What are the criteria for emergency room care in children with head injuries?

Head Injury Criteria for Emergency Room Care in Children

Children with head injuries require emergency room evaluation based on validated clinical decision rules, with the PECARN criteria providing the most robust framework for risk stratification and determining which children need CT imaging versus observation versus safe discharge home. 1

Risk Stratification Framework

The PECARN clinical decision rules stratify children into three risk categories based on age-specific criteria, with different thresholds for children under 2 years versus 2 years and older 1, 2:

High-Risk Criteria (Require Immediate CT and ER Care)

For children ≥2 years old (4.3% risk of clinically important injury) 1, 2:

• Glasgow Coma Scale (GCS) score of 14 or less 1, 2
• Any signs of altered mental status 1, 2
• Signs of basilar skull fracture (hemotympanum, raccoon eyes, Battle sign, cerebrospinal fluid otorrhea/rhinorrhea) 1, 2

For children <2 years old (4.4% risk of clinically important injury) 1, 2:

• GCS score of 14 or less 1, 2
• Any signs of altered mental status 1, 2
• Any palpable skull fracture 1, 2

Intermediate-Risk Criteria (Consider CT or Observation)

For children ≥2 years old (0.8% risk of clinically important injury) 1, 2:

• History of loss of consciousness 1, 2
• Severe headache 1, 2
• Severe mechanism of injury (motor vehicle crash with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by motorized vehicle; fall >1.5 meters; head struck by high-impact object) 1, 2

For children <2 years old (0.9% risk of clinically important injury) 1, 2:

• Loss of consciousness >5 seconds 1, 2
• Severe mechanism of injury 1, 2
• Not acting normally per parent 1, 2
• Non-frontal scalp hematoma 1, 2

Very Low-Risk Criteria (Safe for Discharge Without Imaging)

Children can be safely discharged without CT imaging when they meet ALL of the following criteria (99.9% negative predictive value in children ≥2 years; 100% in children <2 years) 1, 3, 2:

• GCS of 15 1, 2
• Normal mental status 1, 2
• No loss of consciousness (or ≤5 seconds in children <2 years) 1, 2
• No severe mechanism of injury 1, 2
• No severe or worsening headache 1, 2
• No signs of skull fracture 1, 2
• Acting normally per parent (for children <2 years) 1, 2

Imaging Decisions in the Emergency Room

CT imaging is the first-line modality for acute pediatric head trauma due to rapid acquisition, excellent sensitivity for acute hemorrhage and fractures, and no sedation requirement 1, 4:

• Immediate CT is indicated for all high-risk patients 1, 4
• CT may be considered versus observation for intermediate-risk patients, with clinical observation reducing unnecessary CT utilization without delaying diagnosis 4
• CT should be avoided in very low-risk patients who meet all PECARN discharge criteria 4
• Skull radiographs should not be used as they miss up to 50% of intracranial injuries and cannot evaluate brain parenchyma 1, 4

Red Flags Requiring Immediate ER Evaluation

Parents should be instructed to bring children immediately to the ER if any of the following develop 3, 2:

• Loss of consciousness 3
• Severe or worsening headache 3, 2
• Repeated or persistent vomiting 3, 2
• Altered mental status or excessive drowsiness 3, 2
• Seizure activity 3, 2
• Visual changes 3, 2
• Unsteady walking or coordination problems 3, 2
• Unequal pupil size 3, 2
• Scalp deformities or palpable skull defects 3

Special Considerations

Delayed presentations (>24 hours after injury) warrant heightened concern, as these children have a 3.8% rate of traumatic brain injury on CT and 0.8% rate of clinically important traumatic brain injury 5:

• Non-frontal scalp hematoma is strongly associated with traumatic brain injury in delayed presentations (odds ratio 19.0) 5
• Suspicion of depressed skull fracture requires immediate CT evaluation 5

Non-accidental trauma must be considered in children with unexplained injuries, inconsistent history, or concerning patterns, particularly in children <1 year old 1, 2:

• Maintain low threshold for neuroimaging in suspected abuse cases 1
• Consider unrevealed solid organ injury in hemodynamically unstable children 1

Initial management priorities to prevent secondary brain injury include 6:

• Preventing hypoxia and hypotension, which are independently associated with worse outcomes 6
• Maintaining age-appropriate mean arterial pressure targets 1

Discharge Instructions for Low-Risk Patients

Written discharge instructions must include 2:

• Warning signs of serious injury requiring immediate return 2
• Expected symptom course 2
• Instructions for monitoring postconcussive symptoms 2
• Guidance on cognitive and physical rest (complete rest for 24-48 hours, then gradual resumption) 3
• Clear follow-up instructions 2
• Prevention counseling 2

Evidence Quality

The PECARN criteria represent the highest quality evidence, validated in over 40,000 children prospectively, with subsequent independent validation studies in Australia/New Zealand confirming 100% negative predictive value and 99-100% sensitivity 1. This systematic review of 11 clinical practice guidelines identified 34 recommendations based on moderate- to high-quality evidence, with PECARN criteria being the most widely validated approach 1.