What is the evaluation and management of a head injury in an 8-month-old?

Evaluation of Head Injury in an 8-Month-Old

For an 8-month-old with head injury, use the PECARN criteria to determine if CT imaging is needed: obtain immediate non-contrast head CT if the infant has GCS ≤14, altered mental status, or palpable skull fracture; otherwise, the infant can be safely observed without imaging if they have GCS 15, normal mental status, no palpable skull fracture, no nonfrontal scalp hematoma, loss of consciousness ≤5 seconds, and are acting normally per parents. 1, 2

Risk Stratification Using PECARN Criteria

Very Low Risk (No Imaging Required):

• GCS = 15 with normal mental status 1, 2
• No palpable skull fracture 1, 2
• No nonfrontal scalp hematoma (forehead hematomas are lower risk) 1
• Loss of consciousness ≤5 seconds 1, 2
• Acting normally per parents 1, 2
• Stable vital signs 1

Risk of clinically important traumatic brain injury in this group is <0.02% 2

Intermediate Risk (CT or Careful Observation):

• GCS 15 with normal mental status BUT any of: 1, 2
  • Loss of consciousness >5 seconds 1, 2
  • Not acting normally per parent 1, 2
  • Nonfrontal scalp hematoma 1
  • Severe mechanism of injury (high-speed motor vehicle accident, fall from significant height) 1

Risk of clinically important injury in this group is 0.9% 1, 2

High Risk (Immediate CT Required):

• GCS ≤14 1, 2
• Signs of altered mental status 1, 2
• Palpable skull fracture 1, 2

Risk of clinically important injury in this group is 4.4% 1

Imaging Approach

CT is the first-line imaging modality because:

• Rapid acquisition without sedation 1
• Excellent sensitivity for acute hemorrhage and fractures 1
• Superior to skull radiographs, which miss up to 50% of intracranial injuries 1

Do not use skull radiographs - they have only 63% sensitivity for skull fractures, cannot detect intracranial injuries like hemorrhage or edema, and still expose the infant to radiation 3, 1

MRI considerations:

• More sensitive than CT for detecting traumatic lesions 1
• Particularly useful in suspected non-accidental trauma 1
• Impractical acutely due to length of exam and need for sedation in infants 1

Special Considerations for Infants <1 Year

Maintain a low threshold for neuroimaging in this age group because:

• Children <12 months can have significant intracranial injury without obvious signs or symptoms 3
• 29% of abused children without clinical suspicion of intracranial injury had positive neuroimaging 3
• Nearly all children with occult head injury were <1 year of age 3

Consider non-accidental trauma if:

• Unexplained injuries or inconsistent history 1
• Multiple fractures without overt trauma 3
• Femoral fractures in a non-walking infant 3
• Unexplained humeral fractures 3

Observation and Discharge Criteria

Infants with negative CT and normal neurologic exam can be safely discharged with negative predictive value of 100% for neurologic deterioration requiring surgery 2

Hospitalization required for:

• Positive CT findings showing intracranial injury 2
• Abnormal neurologic examination 2
• Patients on anticoagulation or antiplatelet therapy 2

Discharge Instructions (Written and Verbal)

Provide education about warning signs requiring immediate return:

• Persistent vomiting 1, 2
• Increasing drowsiness or excessive sleepiness 1, 2
• Seizure activity 1, 2
• Worsening headache 1, 2
• Changes in behavior or irritability 1, 2
• Unsteady movements 1
• Unequal pupil size 1

Additional counseling should include:

• Expected course of symptoms and recovery 3, 1
• Instructions for monitoring postconcussive symptoms 3, 1
• Prevention of further injury 3
• Clear follow-up instructions 3, 1

Critical timing consideration: 18% of patients who deteriorate after head injury do so between days 2-7, making delayed onset of symptoms particularly concerning 2

Written instructions must be:

• At 6th-7th grade reading level 2
• Font size ≥12 points 2
• Provided in both written and verbal form 2

Follow-Up for Growing Skull Fractures

Infants with minor injuries should be followed up at least once after 2-3 months to evaluate for possible growing fractures, as all cases of growing skull fractures occurred in infants injured during their first year of life 4