Head trauma (peds)

This page is for pediatric patients. For adult patients, see: head trauma (main)

Background

• TBI in the pediatric population is rare, occuring in 0.9% of the 42,412 PECARN population
• The primary ED question is whether or not to perform a head CT to assess for intracranial hemorrhage
  • Cranial ultrasound is a poor screening tool for bleeding
• The PECARN rule has become standard of care to determine which patients need CT imaging
  • In patients <2 yrs the aid is 100% sensitive with NPV of 100%
  • In patient >2 yrs the aid is 96.8% sensitive with NPV of 99.95% (with validation studies showing sensitivity of 100% for TBI and injury requiring neurosurgery

Pediatric GCS

Eye Opening	Verbal	Motor
		6: Normal spontaneous movement
	5: Smiles, coos, babbles	5: Withdraws to touch
4: Opens eyes spontaneously	4: Irritable, crying (but consolable)	4: Withdraws to pain
3: Opens eyes to speech only	3:Inconsolable crying or crying only in response to pain	3: Abnormal flexion to pain (Decorticate response)
2: Opens eyes to pain only	2: Moans in response to pain	2: Abnormal extension to pain (Decerebrate response)
1: Does not open eyes	1: No response	1: No response

Note:

• For Motor score 4, pain is defined flat, fingernail pressure (often performed with the barrel of a pencil).
• For Motor scores 2 and 3, pain is defined by pressing hard on the supraorbital notch. If this unsuccessful, sternal pressure may also be attempted.

Clinical Features

• Persistence of headache, confusion, and amnesia suggests concussion
• Nonfrontal scalp hematoma in <2yo is associated with increased risk of Skull Fracture, ICH
• Clinical symptoms (headache, vomiting, behavior change) do not correlate well with ICH

Differential Diagnosis

Head trauma

• Traumatic brain injury
  • Intracranial hemorrhage
    • Intra-axial
      • Traumatic intracerebral hemorrhage
    • Extra-axial
      • Epidural hemorrhage
      • Subdural hemorrhage
      • Subarachnoid hemorrhage
  • Moderate-to-severe traumatic brain injury
    • Elevated intracranial pressure
  • Mild traumatic brain injury
    • Clinical decision rules for head CT in trauma
    • Post-concussive syndrome
• Orbital trauma
• Maxillofacial trauma
• Scalp laceration
• Skull fracture
  • Basilar skull fracture
  • Skull fracture (peds)
• Pediatric head trauma
  • PECARN head trauma rule

Evaluation

Work-Up

Rules below are according to the of PECARN Head CT Study

<2 years old

PECARN Under Age 2

Any 1 of the following?

• GCS ≤14
• Altered Mental Status
• Palpable Skull Fracture

Then obtain a Non-Con Brain CT (4.4% risk of cTBI)

1 or more of the following?

• Non-frontal scalp hematoma
• LOC ≥ 5 seconds
• Severe injury mechanism
  • pedestrian or bicyclist without helmet struck by motorized vehicle
  • fall >1m or 3ft
  • head struck by high-impact object
• Abnormal activity per parents

Then consider a Non-Con Brain CT or Observation (0.9% risk of cTBI)

≥2 years old - 18 years

PECARN Age 2 and Up

Any 1 of the following?

• GCS ≤14
• Altered Mental Status
• Signs of a basilar skull fracture

Then obtain a Non-Con Brain CT (4.3% risk of cTBI)

1 or more of the following?

• History of vomiting^
• LOC
• Severe injury mechanism
  • Pedestrian or bicyclist without helmet struck by motorized vehicle
  • Fall >2m or 5ft
  • Head struck by high-impact object
• Severe headache

Then consider a Non-Con Brain CT or Observation (0.9% risk of cTBI)

^Consider observation in place of imaging in children with isolated vomiting (no other indication) as the sole risk factor (0.2% risk of cTBI)

Management

Dependent on diagnosis, see:

• Post-concussive syndrome
• Intracranial hemorrhage
• Moderate-to-severe traumatic brain injury
  • Elevated intracranial pressure
• Mild traumatic brain injury

Disposition

• Discharge if:
  • Asymptomatic after 2-4hr obs (not vomiting, nl neuro exam, nl mental status)
  • Head CT normal (delayed deterioration after normal CT is near zero)
• Consider discharge if:
  • Nondisplaced fracture with out intracranial injury (in consultation with neurosx)

See Also

General/Adult

• Head Trauma (Main)
• Concussion
• Skull Fracture
• Maxillofacial Trauma
• C-spine (NEXUS)

Pediatric

• C-spine (peds)
• Abuse (Nonaccidental Trauma)
• GCS (Peds)
• EBQ:PECARN Pediatric Head CT Rule
• Differential diagnosis documentation#Head Trauma

External Links

• MDCalc - PECARN Head Rule