7th post admission day. The mortality rate due to falls and traffic accidents was more or less identical (Table
Discussion Age and sex There was slight male preponderance (Table 1). While up to the age of 4 years this disparity was less striking, in children above the age of 5, males were more frequently involved than females. This may be related to the more active role
6). Post mortem studies were carried out in 11 cases.
Fracture of vault of the skull
Table 5.
the majority of these 11 patients.
Age and death.
Male
Female
Total
Percentage mortality
0--5
214(16)
129~10)
343(26)
7.6
6-- 12
205(13)
93(8)
298(21)
7.0
0-- 12
419(29)
222(18)
641 (47)
7.3
Age in years
Figures in parentheses denote numbers of deaths.
Table 6.
Aetiology and mortality rate. Percentage
Total number of cases
Number of deaths
Fall
505
37
7.3
Traffic
105
8
7.6
Other causes
31
2
6.5
DEVADIGA~HEAD INJURY IN CHILDR~.N
played by boys in games, etc. T h e maximum incidence of head injury was between the age of 3-9 years, with the highest incidence in the 4th year of life. Similar observations have also been made by R o w b o t h a m and his colleagues (1954). Aetiology Most o f the published series (Rowbotham et al. 1954, Hendrick et al. 1964, K a l y a n a r a m a n et al. 1970) indicate that falls account for more than 50 per cent of the cases of head injuries in children. In the present series, falls accounted for nearly 80 per cent of the cases. While in other published series traffic accidents accounted for more than 30 per cent of head injuries (Table 2), in the present study only 16 per cent were due to traffic accidents. This higher incidence of falls is in striking contrast to the cause of head injuries in adults. T h e fact that nearly 20 per cent of the falls were from a terrace, balcony or staircase, suggests that well protected terraces and balconies along with greater care o f children below the age of 5 years would prevent a large percentage of these head injuries. Level of consciousness T h e level of consciousness is the most important parameter in the management of head injury. T h e need for a correct and easily understandable terminology in recording this vital sign has been stressed by Busch (1963), Potter (1961), Fleming (19ill) and McDowell (1963). As terms such as coma, semicoma and confusion have no universally accepted meaning, the level of consciousness should be recorded in terms ol actual response of the patient to various stimuli such as simple questions, sharp commands or painful stimuli. The
295
level of consciousness is a very reliable index of damage to the brain. T h e mortality rate in the group of patients who was not responding to any stimuli was 79.4 per cent in contrast to the one per cent mortality rate noted in the alert and fully conscious group (Table 3). R o w b o t h a m and his colleagues (1954) also noted a higher mortality rate in the deeply unconscious group of children. It is important to stress here that in the management of head injuries, any change in the level of consciousness, particularly deterioration, should alert the people in charge, to a possibility o f intracranial compression. As the emphasis in the treatment of head injuries is to restore life to a normal state, any delay in instituting therapy, particularly in cases of intracranial compression, could defeat this objective. Thus immediate exploratory burr holes or other investigations, if the condition permits, should be undertaken at the slightest suspicion of intracranial haematoma. Pulse While a slow pulse of less than 60 per minute may indicate increased intracranial pressure, this by itself is not an important sign of compression. It is also not uncommon to record a fast pulse in cerebral compression particularly where the compression has gone unnoticed. However, it needs to be stressed here that a slowly decreasing pulse r a t e during the period of observation should be taken as an indication o f compression. If there is also an associated deterioration in level of consciousness then brad~.cardia has a greater significance. In this study, the anal3 sis of 47 children who died, showed that 4 children had a
296
VOL. 42, No. 333
INDIAN JOURNAL OF PEDIATRICS
pulse rate of 60 or less per minute; 18 had a pulse rate o f 80 to 120 per minute; and 25 had a thready and fast pulse with a rate of above 120 per minute. While those 25 patients perhaps represented the terminal stage of head injury, careful observation in 18 children with a normal pulse rate, perhaps could have helped to detect neurological deterioration. This inference is further strengthened by the fact that in the 11 autopsied cases, there were 3 cases of extradural h a e m o r r h a g e and 6 cases o f subdural h a e m o r r h a g e undetected during life.
Blood Pressure It has been rightly stressed that in p r i m a r y head injury, shock is uncommon and its presence in such cases should indicate the possibility o f internal injury to the viscera. In children, however, scalp injury because o f its liberal blood supply and rapid loss of blood, can also give rise to shock. In closed head injury without evidence of internal injury, shock has a grave prognosis as it usually indicates the terminal stage o f head injury.
