What are the next steps for a 2-year-old who hit the back of their head, vomited once, and is now trying to sleep in an urgent care setting at 8:00 PM?

Immediate Management of 2-Year-Old with Head Trauma, Single Vomiting Episode, and Drowsiness

This child requires immediate neurological assessment using PECARN criteria to determine if CT imaging is needed, but isolated vomiting alone does not mandate immediate CT scanning in a neurologically normal child. 1

Risk Stratification Using PECARN Criteria

For children <2 years of age, assess the following high-risk features 1:

• Glasgow Coma Scale score - Must be 15 for low-risk classification 1
• Altered mental status - Any confusion, somnolence beyond normal sleepiness, or inability to recognize parents 1
• Palpable skull fracture - Physical examination of entire scalp 1
• Loss of consciousness >5 seconds - Obtain detailed history from witnesses 1
• Severe mechanism of injury - Motor vehicle crash, fall >3 feet, or struck by high-impact object 1
• Not acting normally per parents - This is critical in toddlers 1

If ANY of these features are present, the child is NOT very low risk and requires CT head within 1 hour. 1

Critical Assessment of "Trying to Sleep"

The phrase "trying to go to sleep" at 8:00 PM requires careful distinction 1:

• Normal bedtime drowsiness - If this is the child's typical bedtime and behavior is otherwise normal, this may be physiologic 2
• Pathologic altered mental status - Inability to stay awake when stimulated, confusion, or somnolence beyond what parents consider normal requires immediate CT 1

Ask parents directly: "Is this different from how your child normally acts at bedtime?" This single question is validated as a PECARN predictor. 1

Vomiting After Head Trauma: Evidence-Based Context

Single episode of vomiting has specific risk implications 3:

• Isolated vomiting (without other PECARN predictors) carries only 0.3% risk of clinically important traumatic brain injury and 0.6% risk of any CT-detected injury 3
• Vomiting is actually more common after minor head injuries than severe ones 2
• Vomiting within 1 hour of eating is physiologic in 72% of cases and typically resolves within 3 hours 2
• Vomiting alone does NOT require CT imaging within 1 hour unless accompanied by other PECARN risk factors 1, 3

Immediate Action Algorithm

Step 1: Complete Neurological Examination (Next 5 Minutes)

• GCS score - must document all three components 1
• Mental status - is child interactive, recognizes parents, consolable? 1
• Palpate entire scalp for step-off deformity or boggy hematoma 1
• Assess for signs of basilar skull fracture (hemotympanum, Battle sign, raccoon eyes, CSF rhinorrhea/otorrhea) 1

Step 2: Detailed History from Parents

• Exact mechanism - height of fall, surface landed on, witnessed impact 1
• Duration of any loss of consciousness 1
• Time of last meal relative to injury 2
• Number of vomiting episodes and timing 3
• "Is your child acting normally for this time of day?" 1

Step 3: Decision Point

If child has GCS 15, normal mental status for bedtime, no palpable fracture, no LOC >5 seconds, minor mechanism, and parents report normal behavior:

• This is PECARN very low risk 1
• CT is NOT indicated 1
• Proceed to observation protocol 1

If ANY PECARN risk factor is present:

• Obtain non-contrast CT head immediately 1
• Do not delay for observation 1

Observation Protocol for Low-Risk Patients

Home observation with frequent waking is NOT supported by evidence and is NOT recommended. 1

Instead, provide written and verbal discharge instructions to return immediately for 1:

• Repeated vomiting (more than 1-2 additional episodes) 1
• Worsening headache 1
• Confusion or memory problems 1
• Abnormal behavior beyond what parents consider normal 1
• Increased sleepiness or inability to wake 1
• Seizures 1
• Focal neurological deficits 1

Management of Vomiting Itself

If child continues to vomit and requires symptomatic treatment 4:

• Ondansetron is safe in head-injured children who have had CT or meet very low-risk criteria 4
• Does not mask serious injury 4
• Reduces return visits to emergency department 4
• Do NOT withhold antiemetics due to unfounded concerns about masking pathology 4

Critical Pitfalls to Avoid

• Do not assume all drowsiness at 8:00 PM is pathologic - distinguish normal bedtime behavior from altered mental status by asking parents if this is typical 1, 2
• Do not order CT for isolated vomiting alone - this has extremely low yield (0.3% ciTBI rate) and exposes child to unnecessary radiation 3
• Do not rely on "observation" protocols with frequent waking - these are not evidence-based and create false reassurance 1
• Do not discharge without written instructions at 6th-7th grade reading level given to both parents and verbally reviewed 1
• Do not miss non-accidental trauma - assess for mechanism inconsistent with developmental stage or injury pattern 1