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 Table of Contents  
FORENSIC FILES
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 211-214

Mild blunt head injury in children: The dilemma of imaging and nature of injury


1 Department of Paediatrics, LHMC and Associated Hospitals, New Delhi, India
2 Department of Forensic Medicine and Toxicology, LHMC and Associated Hospitals, New Delhi, India

Date of Submission15-Jul-2021
Date of Decision22-Jul-2021
Date of Acceptance20-Aug-2021
Date of Web Publication31-Aug-2021

Correspondence Address:
Dr. Sandip Ray
202 B, Pocket B, Mayur Vihar Phase 2, New Delhi - 110 091
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ipcares.ipcares_235_21

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How to cite this article:
Ray S, Sharma AG, Singh S. Mild blunt head injury in children: The dilemma of imaging and nature of injury. Indian Pediatr Case Rep 2021;1:211-4

How to cite this URL:
Ray S, Sharma AG, Singh S. Mild blunt head injury in children: The dilemma of imaging and nature of injury. Indian Pediatr Case Rep [serial online] 2021 [cited 2021 Sep 26];1:211-4. Available from: http://www.ipcares.org/text.asp?2021/1/3/211/325091

A mild blunt head injury (MBHI) is a head injury that is associated with a Glasgow coma scale (GCS) of 13–15 in the absence of focal neurological deficits. It is quite a common injury in childhood, constituting 15%–30% of visits to pediatric emergencies worldwide.[1] Usually, they are not associated with brain injury and long-term sequelae. However, 5% may be clinically important traumatic brain injury (ciTBI) that requires extended observation, intensive supportive care, and even neurosurgical intervention.[2] Risk stratification of the likelihood of a ciTBI (and thus, the need for neuroimaging) following an MBHI can be high (>3%), intermediate (variable), and low (<0.05%). Despite majority of children being at low risk, more than one-third of patients undergo computed tomography (CT) scan of the head, which causes unnecessary sedation, cranial irradiation exposure, and possible increased risk of future malignancy.[3]

These patients are also often present to a pediatrician as a medicolegal case. Thus, there are two main issues that a clinician faces. First, whether a neuroimaging is required or not; and second, whether to label the injury as grievous or simple. As practicing pediatricians, we must know how to manage such cases appropriately. The purpose of this case study is to sensitize our readers to the challenges that are faced in a child with MBHI.


  Case Study Top


A 10-year-old boy presented to the emergency room accompanied by his father with the alleged history of being hit by a brick on his forehead by a neighbor 30 min earlier following a dispute. There were two wounds on the forehead [Figure 1]; one above and the other beneath the lateral end of the right eyebrow. Both had stopped bleeding. There was no history of severe headache, vomiting, loss of consciousness, seizures, bleeding or discharge from the ear, nose or any other site, or trauma to any other part of his body. There was no history of any sexual assault. The last immunization was at 5 years of age.
Figure 1: The medicolegal diagrammatic documentation of the injury

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The resident on duty registered a medicolegal case, informed the institutional police post, and started examination after taking informed consent from the child and his father. The child's vitals were stable. Both wounds were lacerated, measuring 0.5 cm in width and length. There was minimal surrounding edema. There were no other injuries elsewhere on the body. No watery discharge was observed from nose or ears. Bluish discoloration was not seen in the periorbital or periauricular areas. The GCS was 14/15. Both pupils were of normal size and displayed normal reaction. There were no focal neurological deficits or signs of increased intracranial tension. Rest of the systemic examination was normal.

The wounds were sutured with nonabsorbable material after aseptic preparation and local anesthesia. A tetanus shot was given. A noncontrast CT scan of the head and base of the skull was done which revealed no abnormality. The neurosurgical opinion was that of no active intervention. The final diagnosis was an MBHI. The decision regarding the nature of the wound was kept reserved till later. The child was discharged within 24 h after being instructed about danger signs warranting immediate return to the hospital [Box 1]. An oral antibiotic was prescribed for 5 days. The child was advised aseptic dressing of the wound and to come for suture removal after a week.




