Guidelines for Evaluating and Managing Pediatric Falls
The evaluation and management of pediatric patients after a fall should follow a systematic, trauma-informed approach that prioritizes injury severity assessment, appropriate imaging decisions, and comprehensive follow-up care rather than relying solely on fall height as a triage criterion.
Initial Assessment and Triage
Do not use fall height alone to determine injury severity or triage urgency. Research demonstrates that children suffering low-level falls (<15 feet) face similar risks for intracranial and abdominal injuries compared to those falling from greater heights 1. The mortality rate for low-level falls (1.0%) approaches that of high-level falls (2.4%), with all deaths from low-level falls attributable to intracranial injuries with abnormal head CT findings 1.
Scene Safety and Primary Survey
Begin with verification of scene safety, then assess:
- Responsiveness: Check if the child responds to voice or touch
- Breathing and circulation: Look for normal breathing versus gasping; check pulse within 10 seconds
- Neurological status: Level of consciousness, pupillary response, focal deficits 2
Critical Decision Points
If the child is unresponsive with no breathing or only gasping and no pulse:
- Activate emergency response immediately
- Begin CPR with 30 compressions to 2 breaths (single rescuer) or 15:2 ratio when second rescuer arrives
- Use AED as soon as available 2
If the child has a pulse but heart rate <60/min with signs of poor perfusion:
- Start CPR immediately 2
Injury-Specific Evaluation
Head Trauma Assessment
For acute head trauma, conduct a focused neurological examination looking for:
- Altered mental status or loss of consciousness
- Persistent vomiting
- Severe or worsening headache
- Seizure activity
- Focal neurological deficits
- Signs of skull fracture (Battle sign, raccoon eyes, hemotympanum, CSF leak)
Imaging decisions should be based on clinical presentation, not fall height alone 3. The vast majority of pediatric head trauma cases are mild and require no imaging, but identify high-risk features that warrant CT evaluation.
Extracranial Injuries
Systematically assess for:
- Orthopedic injuries: Upper extremity fractures (6.2% incidence), lower extremity fractures (5.6%) - more common with high-level falls 1
- Thoracic injuries: Pulmonary contusion (1.8%), pneumothorax (1.1%) - associated with high-level falls 1
- Abdominal injuries: Liver laceration (1.1%), splenic injury (2.1%), bowel injury (1.0%) - occur equally in low and high-level falls 1
Key clinical pitfall: Abdominal injuries occur with equal frequency regardless of fall height, so maintain high suspicion even for seemingly minor falls 1.
Observation and Disposition
Emergency Department Management
For mild traumatic brain injury without high-risk features:
- Observe for minimum 4-6 hours for symptom development
- Provide standardized discharge instructions focusing on expected symptoms and red flags requiring return
- Include specific guidance on when to seek further medical attention 4
Discharge instructions must address:
- Expected symptom progression
- Return precautions (persistent vomiting, worsening headache, altered consciousness, seizures)
- Activity restrictions and return-to-sports guidelines
- Injury prevention strategies 4
Hospital Admission Criteria
Admit for:
- Abnormal neurological examination
- Intracranial injury on imaging
- Persistent altered mental status
- Inability to tolerate oral intake
- Concern for inadequate home observation
- Significant extracranial injuries requiring monitoring
Psychosocial Considerations
Abuse Evaluation
All providers must evaluate for potential abuse when assessing injured children 5, 6. However, recognize that CPS referrals after unintentional falls are appropriately associated with injury severity and fall characteristics rather than demographic factors 7.
Indicators warranting abuse consideration:
- Injury inconsistent with developmental stage
- Changing or inconsistent history
- Delay in seeking care
- Pattern of repeated injuries
- Behavioral indicators in the child
Report concerns to appropriate authorities equitably across all demographics 5.
Mental Health Support
Screen for stress reactions related to injury in both the child and family 6. Optimal recovery requires a trauma-informed approach with:
- Assessment of pre-injury mental health history
- Screening for post-traumatic stress symptoms
- Provision of appropriate psychological resources tailored to individual needs 5
- Early identification of patients at risk for prolonged recovery 8
Follow-Up and Rehabilitation
Concussion Management
For diagnosed concussion, implement a biopsychosocial approach:
- Provide early education about expected recovery (most recover within typical windows)
- Develop individualized management plans based on pre-concussion history
- Coordinate multidisciplinary care for patients at risk of prolonged symptoms 8
- Avoid prolonged strict rest; encourage gradual return to activity as tolerated
Comprehensive Rehabilitation
For children with significant injuries requiring rehabilitation:
- Ensure access to pediatric-specific physical, occupational, cognitive, and speech therapy
- Provide trauma-informed psychological and social supports
- Begin rehabilitation during the inpatient phase when possible 5
- Coordinate long-term follow-up to support successful community reintegration
System-Level Considerations
Emergency departments should maintain pediatric readiness with providers competent in pediatric trauma evaluation and management 5, 6. Non-pediatric centers must be capable of initial stabilization and appropriate transfer to specialized pediatric trauma centers when indicated 6.
Common pitfall: Assuming low-level falls are uniformly low-risk. Maintain appropriate vigilance regardless of reported fall height, as injury severity depends on mechanism, landing surface, and patient factors rather than height alone 1.