Head trauma (peds)

(Redirected from Pediatric head trauma)

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


  • 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[1]
  • 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[2][3]

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


  • 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

Differential Diagnosis

Head trauma



Rules below are according to the of PECARN Head CT Study[4]

<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)[5]


Dependent on diagnosis, see:


  • 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



External Links


  1. Elkhunovich, M., Sirody, J., McCormick, T., Goodarzian, F., & Claudius, I. (2018). The Utility of Cranial Ultrasound for Detection of Intracranial Hemorrhage in Infants. Pediatric Emergency Care, 34(2), 96–101.
  2. Holmes JF, Palchak MJ, MacFarlane T, et al. Performance of the pediatric glasgow coma scale in children with blunt head trauma. Acad Emerg Med. 2005 Sep;12(9):814-9.
  3. James HE. Neurologic evaluation and support in the child with an acute brain insult. Pediatr Ann. 1986 Jan;15(1):16-22.
  4. 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
  5. 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