Management of Head Injury in a 3-Year-Old Child
Healthcare professionals should use validated clinical decision rules like the PECARN criteria to identify children with mild traumatic brain injury (mTBI) at low risk for intracranial injury (ICI) in whom head CT is not indicated, as well as children who may warrant head CT. 1
Initial Assessment and Risk Stratification
Primary Assessment
- Assess airway, breathing, and circulation
- Evaluate Glasgow Coma Scale (GCS) score
- Check for signs of increased intracranial pressure
- Evaluate for cervical spine injury
Risk Factors for Intracranial Injury
The following factors increase risk for clinically important intracranial injury:
- Vomiting
- Loss of consciousness
- Severe mechanism of injury
- Severe or worsening headache
- Amnesia
- Nonfrontal scalp hematoma
- GCS score less than 15
- Clinical suspicion for skull fracture 1
Diagnostic Imaging Decision-Making
When to Obtain Head CT
Head CT should not be routinely obtained for all children with head injuries but should be considered when:
- Child has GCS < 15
- Signs of altered mental status
- Palpable skull fracture
- History of vomiting (especially if persistent)
- Severe mechanism of injury (motor vehicle accident, fall from significant height)
- Loss of consciousness > 5 seconds
- Severe headache
- Abnormal behavior per parent 1
When CT Can Be Avoided
CT can be avoided in children who:
- Have normal mental status
- No loss of consciousness
- No vomiting
- No severe headache
- No signs of basilar skull fracture
- No concerning mechanism of injury 1
Management Based on Severity
Mild Head Injury (GCS 14-15)
- Observation for at least 4-6 hours
- Monitor vital signs, pupillary response, and neurological status
- Provide nonopioid analgesia (ibuprofen or acetaminophen) for headache 1
- Counsel family on signs of deterioration requiring return to medical care
- Consider discharge if symptoms improve and reliable caretakers are available 2
Moderate to Severe Head Injury (GCS ≤ 13)
- Immediate neuroimaging
- Maintain cervical spine precautions
- Consider transfer to pediatric trauma center or adult trauma center with pediatric expertise 1
- Maintain adequate cerebral perfusion pressure (CPP)
- For 3-year-olds, aim for CPP > 40 mmHg 1
- Treat increased intracranial pressure if present
- Consider mannitol 1-2 g/kg body weight over 30-60 minutes if indicated 3
Observation and Monitoring
Inpatient Observation Indications
- Abnormal CT findings
- Persistent vomiting or severe headache
- Deteriorating neurological status
- Seizures
- Multiple injuries
- Suspected non-accidental trauma
- Unreliable home situation for observation
Home Observation Criteria
- Normal neurological examination
- No concerning symptoms (vomiting, severe headache)
- Reliable caregivers who can monitor the child
- Clear discharge instructions provided
- Easy access to return for care if needed 2
Discharge Instructions
Warning Signs to Return to Medical Care
- Persistent vomiting
- Worsening headache
- Increased sleepiness or difficulty waking
- Seizures
- Unusual behavior
- Unequal pupils
- Weakness in arms or legs
- Difficulty walking or talking
Follow-up Care
- Ensure proper sleep hygiene to facilitate recovery 1
- Gradual return to normal activities as tolerated
- Follow-up with primary care provider within 1-2 weeks
Common Pitfalls and Caveats
Age-Related Considerations: Children under 2 years have higher risk of skull fractures and intracranial injuries even with minor trauma mechanisms. Although your patient is 3 years old, be aware that younger children require extra vigilance 4.
Radiation Risk: CT scans carry radiation risks that should be discussed with parents. Balance the risk of missing an intracranial injury against radiation exposure 1.
Sedation Risks: Some children require sedation for imaging, which carries additional risks 1.
Non-Accidental Trauma: Always consider the possibility of non-accidental trauma, especially when the history is inconsistent with the injury pattern 5.
Delayed Symptoms: Some children develop symptoms hours or days after the injury. Clear discharge instructions are essential 6.
Overreliance on Normal Examination: Even children with normal neurological examinations can have intracranial injuries, especially those under 12 months of age 4.