From the Guidelines
Children who have experienced a fall with head impact should undergo a computed tomography (CT) scan of the head if they exhibit any high-risk factors for clinically significant traumatic brain injury, as identified by the PECARN criteria, including altered mental status, signs of basilar skull fracture, or severe mechanism of injury. The decision to perform a CT scan is guided by the need to balance the risk of missing a significant injury against the concerns of radiation exposure, particularly in children whose developing brains are more sensitive to radiation effects 1.
Key Considerations for CT Scan
- Age younger than 2 years
- Vomiting
- Loss of consciousness
- Severe mechanism of injury
- Severe or worsening headache
- Amnesia
- Nonfrontal scalp hematoma
- Glasgow Coma Scale score less than 15
- Clinical suspicion for skull fracture
According to the most recent and highest quality study, CT head without IV contrast is usually appropriate for the initial imaging of children with minor acute blunt head trauma (excluding suspected abusive head trauma) with high risk for clinically important brain injury per PECARN criteria 1. The PECARN decision rules are validated clinical decision tools that help identify children at low risk for intracranial injury (ICI) in whom head CT is not indicated, as well as those who may be at higher risk for clinically important ICI and thus may warrant head CT 1.
Special Considerations
- Children under 2 years require special consideration due to their inability to communicate symptoms clearly.
- Observation may be appropriate for mild injuries without concerning features.
- Clinical decision rules like PECARN help guide these decisions, aiming to identify injuries requiring intervention while minimizing unnecessary radiation exposure.
From the Research
Guidelines for CT Scan of the Head in Pediatric Patients
The decision to perform a computed tomography (CT) scan of the head in pediatric patients after a fall with head impact depends on various factors, including the severity of the injury, clinical presentation, and risk of intracranial injury.
- The Pediatric Emergency Care Applied Research Network clinical decision rule for CT scans can help identify children at high risk of intracranial injury 2.
- Children with mild head injury (Glasgow Coma Scale (GCS) 15-13) may not require immediate CT scan, but those with severe head injury (GCS <12) or multiple trauma should undergo immediate cranial CT scan and hospitalization 3.
- Clinical features such as loss of consciousness, amnesia, Glasgow Coma Scale less than 15, and focal neurological deficits can indicate a higher risk of intracranial injury 4.
- A skull x-ray scan may be recommended for children younger than 2 years of age if a skull fracture is suspected, and the presence and type of skull fracture can determine if a CT scan of the head and consultation with a neurosurgeon is warranted 2.
Indications for Head CT Scan
The following indications for head CT scan have been identified:
- Abnormal examination findings, including depressed skull fracture and base of skull fracture 5.
- Concerning mechanism of injury, such as a fall greater than 3 feet or five stairs 5.
- Clinical features such as loss of consciousness, amnesia, Glasgow Coma Scale less than 15, and focal neurological deficits 4.
- Severe head injury (GCS <12) or multiple trauma 3.
Clinical Decision Rules
Several clinical decision rules, including CATCH, CHALICE, and PECARN, have been developed to guide the decision to perform a head CT scan in pediatric patients with head injury 5.
- These rules can help identify children at high risk of intracranial injury and reduce unnecessary CT scans.
- However, physician-reported CT triggers may differ from clinical decision rule-recommended triggers, highlighting the need for prospective validation of these rules in different settings 5.