Pupillary reactions T h e size, symmetry and reaction of the pupils is of importance particularly if the pupils are unequal. In the large majority of children who responded normally to questions, the pupillary size and reaction were normal. However, there were 23 cases of unequal pupils out of whom 10 were faiHy alert. Slightly dilated but normally reacting pupils in 33; constricted and normally reacting in 10; dilated and fixed pupils in 10 and constricted nonreacting pupils in 5 cases were noted. All the 10 children with dilated and fixed pupils died indicating this to be a very grave sign.
It is i m p o r t a n t here to note that o f the 23 children with inequality of the pupils, 10 were alert. This indicates that unilateral dilatation o f the pupils in the absence of other focal signs such as hemiparesis or reflex changes may indicate contusion of the optic or the oculomotor nerves. A distinction between the II and I I I cranial nerve injury can be made clinically by noting the direct and consensual light reflexes, provided the child is co-operative.
X-ray of skull Fracture of the skull was noted in 78 cases. T h e r e were 6 cases of depressed fracture of the skull of which 4 were compound in nature. Thus in this series about 12 per cent of the children had radiological evidence of head injury. This is less than that reported by Hendrick et al. (1964).
Management Antibiotics were used in all cases with evidence of external injury to the head or body. T h e airway was maintained mainly by posture and suction. No traeheostomy was done in this series. Suturing of the scalp wound was done in 105 cases, and elevation of depressed fractures in 3 cases. Exploratory burr holes done in 4 cases revealed one case each of subdural haematoma, extradural haematoma and cerebral oedema. One case was negative. However, the fact that in the 11 cases submitted for autopsy there were 3 cases of extradural hz)em~atoma and 6 of subdural haematoma, suggests that increased vigilance and expertise is needed in the management of head injuries. This study points to the need for management of head injuries by neurosurgeons wherever possible cr neurosurgically oriented general surgeons or general
DEVADIGA--HEAD
297
I N J U R Y IN C H I L D R E N
surgeons who have had some training in the art and practice of neurosurgery. T h e fact that such an a p p r o a c h can reduce mortality mainly by detection and effective management of compression has been clearly documented in the literature. The fact that 10 patients died within an hour after admission, indicates the serious nature of injury in these children. T h e r e were another 26 deaths within the next 23 hours. Perhaps in the 10 patients who died between the 1st and 2nd day of admission, greater vigilance might have been useful. However, it must be stressed that even masterly activity may not be useful in patients with bilateral dilated fixed pupils, decerebrate response to painful stimuli, Cheyne-Stokes type of breathing and fast thready pulse. A combination of these findings were noted in more than h a l f of the 47 patients who died. Summary
641 consecutive cases of head injuries admitted to the I r w i n Hospital, New Delbi, were studied. A fall was the most common cause of head injury in children. T h e study stresses the importance of the level of consciousness in the assessment as well as management of head injuries. The very low number of cases undergoing surgical intervention in the series and the presence of significant findings of compression in 11 autopsied cases, suggest the need for more expertise and vigilance in the management of head injuries.
The author wishes to thank the Director-Principal, Maulana Azad Medical College and the Medical Superintendent, Irwin Hospital, New Delhi, for their permission to pu,sue this study and the staff of various surgical units for their willing co-operation and help. References
Busch, E.A.V. (1963). Brain stem contusion: Differential diagnosis: Therapy and Prognosis, In Clinical Neurosurgery, Proceedings of the Congress o! Neurological Surgeons. Williams and Wilkins, New York, p. 18. Calvert, J.M. (1960). Problems in the modern practice of head injury. Aust..N.~. o7. Surg. 29, 344. Craft, A.W, Shaw, D.A. and Cartlidge, N.E.F. (1972). Head injuries in children. Brit. Med. ft. 4, 200. Fleming, R.A. (1961). Management of head injuries, ft. Internat. Coll. Surg. 36, 782. Hendrick, E.B., Harwood-I-Iash, D.C.F. and Hudson, A.R. (1964). Head injuries in children. A survey of 4,465 consecutive cases at the Hospital for Sick Children, Toronto, Canada. Clinical Neurosurgery. Williams and Wilkins, Baltimore, p. 46. Kalyanaraman, S., Ramamoorthy, K. and Ramamurthi, B. (1970). An analysis of two thousand cases of head injury. Neurology (India), XVIII, 1, 3. McDowell, F.H. (1963). Head trauma. In Cecil-Loeb's Textbook of Medicine. Ed. Benson, P. and McDermott, W, 11th Ed. Saunders, Philadelphia. p. 1693. Potter, J.M. (1961). The Practical Management of Head Injuries. Llo.~dLuke, London. Rao, B . D . (1959). A critical reviewof 250 consecutive head injuries in Hyderabad. Proc. Ind. Acad. Sd. 1, 122. Rowbotham, G.F., Maciver, I.N., Dickson, J., and Bousefield, M.F. (1954). Analysis of 1400cases of acute head injury. Brit, Med, o7. 1,726.
