What is the management for a 6-month-old infant with a Glasgow Coma Scale (GCS) score of 15 and supraorbital swelling after a fall from 3 feet onto a tiled floor?

Management of Supraorbital Swelling in a 6-Month-Old After a Fall

For a 6-month-old infant with normal Glasgow Coma Scale (GCS) score and supraorbital swelling after a fall from 3 feet onto a tiled floor, observation at home with appropriate caregiver instructions is recommended rather than routine CT imaging.

Initial Assessment

Clinical Evaluation

• GCS Assessment: A normal GCS (15) is reassuring but not sufficient alone to rule out injury in infants
• Examination of the Swelling:
  • Assess for underlying bony step-offs or crepitus that might suggest fracture
  • Evaluate pupillary size and reactivity
  • Check for other signs of trauma (bruising elsewhere, retinal hemorrhages)

Risk Stratification Using PECARN Criteria

For children <2 years old, the PECARN criteria provide excellent guidance 1, 2:

• Very Low Risk (observation appropriate):

  • Normal mental status
  • No loss of consciousness
  • Non-severe injury mechanism
  • No palpable skull fracture

• Intermediate/High Risk (imaging warranted):

  • Abnormal mental status
  • Scalp hematoma (especially if non-frontal)
  • Loss of consciousness ≥5 seconds
  • Severe injury mechanism
  • Not acting normally per parents

Management Decision

When CT Imaging Is Indicated

CT imaging should be considered if ANY of the following are present 1:

• Altered mental status or GCS <15
• Palpable skull fracture
• Vomiting (especially persistent)
• Loss of consciousness
• Severe mechanism of injury (higher than 3 feet fall)
• Not acting normally according to parents
• Signs of basilar skull fracture

When Observation Is Appropriate

If the infant meets all PECARN very low-risk criteria:

• Normal mental status
• No loss of consciousness
• Non-severe injury mechanism (3-foot fall is borderline)
• No palpable skull fracture
• Acting normally according to parents

Observation Protocol

If observation is chosen 2:

1. Monitor for 4-6 hours either in a healthcare setting or at home with reliable caregivers
2. Assess for:
   • No deterioration in neurological status
   • No development of concerning symptoms (vomiting, irritability)
   • Normal behavior according to parents

Discharge Instructions

Provide clear instructions to return if the infant develops 2:

• Persistent vomiting
• Excessive sleepiness or difficulty waking
• Unusual behavior or confusion
• Seizures
• Weakness in arms or legs
• Worsening swelling or bruising

Special Considerations

• Age Factor: Infants under 12 months have higher risk of clinically significant traumatic brain injury even with minor mechanisms 1, 2
• Supraorbital Location: While non-frontal hematomas carry higher risk, the supraorbital location warrants careful examination to rule out orbital fracture 1
• Radiation Risk: CT imaging carries radiation risks that must be balanced against the low probability of clinically important traumatic brain injury in very low-risk patients 1

Follow-up

Schedule follow-up within 24-48 hours to reassess the swelling and ensure appropriate resolution if managed with observation.