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INTRODUCTION

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Rehabilitation medicine is the multispecialty discipline involved in diagnosis and therapy of individuals with congenital and acquired disabilities. The goals of rehabilitation medicine are to maximize functional capabilities and improve quality of life. Disabilities are described using the World Health Organization's International Classification of Function, Health, and Disability. Three aspects are evaluated in every patient: (1) the impact of the disability on body structure and function, (2) the impact of the disability on activity and participation in society, and (3) the environmental factors with an impact on the individual's function. These three areas are the common framework for discussion of a disabling condition and its therapy.

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PEDIATRIC BRAIN INJURY

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ESSENTIALS OF DIAGNOSIS

  • Severe head injury: Glasgow Coma Score (GCS) of < 9

  • Moderate head injury: GCS of 9–13

  • Mild head injury: GCS of 13–15

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There are an estimated 475,000 emergency department visits for brain injuries per year among children from birth through 14 years of age, with 3000 deaths and 37,000 hospitalizations. Children with brain injuries may have long-term deficits and disabilities that must be identified and treated.

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Pathogenesis

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Brain injury is classically divided into two categories based upon the timing of the pathologic findings: primary and secondary injury.

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Primary injury occurs at the time of trauma, causing focal and diffuse damage. Focal damage includes skull fracture, parenchymal bruising or contusion, extraparenchymal or intraparenchymal hemorrhage, blood clots, tearing of blood vessels, or penetrating injury. Diffuse damage includes diffuse axonal injury and edema. Consequences of primary injury, either focal or diffuse, include cellular disruption with release of excitatory amino acids, opiate peptides, and inflammatory cytokines.

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Secondary injury is the loss of cellular function accompanying primary injury that results in loss of cerebrovascular regulation, altered cellular homeostasis, or cell death and functional dysregulation. A primary injury can initiate the processes of secondary programmed cell death (apoptosis), which further exacerbates the primary injury. Secondary injury may develop hours or days after the initial insult. It appears to be precipitated by elevated intracranial pressure, cerebral edema, and release of neurochemical mediators. Current treatment paradigms are focused on treating and preventing secondary injury.

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Clinical Findings

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Classification & Assessment of Injury Severity

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Traumatic brain injury is usually categorized as open or closed. Open injuries are the result of penetration of the skull by missile or sharp object or deformation of the skull with exposure of the underlying intracranial tissues. Closed injuries are the result of blunt trauma to the head, which causes movement (intracranial acceleration or deceleration and rotational forces) and compression of brain tissue. Brain contusions are referred to as coup (occurring at the site of injury) or contra-coup (occurring on the side of the brain opposite the injury). Rating the severity of injury and eventual outcomes is important in medical management. Included below are ...

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