October, 1975
No. 333
HEAD INJURY IN CHILDREN* K. V. D~VADIO~, Manipal In developed countries, head injury ranks as a major cause of d e a t h in children beyond the first year of life. This subject is of great concern to the parents, family doctors, paediatriclans and neurosurgeons. With rapid industrialization resulting in increased traffic accidents and urbanization leading to problems of housing, there is every indication that head injury would become a major problem in our country too. H e a d injury in children differs from that in adults in its aetiology, its long term effect on personality and behaviour and the possibility of post-traumatic epilepsy. As falls are the main cause of head injuries in children (Calvert 1960, Hendrlck et al. 1964, K a l y a n a r a m a n et al. 1970, Rao 1959, R o w b o t h a m tt al. 1954), there is some scope for the prevention o f head injuries related to fails. T h e present study deals with an analysis of head injuries in children in art urban set up. Material a n d M e t h o d s This is a study of consecutive head injuries admitted to the Irwin Hospital, New Delhi from i962-1964. *From the Department of Neurological Sciences, Kasturba Medical College and Hospital, Manipal-57 6119, South India. Based on M.S. thesis "Clinical study of Head Injury" Delhi University. Received June I0, 1975.
Observations T h e r e was a total of 641 cases, of whom 419 were males and 222 females (Table 1). Only children upto the age of 13 years have been included in this study. T h e incidence of head injury was lowest in infants below one year o f age. T h e main cause of head injury in the present study was a fall. In children below the age o f 4 years, the fall was mainly from the terrace, balcony or staircase. Above this age, the fall mostly occurred while playing. Traffic accidents were responsible for 16 per cent of head injuries (Table 2). 85 per cent of the children on admission were found to be fully conscious or responded to sharp commands and only 5 per cent were deeply unconscious or comatose (Table 3). Vomiting was noted soon or a few hours after the injury in 144 cases. Most of them had bleeding from the nose or mouth. Subgaleal h a e m a t o m a was noted in 137 cases. X - r a y revealed evidence o f a skull fracture in 78 cases. Nearly two-thirds of the patients were hospitalized for less than 2 days and another 25 per cent were discharged within 7 days. Thus less than 10 per cent of the children remained in the hospital for more than 10 days (Table 4).
292
VOL. 42, No. 233
XNDtANJOURNAL OF PEDIATRICS
Table 1, Age in years .
Incidence of head injury
Male .
.
.
.
r,i
Female
~
Total
it
i
Percentage
ii
|ll
i
Under 1 year
7
4
11
1.9
1--2
24
16
40
6.2
2--3
37
21
58
9.0
3--4
46
38
8~
13.1
4--5
50
25
75
11.7
5--6
50
25
75
11.7
6--7
45
20
65
10.1
7--8
28
17
45
7.0
8--9
41
18
59
9.2
9m10
29
8
37
5.8
10--11
24
18
42
6.6
11--12
13
3
16
2.4
12m13
25
9
34
5.3
Total
419
222
641
100.0
Table 2. Aetiology of head injuries. Rowbotham et alo (1954) No.
%
Hendrick et al. (1964) No.
%
Kalyanaraman et al. (1970) No.
%
Present series
No.
%
Fall
207
51.8
2359
52.9
443
59.0
505
78.8
Traffic accidents
147
36.7
1419
31.8
293
39.0
105
16.4
46
11.5
687
15.3
15
2.0
31
4.8
Miscellaneous
293
DEVADIGA-- HEAD INJURY IN CHILDREN
T a b l e 3. Level of consciouness at admission and mortality.
Total number
Percentage
Number of deaths
204
31.8
2
1.0
342
53.4
4
1.1
Responds to painful stimuli
61
9.5
14
22.8
No response
34
5.3
27
79.4
641
100.0
47
7.3
Alert and fullly conscious Responds to sharp commands
Total
T a b l e 4.
