Head trauma (peds)

Background

  • Persistence of headache, confusion, and amnesia suggests concussion
  • Worsening of symptoms suggests intracranial injury
  • Scalp hematoma in <2yo is assoc w/ incr risk of skull fx, ICH
  • Clinical symptoms (headache, vomiting, behavior change) do not correlate well with ICH

Work-Up

Do I need to obtain a head CT based on the PECARN Rule?[1]

Rules below are according to the of PECARN Head CT Study[2]

<2 years old

PECARN Under Age 2

Any 1 of the following?

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?

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)[3]

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 fx w/o intracranial injury (in consultation w/ neurosx)

See Also

External Links

Source

  • Holmes et al. Do Children With Blunt Head Trauma and Normal Cranial CT Require Hospitalization for Neurologic Observation?, Annals of Emergency Medicine, vol 58, 2011
  1. Kupperman 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 374(9696): 1160, 2009
  2. PECARN Rule Kupperman 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 374(9696): 1160, 2009
  3. Dayan PS, et al. "Association of Traumatic Brain Injuries with Vomiting in Children with Blunt Head Trauma. June 2014. Annals of EM. 63(6):657-665