What is the appropriate management for a 17‑month‑old who fell onto a hard surface, struck his head, and is now vomiting?

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Last updated: September 23, 2026 • View editorial policy

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Management of 17-Month-Old with Head Trauma and Vomiting

This child requires immediate emergency department evaluation and head CT imaging. Based on PECARN criteria for children <2 years of age, vomiting after head trauma places this patient in the intermediate-risk category, and given the mechanism (fall onto hard floor), CT imaging is strongly recommended 1.

Risk Stratification Using PECARN Criteria

For children <2 years old, this patient falls into the intermediate-risk category because:

  • Vomiting is present after head trauma
  • The mechanism involves a fall onto a hard surface

The risk of clinically important traumatic brain injury in intermediate-risk patients is approximately 0.9% 1. While this may seem low, it is substantial enough to warrant imaging, particularly given:

  • The young age (17 months) makes clinical observation more challenging
  • Vomiting is a validated risk factor for intracranial injury
  • The hard floor impact represents a potentially severe mechanism

Immediate Management Algorithm

Step 1: Emergency Department Transport

  • Transport to ED immediately
  • Monitor for signs of deterioration during transport
  • Watch for altered mental status, seizures, or worsening vomiting

Step 2: Clinical Assessment in ED Evaluate for high-risk features that would mandate immediate CT:

  • Glasgow Coma Scale score (if <15, this becomes high-risk)
  • Palpable skull fracture
  • Altered mental status beyond normal post-traumatic behavior
  • Signs of basilar skull fracture
  • Loss of consciousness >5 seconds

Step 3: Imaging Decision

  • CT head without contrast is the appropriate imaging modality 1
  • CT provides rapid acquisition and excellent sensitivity for acute intracranial hemorrhage and fractures
  • Use pediatric-specific protocols with size-appropriate radiation dose reduction 1

Why CT is Recommended Despite Intermediate Risk

The guidelines support CT imaging in intermediate-risk patients when 1:

  • Parental preference for definitive evaluation exists
  • Multiple risk factors are present (vomiting + hard surface fall)
  • Observational assessment is challenging (as in young infants)
  • Clinical symptoms persist or worsen

Isolated vomiting (vomiting without other concerning features) carries a very low risk of clinically important traumatic brain injury (0.2%) 2. However, this case involves vomiting plus a significant mechanism (fall onto hard floor), which elevates concern.

Critical Pitfalls to Avoid

Do not use skull radiographs - they miss up to 50% of intracranial injuries and are insufficient for evaluation 1. Intracranial injury can occur without fracture.

Do not rely on observation alone in this age group with vomiting present. While observation may be appropriate for some intermediate-risk patients, the combination of young age (making assessment difficult) and vomiting warrants imaging 1.

Do not dismiss vomiting timing - vomiting that occurs >1 hour after meals tends to be more protracted and concerning than vomiting within 1 hour of eating 3. Document the timing relative to last meal.

If CT is Negative

  • Observe for 4-6 hours minimum
  • Monitor for persistent headache, continued vomiting, altered behavior, or seizures
  • Provide clear discharge instructions about warning signs
  • Arrange follow-up for post-concussive symptoms

If CT Shows Intracranial Injury

Even minor findings require:

  • Neurosurgical consultation
  • Admission for monitoring
  • Serial neurological assessments
  • Repeat imaging if clinical deterioration occurs 4

Special attention to epidural hematomas >10mm - these carry the highest risk of requiring emergency neurosurgery 4.

Observation Criteria if CT Deferred

If the clinical team and family opt for observation instead of immediate CT (acceptable in intermediate-risk with shared decision-making), admit and monitor for:

  • Worsening or persistent vomiting
  • Headache that doesn't improve
  • Altered mental status or behavior changes
  • Seizure activity
  • Bradycardia or other hemodynamic changes
  • Focal neurological deficits

Any of these warrant immediate CT imaging 4, 5.

The bottom line: At 17 months with vomiting after head trauma onto a hard surface, this child needs ED evaluation with strong consideration for CT imaging to rule out clinically important traumatic brain injury. The risk-benefit analysis favors imaging given the age, mechanism, and presence of vomiting as a validated risk factor 1.

References

1
Guideline

acr appropriateness criteria® head trauma-child.

Journal of the American College of Radiology, 2020

3
Research

Vomiting in children following head injury.

Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery, 1987

5
Research

Minor head injuries in children - an approach to management.

Australian family physician, 2010

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.