Percentage
Length of stay in the hospital by age and sex.
0--5Yr.
6 - - 12 Yr. Total F
Less than 2 days
I39
80
117
52
388
60.5
3 - - 7 days
53
33
63
24
173
27.0
8--10 days
10
7
6
3
26
4.0
12
9
19
14
5t
8.5
214
129
205
93
641
100.0
More than I0 days Total
M
Percentage
M
F
294
VOL. 42, No. 333
INDIANJOURNAL OF PEDIATRICS
There was a total of 47 deaths, with 26 occurring in children below the age of 5 years and the remaining above that age group (Table 5). No significant difference in mortality rate was noted in these two arbitrary age groups. Ten patients died within an hour after admission, another 26 within 24 hours, thus accounting for 36 of 47 deaths within 24 hours of admission.
was noted in 6 and basal fractures in 3. Extradural haemorrhage was present in 3, subdural in 6, subarachnoid haemorrhage in 3, laceration or contusion of the brain in 7 and brain stem haemorrhage in 2, The findings noted at post mortem examination suggested severe brain damage in
O f the remaining 11 patients 8 died within 48 hours and 2 within 72 hours. One patient died on the 7th post admission day. The mortality rate due to falls and traffic accidents was more or less identical (Table
Discussion Age and sex There was slight male preponderance (Table 1). While up to the age of 4 years this disparity was less striking, in children above the age of 5, males were more frequently involved than females. This may be related to the more active role
6). Post mortem studies were carried out in 11 cases.
Fracture of vault of the skull
Table 5.
the majority of these 11 patients.
Age and death.
Male
Female
Total
Percentage mortality
0--5
214(16)
129~10)
343(26)
7.6
6-- 12
205(13)
93(8)
298(21)
7.0
0-- 12
419(29)
222(18)
641 (47)
7.3
Age in years
Figures in parentheses denote numbers of deaths.
Table 6.
Aetiology and mortality rate. Percentage
Total number of cases
Number of deaths
Fall
505
37
7.3
Traffic
105
8
7.6
Other causes
31
2
6.5
DEVADIGA~HEAD INJURY IN CHILDR~.N
played by boys in games, etc. T h e maximum incidence of head injury was between the age of 3-9 years, with the highest incidence in the 4th year of life. Similar observations have also been made by R o w b o t h a m and his colleagues (1954). Aetiology Most o f the published series (Rowbotham et al. 1954, Hendrick et al. 1964, K a l y a n a r a m a n et al. 1970) indicate that falls account for more than 50 per cent of the cases of head injuries in children. In the present series, falls accounted for nearly 80 per cent of the cases. While in other published series traffic accidents accounted for more than 30 per cent of head injuries (Table 2), in the present study only 16 per cent were due to traffic accidents. This higher incidence of falls is in striking contrast to the cause of head injuries in adults. T h e fact that nearly 20 per cent of the falls were from a terrace, balcony or staircase, suggests that well protected terraces and balconies along with greater care o f children below the age of 5 years would prevent a large percentage of these head injuries. Level of consciousness T h e level of consciousness is the most important parameter in the management of head injury. T h e need for a correct and easily understandable terminology in recording this vital sign has been stressed by Busch (1963), Potter (1961), Fleming (19ill) and McDowell (1963). As terms such as coma, semicoma and confusion have no universally accepted meaning, the level of consciousness should be recorded in terms ol actual response of the patient to various stimuli such as simple questions, sharp commands or painful stimuli. The
295
level of consciousness is a very reliable index of damage to the brain. T h e mortality rate in the group of patients who was not responding to any stimuli was 79.4 per cent in contrast to the one per cent mortality rate noted in the alert and fully conscious group (Table 3). R o w b o t h a m and his colleagues (1954) also noted a higher mortality rate in the deeply unconscious group of children. It is important to stress here that in the management of head injuries, any change in the level of consciousness, particularly deterioration, should alert the people in charge, to a possibility o f intracranial compression. As the emphasis in the treatment of head injuries is to restore life to a normal state, any delay in instituting therapy, particularly in cases of intracranial compression, could defeat this objective. Thus immediate exploratory burr holes or other investigations, if the condition permits, should be undertaken at the slightest suspicion of intracranial haematoma. Pulse While a slow pulse of less than 60 per minute may indicate increased intracranial pressure, this by itself is not an important sign of compression. It is also not uncommon to record a fast pulse in cerebral compression particularly where the compression has gone unnoticed. However, it needs to be stressed here that a slowly decreasing pulse r a t e during the period of observation should be taken as an indication o f compression. If there is also an associated deterioration in level of consciousness then brad~.cardia has a greater significance. In this study, the anal3 sis of 47 children who died, showed that 4 children had a
296
VOL. 42, No. 333
INDIAN JOURNAL OF PEDIATRICS
pulse rate of 60 or less per minute; 18 had a pulse rate o f 80 to 120 per minute; and 25 had a thready and fast pulse with a rate of above 120 per minute. While those 25 patients perhaps represented the terminal stage of head injury, careful observation in 18 children with a normal pulse rate, perhaps could have helped to detect neurological deterioration. This inference is further strengthened by the fact that in the 11 autopsied cases, there were 3 cases of extradural h a e m o r r h a g e and 6 cases o f subdural h a e m o r r h a g e undetected during life.
