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Traumatisme crânien chez l’enfant

Head injury in children

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Réanimation

Résumé

Les traumatismes crâniens (TC) de l’enfant sont fréquents et bénins dans leur grande majorité. Les formes graves, définies par un score de Glasgow (GCS) < 9, restent la 1ère cause de décès accidentel dès l’âge d’un an. Leur gravité réside dans la survenue de lésions intracrâniennes (LIC) mises en évidence par la tomodensitométrie cérébrale. Les TC graves relèvent de mesures thérapeutiques protocolisées dans un centre pédiatrique spécialisé. L’objectif est de prévenir les lésions cérébrales secondaires. La réanimation précoce débute sur les lieux de l’accident par le maintien des fonctions vitales. La prise en charge optimale de la multitude d’enfants consultant pour un TC mineur (GCS : 13–15) reste à définir. Elle repose sur l’évaluation de la gravité potentielle du TC qui seule détermine l’indication d’une tomodensitométrie. L’urgentiste doit mettre en balance le risque de manquer une LIC neurochirurgicale avec celui de malignité future liée aux radiations ionisantes. La valeur prédictive de LIC d’une fracture du crâne, d’un céphalhématome, d’une perte de connaissance initiale, d’une amnésie, d’une convulsion immédiate, de vomissements, de céphalées, d’une cinétique élevée et d’un âge < 2 ans est controversée. Les règles de décision clinique publiées permettent d’identifier les rares LIC avec une excellente sensibilité mais au prix d’un nombre élevé de tomodensitométries cérébrales normales. Le recours à une brève période d’observation des enfants dont la bénignité du TC ne peut être affirmée dès l’évaluation clinique initiale est une alternative de choix.

Abstract

Head trauma in children is common and overwhelmingly benign. Severe forms, defined by a Glasgow Coma Scale (GCS) < 9, are the leading cause of death in children aged more than one year. Severity is related to the intracranial injuries identified by computed tomography (CT)-scan. Management of severe traumatic brain injuries (TBI) based on standardized critical care strategy in paediatric trauma centers aims to prevent secondary brain injuries. Early resuscitation starts on the scene and first need to stabilize main functions. Optimal management of the multitude of children with mild blunt head trauma (GCS: 13–15) remains to define. It relies on prognosis evaluation that determines the need for CT-scan. Emergency physicians must balance the possibility of missing a clinically significant TBI, especially those needing acute neurosurgery and the risks of future malignancies associated with ionizing radiation. The predictive values for TBI of skull fracture, scalp hematoma, loss of consciousness, amnesia, seizure, vomiting, rapid kinetics as well as age less than 2 years are controversial. Clinical decision rules identify TBI with an excellent sensitivity but with a high rate of obtaining normal CT-scans. The short observation of children for whom the benignity of head trauma cannot be definitively assessed based on the initial clinical evaluation seems to be beneficial.

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Authors and Affiliations

  1. Service des urgences pédiatriques, hôpital Necker-Enfants Malades, AP-HP, Paris, France

    G. Patteau & G. Chéron

  2. Université Paris Descartes, 149 rue de Sèvres, F-75743, Paris cedex 15, France

    G. Chéron

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  1. G. Patteau
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  2. G. Chéron
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Correspondence to G. Patteau.

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Patteau, G., Chéron, G. Traumatisme crânien chez l’enfant. Réanimation 23, 507–516 (2014). https://doi.org/10.1007/s13546-014-0920-y

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  • DOI: https://doi.org/10.1007/s13546-014-0920-y

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