What to assess in a pediatric patient with a head injury?

Assessment of Pediatric Head Injury

Use the PECARN (Pediatric Emergency Care Applied Research Network) criteria to stratify risk and guide imaging decisions in children with head trauma, as this validated approach minimizes unnecessary radiation while identifying clinically important injuries. 1, 2

Initial Clinical Assessment by Age Group

Children ≥2 Years Old

High-Risk Features (4.3% risk of clinically important injury): 1

• Glasgow Coma Scale (GCS) score of 14
• Any signs of altered mental status
• Signs of basilar skull fracture (hemotympanum, periorbital ecchymosis, Battle's sign, CSF otorrhea/rhinorrhea)

Intermediate-Risk Features (0.8% risk): 1

• GCS of 15 with normal mental status but:
  • History of loss of consciousness
  • Vomiting
  • Severe mechanism of injury (high-speed motor vehicle collision, fall from significant height)
  • Severe headache

Very Low Risk: 2

• GCS 15, normal mental status, stable vital signs
• No loss of consciousness
• No concerning mechanism
• Normal behavior

Children <2 Years Old

High-Risk Features (4.4% risk of clinically important injury): 1

• GCS score of 14
• Any signs of altered mental status
• Any palpable skull fracture

Intermediate-Risk Features (0.9% risk): 1

• GCS of 15 with normal mental status but:
  • Loss of consciousness >5 seconds
  • Severe mechanism of injury
  • Not acting normally per parent
  • Nonfrontal scalp hematoma

Critical Point: Children <12 months have the highest incidence of skull fracture/intracranial injury (29%) compared to 13-24 months (4%), making this age group particularly high-risk. 3

Imaging Decisions

When CT Head is Strongly Recommended

Immediate non-contrast CT for: 1

• All high-risk patients (GCS ≤14, altered mental status, basilar skull fracture signs, palpable skull fracture in infants)
• Moderate-to-severe head trauma (GCS ≤13)
• Severe headache with other risk factors or worsening headache 1
• Any neurologic deterioration during observation 1

When Observation May Replace CT

For intermediate-risk patients, observation is acceptable unless: 1

• Parental preference for imaging
• Multiple risk factors present
• Worsening symptoms during observation
• Young infant where observational assessment is challenging

Imaging Modality Selection

CT is first-line because: 1

• Rapid acquisition (critical for unstable patients)
• Excellent sensitivity for acute hemorrhage and fractures
• No sedation required

Skull radiographs should NOT be used - they miss up to 50% of intracranial injuries and cannot evaluate brain parenchyma. 1

MRI considerations: 1

• More sensitive than CT for detecting traumatic lesions
• Particularly useful in suspected non-accidental trauma to identify multiple injuries of varying ages 1
• Impractical acutely due to length of exam, need for sedation in young children, and delayed results
• Should not delay CT in symptomatic children 1

Red Flag Symptoms Requiring Immediate Evaluation

Instruct caregivers to return immediately for: 2

• Persistent or worsening vomiting
• Increasing drowsiness or difficulty arousing
• Seizure activity
• Worsening or severe headache
• New neurological symptoms (weakness, vision changes, slurred speech)
• Unsteady gait
• Unequal pupil size
• Behavioral changes or irritability

Special Considerations

Non-Accidental Trauma (Suspected Abuse)

Maintain low threshold for neuroimaging in: 1

• Children <1 year with any concerning findings
• Any child with unexplained injuries or inconsistent history
• Consider MRI brain AND cervical spine (unsuspected spinal injuries in >36% of cases) 1
• Subdural hematoma (especially bilateral, interhemispheric, or posterior fossa) is most common finding 1

Vascular Injury Assessment

CTA is NOT routine but consider if: 1

• Basilar skull fracture through vascular canal
• Clinical signs of arterial stroke
• Unexplained neurologic deficits

Vascular injuries are uncommon in pediatric minor head trauma and primarily cervical rather than intracranial. 1

Common Pitfalls to Avoid

• Don't rely on mechanism alone: 7% of complications occur from falls ≤3 feet. 3
• Don't assume normal behavior excludes injury: 92% of children with isolated skull fractures and 75% with intracranial injury had normal consciousness and non-focal exams at diagnosis. 3
• Don't use clinical symptoms as sole predictors: 62% of children with skull fractures and 58% with intracranial injury had no loss of consciousness, vomiting, seizure, or behavioral change. 3
• Location matters: Nonfrontal scalp hematomas carry higher risk than frontal hematomas in infants. 2

Discharge Instructions

For low-risk patients discharged without imaging, provide: 1

• Written warning signs of serious injury
• Description of expected symptom course
• Instructions for monitoring postconcussive symptoms
• Guidance on cognitive and physical rest (24-48 hours relative rest initially) 1
• Clear follow-up instructions
• Prevention counseling