What are the concerning symptoms and treatment options for pediatric head injury?

Concerning Symptoms in Pediatric Head Injury

Children with severe or worsening headache, altered mental status, persistent vomiting, signs of skull fracture, or Glasgow Coma Scale (GCS) score ≤13 require emergent neuroimaging to rule out intracranial complications, which occur in approximately 2% of cases even with seemingly mild presentations. 1

Red Flag Symptoms Requiring Immediate Action

Symptoms Mandating Emergent Head CT

• Severe or progressively worsening headache, particularly when associated with other risk factors, carries a 1.9% risk of intracranial complications in children with GCS 13-15 1, 2
• Altered mental status including confusion, disorientation, or difficult arousal 1, 3
• Acutely worsening symptoms during observation period require emergent neuroimaging 1
• Signs of basilar skull fracture (Battle's sign, raccoon eyes, hemotympanum, CSF otorrhea/rhinorrhea) - these children have an 11-fold increased risk of requiring inpatient admission 4, 3
• GCS score ≤13 or any decline in GCS 1, 5
• Seizures following head trauma 4, 3
• Focal neurological deficits including weakness, vision changes, or anisocoria 5, 4

High-Risk Mechanisms and Historical Features

• Road traffic accidents (motor vehicle, auto-pedestrian, bicycle) are independent predictors of moderate-to-severe injury with significantly elevated risk 3
• Loss of consciousness lasting >30 seconds or any witnessed LOC 1, 4
• Post-traumatic amnesia to the event or persistent amnesia 1, 4
• Concern for non-accidental trauma increases risk 6-fold for traumatic brain injury on CT 6

Vomiting: Context-Dependent Risk Stratification

Isolated vomiting alone (without other CDR predictors) carries minimal risk - only 0.3% have clinically important TBI and 0.6% have any TBI on CT, making observation without immediate imaging appropriate. 6

However, vomiting combined with other features significantly increases risk:

• Vomiting + skull fracture signs: OR 112.96 for TBI on CT 6
• Vomiting + altered mental status: OR 2.4 for clinically important TBI 6
• Vomiting + headache: OR 2.3-2.55 for TBI 6
• Vomiting + acting abnormally: OR 1.83-1.86 for TBI 6

Initial Treatment Approach

Acute Symptom Management

Administer nonopioid analgesics (ibuprofen 10 mg/kg every 6-8 hours, max 400 mg/dose; or acetaminophen 15 mg/kg every 4-6 hours, max 650 mg/dose) as first-line treatment for headache while simultaneously assessing for red flags. 2, 7

• Never prescribe opioids for post-traumatic headache - they worsen outcomes 2, 7
• Limit analgesic use to 2-3 days per week to prevent medication overuse headache, the most common preventable cause of chronic post-traumatic headache 2
• Do not use 3% hypertonic saline outside research settings despite limited evidence of immediate benefit 1, 2

Observation vs. Imaging Decision

Use validated clinical decision rules (PECARN, CATCH, CHALICE) to determine imaging necessity rather than routine CT for all head injuries. 1, 5

• Skull radiographs should never be used for diagnosis or screening for intracranial injury 1
• Children meeting low-risk criteria can be safely observed without immediate CT 1, 5
• Do not use biomarkers outside research settings for diagnosis 1

Discharge Instructions and Warning Signs

Families must receive explicit instructions to return immediately for: worsening or severe headache, increased drowsiness, repeated vomiting, confusion, vision changes, weakness, difficulty recognizing people or places, or seizures. 1, 5

Additional discharge guidance should include: 1

• Description of injury and expected symptom course
• Instructions for monitoring postconcussive symptoms
• 24-48 hours of relative rest (activities of daily living permitted as tolerated) 1
• Prevention of further injury
• Gradual return to school with accommodations as needed 5
• Clear follow-up instructions at 2-4 weeks 2

Management of Persistent Symptoms

Headache persisting beyond 2 months requires multidisciplinary evaluation including pediatric neurology, reassessment for analgesic overuse, and evaluation for comorbid sleep disturbance, mood disorders, or cognitive dysfunction. 1, 2

• Children with persistent vestibulo-oculomotor dysfunction (dizziness, balance problems) should be referred to vestibular rehabilitation programs 1
• Implement proper sleep hygiene as adequate sleep facilitates TBI recovery 1
• Cognitive dysfunction should be evaluated within the context of other symptoms, as headache pain itself can disrupt cognitive processing 1

Common Pitfalls to Avoid

• Never dismiss severe headache as "just a concussion symptom" without imaging when other risk factors are present - nearly 2% have intracranial injury even with mild presentations 2
• Do not routinely image all children with vomiting - isolated vomiting has <1% risk of significant injury 6
• Avoid excessive analgesic use beyond 2-3 days per week to prevent rebound headache 2
• Do not delay imaging in children with acutely worsening symptoms during observation 1