What is the appropriate emergency management for a 20‑month‑old child who fell from 1–3 steps, vomited, has a history of vomiting when upset, and is alert and able to breastfeed?

Emergency Management: Observation Without Routine Head CT

For this 20-month-old with a low-height fall (1-3 steps), isolated vomiting with a known history of vomiting when crying, and who is alert, consolable, and breastfeeding normally, routine head CT is not indicated—close observation at home with clear return precautions is appropriate 1.

Risk Stratification Using PECARN Criteria

Apply the validated PECARN clinical decision rule to assess risk for intracranial injury (ICI) 1:

Risk factors present in this child:

• Age < 2 years (yes)
• Vomiting (yes)

Risk factors ABSENT:

• Loss of consciousness (no)
• Severe mechanism of injury (no—1-3 steps is minor)
• Severe or worsening headache (cannot assess but child consolable)
• Glasgow Coma Scale < 15 (no—child alert, interactive)
• Nonfrontal scalp hematoma (not mentioned)
• Clinical suspicion for skull fracture (not mentioned)

Clinical Context: Vomiting After Minor Head Injury

The vomiting in this case is likely benign because 2:

• Post-traumatic emesis is more common after minor head injuries than severe ones
• Vomiting occurs more frequently in children > 2 years, but this child has a documented history of vomiting while crying
• The child is neurologically stable (consolable, breastfeeding, responding appropriately)

Critical distinction: This child's vomiting pattern fits their baseline behavior when upset, not necessarily indicating ICI.

Management Algorithm

Immediate assessment:

1. Confirm GCS 15 (alert, consolable, age-appropriate interaction)
2. Examine for scalp hematomas (especially non-frontal), palpable skull deformity
3. Assess mechanism: 1-3 steps = low-risk mechanism
4. Document neurologic baseline

Decision pathway:

• If all high-risk features absent (as in this case): No head CT indicated 1
• If isolated vomiting only risk factor: Observation appropriate, especially with history of vomiting when upset 2
• If multiple risk factors or concerning exam: Consider head CT after discussing radiation risks with family 1

Disposition: Home Observation

Discharge home is appropriate with:

• Written head injury precautions
• Return immediately if: persistent/worsening vomiting, altered mental status, severe headache, seizure, weakness, vision changes, or increasing irritability
• Follow-up within 24 hours

Rationale: Up to 7.5% of children with mTBI have ICI, but this child has minimal risk factors and normal neurologic examination 1. The majority of infants with minor head trauma can be safely discharged home 3.

Common Pitfalls to Avoid

• Don't over-image based on vomiting alone, especially when the child has a known history of vomiting with crying 1, 2
• Don't dismiss the fall entirely—ensure parents understand return precautions
• Don't forget to discuss radiation risks if CT is being considered 1
• Consider non-accidental trauma in any infant head injury, but witnessed low-height falls with appropriate history are typically accidental

The key here is that vomiting after minor head injury in children under 2 is common and often benign, particularly when the child remains neurologically intact and has a behavioral explanation for the vomiting 2.