What testing should be ordered for a 1.5-year-old child with head trauma and symptoms of dizziness?

Head Trauma Assessment in a 1.5-Year-Old with Dizziness

Apply the PECARN criteria to determine if this child needs a CT scan—most children with minor head trauma and dizziness do not require imaging if they meet very low-risk criteria. 1

Risk Stratification Using PECARN Criteria

For a 1.5-year-old child (under 2 years), you must assess the following high-risk and intermediate-risk features to guide your imaging decision 2:

High-Risk Features (CT Head Required)

• Glasgow Coma Scale (GCS) score of 14 or less 2
• Any signs of altered mental status beyond baseline 2
• Any palpable skull fracture 2
• Risk of clinically important injury: 4.4% 1

Intermediate-Risk Features (Consider CT or Observation)

• GCS of 15 with normal mental status BUT any of: 2
  • Loss of consciousness >5 seconds 2
  • Severe mechanism of injury (high-speed MVC, fall from significant height) 2
  • Not acting normally per parent 2
• Risk of clinically important injury: 0.9% 1

Very Low-Risk Features (No Imaging Needed)

• GCS of 15 2
• No palpable skull fracture 2
• No nonfrontal scalp hematoma 2
• Loss of consciousness <5 seconds or none 2
• No severe mechanism of injury 2
• Acting normally per parents 2
• Risk of clinically important injury: <0.02% 2

Specific Approach to Dizziness

Dizziness alone does not automatically warrant imaging in a 1.5-year-old if other PECARN criteria are favorable. 3, 4 The key is determining whether the child meets high-risk or intermediate-risk criteria based on the factors above, not the dizziness symptom itself.

If High-Risk: Order CT Head Without Contrast

• CT head without IV contrast is the appropriate initial test 2
• Provides rapid assessment for intracranial hemorrhage and skull fractures 5
• No sedation required, unlike MRI 2
• Sensitivity for acute hemorrhage is excellent 5

If Intermediate-Risk: Clinical Decision Required

You have two options: 2

• Option 1: Careful clinical observation for 4-6 hours with serial neurologic assessments 2
• Option 2: CT head without contrast if: 2
  • Parental preference for imaging
  • Multiple intermediate-risk factors present
  • Worsening symptoms during observation
  • Difficulty assessing a young infant clinically

If Very Low-Risk: No Imaging

Do not order any imaging studies 2, 1—the PECARN criteria have 100% negative predictive value and 100% sensitivity in children under 2 years for this category 2

What NOT to Order

• Skull radiographs: Miss up to 50% of intracranial injuries and cannot evaluate brain parenchyma 2, 1
• MRI in acute setting: Impractical due to length of exam, need for sedation, and delay in diagnosis 2, 5
• CTA/MRA: Not indicated unless basilar skull fracture through vascular canal or unexplained neurologic deficits are present 1

Critical Pitfall to Avoid

Do not assume dizziness equals intracranial injury. Post-traumatic dizziness is common after head trauma and frequently has a benign peripheral vestibular cause (benign paroxysmal positional vertigo, labyrinthine concussion) rather than intracranial pathology 3, 6, 4. The decision to image should be based on PECARN risk stratification, not the presence of dizziness alone 2, 1.

Discharge Instructions if No Imaging Performed

Provide written instructions to parents about warning signs requiring immediate return 1:

• Persistent or worsening vomiting 1
• Increasing drowsiness or difficulty waking 1
• Seizure activity 1
• Worsening headache 1
• New neurological symptoms (weakness, vision changes, unequal pupils) 1
• Changes in behavior or irritability 1