  Let's Ask the Expert Top


What are the indications for neuroimaging a child with mild blunt head injury?

Many algorithms and clinical decision rules have been developed for identifying children with MBHI who require neuroimaging (noncontrast CT scanning or magnetic resonance imaging) and intensive monitoring. These are used in conjunction with the clinician's judgment based on the level of expertise.[4] The Pediatric Emergency Care Applied Research Network is the most commonly used tool worldwide and is based on the age of the child [Figure 2]. Children >2 years with high risk (seizure, altered mental status with GCS ≤14, or findings indicative of a skull/basilar skull fracture) require immediate imaging. Those with intermediate risk (presence of vomiting, headache, history of loss of consciousness, or an injury caused by a high-risk mechanism like a motor collision) are observed for 4–6 h and advised imaging if there is no improvement or worsening of symptoms. Those who are at low risk (absence of any of the aforementioned factors) do not require neuroimaging.[5]
Figure 2: Pediatric Emergency Care Applied Research Network algorithm for prediction of clinically important traumatic brain injury in children.[2],[5] *AMS: Altered mental status: Agitation, somnolence, repetitive questioning, or slow response to verbal communication. #: Severe mechanism: MVC with patient ejection, death of another passenger, rollover; pedestrian or bicyclist w/o helmet struck by motorized vehicle; fall from >0.9 m or 3ft; head struck by high-impact object. $: Patients with certain isolated findings (i.e., no other findings suggestive of traumatic brain injury, such as isolated LOC, isolated headache, isolated vomiting, and certain types of isolated scalp hematomas in infants >3 months. @: Motor vehicle crash with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by a motorized vehicle; falls of more than 1.5 m/5 feet; head struck by a high-impact object

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Would we call the wounds sustained by this patient grievous?

A grievous hurt involves any of the following:[6] (i) emasculation; (ii) permanent privation of the sight of either eye; (iii) permanent privation of the hearing of either ear; (iv) privation of any member or joint; (v) destruction or permanent impairing of the powers of any member or joint; (vi) permanent disfiguration of the head or face; (vii) fracture or dislocation of a bone or tooth; and (viii) any hurt that endangers life or that causes the sufferer to be during the space of 20 days in severe bodily pain, or unable to follow his ordinary pursuits.

In the present case, the first five and seventh clauses are clearly not applicable. Whether the injuries would cause permanent disfigurement was uncertain at that point in time. This will only become apparent later, posthealing. However, minor lacerations on the head or face are generally not regarded as “grievous” by the Court, as they usually do not lead to permanent disfiguration. This clause is usually applicable in injuries caused by vitriol age (throwing of corrosives), which destroys identifying features on the face or head of the victim.

Let us now consider the eighth clause: endangerment of life or severe bodily pain or interference in daily activities during the following 20 days. The injury was definitely life-endangering as blunt trauma to the head can cause death. An injury is labeled as dangerous or endangering to life when the injury would be invariably fatal in the absence of medical or surgical intervention. Thus, it can be judged objectively by asking the question whether the injury would have resulted in death if the victim had not got timely medical/surgical help.

Whether an injury will be debilitating for the next few weeks is again a matter of time and an opinion that can be made only prospectively, depending upon the opinion of the treating doctor; whether the victim will be fit enough to be discharged within a few hours, a few days, or a few weeks. Hence, it is best to keep the opinion as “reserved” at admission. Once the follow-up of the victim is complete, a decision can be made regarding whether it is “grievous” or not. In this case, it was not grievous as he was discharged within a day of admission.

What are the role and responsibilities of the treating physician?

