Introduction: Traumatic Brain Injuries (TBIs) can range from mild to severe, and may result in increased intracranial pressure (ICP). Increased ICP causes hallmark physical signs, such as diaphoresis, emesis, fixed pupils, and altered mental status. Monitoring the patient's score on the Glasgow Coma Scale (GCS) and cranial CT scans are routine measures used in clinical practice to monitor the development of a TBI.
Presentation of the case: A 6-year-old male fell off his father's shoulders and subsequently presented to ED for suspected head trauma. He was transferred to our Level 1 Trauma Center after a head CT scan demonstrated a subdural hematoma. His GCS score remained 15. The next day he began to have episodes of apnea and desaturation. Further imaging indicated expansion of the hematoma with a 5mm midline shift. He remained consistently alert and a neurological exam revealed cranial nerves to be grossly intact. Increased ICP was reduced with several days of hypertonic saline treatment without surgical intervention.
Discussion: TBIs can have long-lasting effects in pediatric patients and are typically assessed using both diagnostic imaging and clinical judgment. CT scans are used to assess for hematoma development, while loss of consciousness (LOC) and altered mental status are standard clinical diagnostic indicators of increased ICP. This patient remained alert with a GCS score of 15, although he had clinical signs of increased ICP including apnea and bradycardia with a midline shift confirmed on imaging.
Conclusion: While GCS is an important prognostic indicator in TBI, patients should still be monitored to assure resolution of all symptoms.
Keywords: Apnea; Bradycardia; GCS, Glasgow Coma Scale; ICH, Intracranial Hemorrhages; ICP, Intracranial Pressure; Intracranial pressure; Midline shift; TBI, Traumatic Brain Injury; Trauma.