Does a 3-year-old child with facial contusions, no loss of consciousness (LOC), and a Glasgow Coma Scale (GCS) score of 15 after a fall, who is also recovering from a recent illness, require Emergency Department (ED) follow-up?

ED Follow-Up Assessment for 3-Year-Old with Minor Head Trauma

This child does not require Emergency Department evaluation and can be safely observed at home with appropriate return precautions. 1

Risk Stratification Using PECARN Criteria

Your child falls into the very low risk category for clinically important traumatic brain injury based on validated clinical decision rules. 1

Very Low Risk Criteria Met (All Present):

• GCS = 15 throughout observation 1
• No loss of consciousness 1
• No signs of basilar skull fracture (no raccoon eyes, Battle's sign, hemotympanum, or CSF leak) 1
• No vomiting 1
• No severe mechanism of injury (fall from standing height, even at a run, is not considered severe) 1
• No severe headache 1
• No other signs of altered mental status (appropriate interaction, normal awakening from nap) 1

The PECARN criteria demonstrate that children meeting all very low risk criteria have a <0.02% risk of clinically important traumatic brain injury, making CT imaging and ED evaluation unnecessary. 1, 2

Addressing the Confounding Factor: Recent Viral Illness

The decreased activity and appetite you're observing are most likely attributable to the concurrent viral illness rather than head trauma, given: 1

• The child is only 24-28 hours into recovery from viral illness (typical viral symptoms persist 3-7 days) 1
• Normal neurological examination (appropriate interaction, equal pupils, normal awakening) 1
• Absence of progressive neurological deterioration 1
• Facial contusions are superficial injuries that do not increase intracranial injury risk when other high-risk features are absent 1

Safe Home Observation Protocol

Discharge the child home with strict return precautions rather than ED evaluation. 1, 2

Return to ED Immediately If:

• Persistent or worsening vomiting (≥2 episodes) 1
• Deteriorating level of consciousness or difficulty arousing 1
• Severe or worsening headache 1
• New focal neurological deficits (weakness, vision changes, slurred speech) 1
• Seizure activity 1
• Behavioral changes beyond what's expected from viral illness (extreme irritability, confusion, repetitive questioning) 1, 2
• Clear or bloody fluid from nose or ears 1

Expected Post-Concussive Symptoms (Monitor But Don't Require ED Visit):

• Mild dizziness 2
• Mild nausea without vomiting 2
• Fatigue (difficult to distinguish from viral illness in this case) 2
• Mild irritability 2

Critical timing note: 18% of patients who deteriorate after head injury do so between days 2-7, making vigilant observation during this window essential. 2

Why CT Imaging Is Not Indicated

The CDC guidelines explicitly state that children meeting very low risk criteria should not undergo routine CT imaging due to: 1

• Radiation exposure carries lifetime cancer risk in children 1
• Potential need for sedation in young children increases procedural risk 1
• Extremely low yield (<0.02%) for detecting clinically important injury 1, 2
• No evidence that CT changes management in asymptomatic very low-risk patients 1

Clinical Pitfall to Avoid

Do not attribute all symptoms to the head trauma when a concurrent illness is present. The viral illness timeline (24-28 hours into recovery) makes decreased activity and appetite expected findings. However, maintain heightened vigilance for new or progressive neurological symptoms that would be inconsistent with simple viral recovery. 1

Documentation for Virtual Urgent Care

Provide written and verbal discharge instructions at 6th-7th grade reading level with font size ≥12 points, clearly outlining return precautions. 2 Ensure parents understand the difference between expected viral illness symptoms and concerning neurological deterioration. 2