After taking history and consent for examination, the following steps should be performed:

  • Assessment of the child's airway, breathing, circulation, disability, and state of consciousness and exposure status within a few seconds. Movement of the neck should be avoided while handling the patient just in case cervical spine injury is also present
  • A blood sample should be collected for drug analysis (especially when intoxication or abuse is suspected). This should be packed, sealed, labeled separately, placed in a bag, and handed over to the police personnel
  • Appropriate treatment of the physical and scalp injuries. Expert opinion from the surgery, neurosurgery, and/or orthopedics departments should be taken, if warranted. The treating physician decides where the patient is admitted and the time of discharge
  • At discharge, indications for immediate return should be explained [Box 1].



  Legislature: Hurt and Grievous Hurt Top


According to Section 319 of the Indian Penal Code (IPC), causing “Hurt” is defined as causing bodily pain, disease, or infirmity to any person. Pain covers only physical bodily pain. The term “infirmity” is applicable to a temporary or permanent condition in which one or more organs are unable to carry out normal bodily function. Infirmity can also be mental, i.e. if somebody is threatened with death and the victim ceases to heave home out of fear. Hurt is punishable under Section 323 of the IPC. Section 321 of the IPC is an extension of Section 319. It deals with the term “voluntarily causing hurt.” This is defined as “whoever does any act with the intention of thereby causing harm to any person, or with the expertise that he's likely thereby to reason hurt to any individual, and does thereby motive harm to any person.” In this case, it is essential that an element of “mens rea” (the intention or knowledge of wrongdoing that constitutes part of a crime) is proved.

Similarly, Section 320 of the IPC deals with the definition of “grievous hurt” and Section 322 defines the offense of “voluntarily causing grievous hurt.” The eight specific situations that are included in the definition have been outlined earlier. The Indian Penal Code explains 'voluntarily causing grievous hurt' as when the offender not only causes grievous hurt, but had the intention of causing grievous hurt or knew that his/her actions would likely cause grievous hurt. A simple injury is conventionally defined as “any injury that is neither extensive, nor serious, and heals rapidly without leaving any deformity or disfiguration.”

It is important for a clinician to be cognizant of these definitions and the subtle differences between the two because of the following judicial implications.

  • The injuries caused in Section 319 IPC (hurt) are not specified and there is no mention of risk to life, whereas in Section 320 IPC (grievous hurt), the risk of life is much graver
  • Hurt is not punishable in itself. For hurt to be punishable, it must be accompanied by other offenses. However, grievous hurt is punishable in itself
  • The offense of hurt is noncognizable, bailable, and triable by any Magistrate. However, the offense of grievous hurt is cognizable, bailable, and compoundable with the permission of the Court
  • The punishment for hurt is given under Section 323 of the IPC which is “imprisonment of either description for a term which may extend to 1 year, or with fine which may extend to one thousand rupees, or with both.” The punishment for grievous hurt is given under Section 325 of the IPC, which is “imprisonment of either description for a term which may extend to 7 years, and shall also be liable to fine.”


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
McKinlay A, Grace RC, Horwood LJ, et al. Prevalence of traumatic brain injury among children, adolescents and young adults: Prospective evidence from a birth cohort. Brain Inj 2008;22:175-81.  Back to cited text no. 1
    
2.
Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: A prospective cohort study. Lancet 2009;374:1160-70.  Back to cited text no. 2
    
3.
Mannix R, Meehan WP, Monuteaux MC, et al. Computed tomography for minor head injury: Variation and trends in major United States pediatric emergency departments. J Pediatr 2012;160:136-9.e1.  Back to cited text no. 3
    
4.
Easter J, Bakes K, Dhaliwal J, et al. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: A prospective cohort. Ann Emerg Med 2014;64:145-52.  Back to cited text no. 4
    
5.
Kocyigit A, Serinken M, Ceven Z, et al. A strategy to optimize CT use in children with mild blunt head trauma utilizing clinical risk stratification; could we improve CT use in children with mild head injury? Clin Imaging 2014;38:236-40.  Back to cited text no. 5
    
6.
Atal DK, Naik SK, Das S. Hurt and grievous hurt in Indian context. J Indian Acad Forensic Med 2013;35:160-64.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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