Trauma may occur on the cellular or global level. In the context of multisystem trauma, a hypovolemic state may create insufficient cerebral perfusion. Such hypovolemic states may be created by other "traumatic" insults, such as primary peritonitis or ruptured appendicitis with hypovolemia. Children may have transient loss of consciousness after closed head injury. Occasionally, a seizure may occur immediately after closed head injury, resulting in AMS from the postictal state. The signs and symptoms of acute epidural hematoma are typically posttraumatic loss of consciousness followed by a lucid interval and then rapid AMS. Acute epidural hematoma can also present with a gradual loss of consciousness associated with ipsilateral pupillary dilatation. As in adults, subdural hematomas may be acute, subacute, or chronic. Most children with subdural hematomas have external signs of trauma. The exceptions are abused infants, typically less than 6 months of age, who may present without external signs of injury. Abused children who are shaken typically present with a history of vomiting, seizures, and changes in respiratory pattern associated with AMS. Retinal hemorrhages or a tense fontanel may suggest the diagnosis. Children with blunt head trauma are more inclined than adults to develop diffuse cerebral swelling, increased intracranial pressure, and AMS without extracerebral or intracerebral collections of blood. While uncommon in childhood, cerebrovascular accidents, including bleeding from arteriovenous malformations, may cause focal neurologic deficits followed by status epilepticus and coma.
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