Blood Pressure It has been rightly stressed that in p r i m a r y head injury, shock is uncommon and its presence in such cases should indicate the possibility o f internal injury to the viscera. In children, however, scalp injury because o f its liberal blood supply and rapid loss of blood, can also give rise to shock. In closed head injury without evidence of internal injury, shock has a grave prognosis as it usually indicates the terminal stage o f head injury.
Pupillary reactions T h e size, symmetry and reaction of the pupils is of importance particularly if the pupils are unequal. In the large majority of children who responded normally to questions, the pupillary size and reaction were normal. However, there were 23 cases of unequal pupils out of whom 10 were faiHy alert. Slightly dilated but normally reacting pupils in 33; constricted and normally reacting in 10; dilated and fixed pupils in 10 and constricted nonreacting pupils in 5 cases were noted. All the 10 children with dilated and fixed pupils died indicating this to be a very grave sign.
It is i m p o r t a n t here to note that o f the 23 children with inequality of the pupils, 10 were alert. This indicates that unilateral dilatation o f the pupils in the absence of other focal signs such as hemiparesis or reflex changes may indicate contusion of the optic or the oculomotor nerves. A distinction between the II and I I I cranial nerve injury can be made clinically by noting the direct and consensual light reflexes, provided the child is co-operative.
X-ray of skull Fracture of the skull was noted in 78 cases. T h e r e were 6 cases of depressed fracture of the skull of which 4 were compound in nature. Thus in this series about 12 per cent of the children had radiological evidence of head injury. This is less than that reported by Hendrick et al. (1964).
Management Antibiotics were used in all cases with evidence of external injury to the head or body. T h e airway was maintained mainly by posture and suction. No traeheostomy was done in this series. Suturing of the scalp wound was done in 105 cases, and elevation of depressed fractures in 3 cases. Exploratory burr holes done in 4 cases revealed one case each of subdural haematoma, extradural haematoma and cerebral oedema. One case was negative. However, the fact that in the 11 cases submitted for autopsy there were 3 cases of extradural hz)em~atoma and 6 of subdural haematoma, suggests that increased vigilance and expertise is needed in the management of head injuries. This study points to the need for management of head injuries by neurosurgeons wherever possible cr neurosurgically oriented general surgeons or general
DEVADIGA--HEAD
297
I N J U R Y IN C H I L D R E N
surgeons who have had some training in the art and practice of neurosurgery. T h e fact that such an a p p r o a c h can reduce mortality mainly by detection and effective management of compression has been clearly documented in the literature. The fact that 10 patients died within an hour after admission, indicates the serious nature of injury in these children. T h e r e were another 26 deaths within the next 23 hours. Perhaps in the 10 patients who died between the 1st and 2nd day of admission, greater vigilance might have been useful. However, it must be stressed that even masterly activity may not be useful in patients with bilateral dilated fixed pupils, decerebrate response to painful stimuli, Cheyne-Stokes type of breathing and fast thready pulse. A combination of these findings were noted in more than h a l f of the 47 patients who died. Summary
641 consecutive cases of head injuries admitted to the I r w i n Hospital, New Delbi, were studied. A fall was the most common cause of head injury in children. T h e study stresses the importance of the level of consciousness in the assessment as well as management of head injuries. The very low number of cases undergoing surgical intervention in the series and the presence of significant findings of compression in 11 autopsied cases, suggest the need for more expertise and vigilance in the management of head injuries.
The author wishes to thank the Director-Principal, Maulana Azad Medical College and the Medical Superintendent, Irwin Hospital, New Delhi, for their permission to pu,sue this study and the staff of various surgical units for their willing co-operation and help. References
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