What is the management approach for a 4-year-old child with a history of fall, presenting with vomiting, headache, and delayed fever, suspected of having a head injury with intracranial complications?

Management of 4-Year-Old with Head Injury, Vomiting, Headache, and Delayed Fever

This child requires urgent hospital admission with immediate non-contrast CT brain imaging, stabilization with airway/breathing/circulation assessment, and empiric antibiotics if intracranial infection is suspected based on fever presentation, with neurosurgical consultation available for any identified intracranial complications. 1, 2

Immediate Triage and Risk Stratification

This 4-year-old presents with high-risk features requiring urgent intervention:

• Vomiting after head trauma is a validated PECARN intermediate-to-high risk criterion for clinically important traumatic brain injury, with estimated injury risk of 0.8-0.9% 1
• Headache following trauma represents a concerning symptom, particularly if severe or progressive 3
• Delayed fever (appearing after initial trauma) raises critical concern for intracranial infection complication such as meningitis, subdural empyema, or brain abscess 1

The combination of post-traumatic symptoms with fever is not typical for uncomplicated mild traumatic brain injury and mandates investigation for infectious complications 1, 2

Emergency Assessment Protocol

Airway, Breathing, Circulation (ABC) Priority

Immediate clinical assessment must follow this sequence: 1

• Airway patency: Check for irregular breathing, drooling, or pooling secretions suggesting respiratory depression or complex seizures 1
• Breathing adequacy: Assess for tachypnea, increased work of breathing, hypoxia (oxygen saturations <95%) 1
• Circulatory status: Evaluate for shock (tachycardia, cool peripheries, capillary refill ≥3 seconds, blood pressure <80 mmHg) 1
• Neurological status: Document Glasgow Coma Scale score, pupillary responses, focal neurological signs 1

Critical Red Flags Requiring Immediate Intervention

• Depressed conscious level of any degree 1
• Active seizure activity 1
• Signs of increased intracranial pressure (altered mental status, abnormal neurological examination) 4, 3
• Evidence of shock or severe dehydration 1

Neuroimaging Strategy

Immediate Non-Contrast CT Brain

CT brain without contrast is the mandatory first imaging study for this presentation: 1, 2

• Sensitivity 98-100% for acute intracranial hemorrhage and mass effect within first hours 2
• Indicated for all children with vomiting after head trauma per PECARN intermediate risk criteria 1
• Essential before lumbar puncture if intracranial infection suspected, to assess for mass effect and herniation risk (90% specificity) 1, 2
• CT detects skull fractures, epidural hematoma, subdural hematoma, cerebral contusion, and cerebral edema 1, 5

Critical pitfall: Do not delay CT imaging for clinical observation in this scenario—the combination of trauma symptoms plus fever mandates immediate imaging 1

When to Add MRI Brain

MRI with and without contrast should follow CT if: 1

• CT shows intracranial abnormality requiring further characterization 1
• Clinical suspicion for intracranial infection (meningitis, encephalitis, abscess) remains high despite negative CT 1
• MRI provides superior detection of small extra-axial hemorrhage, parenchymal injury, and infectious complications 1
• MRI sequences for infection: T2 FLAIR (vasogenic edema, meningeal enhancement), diffusion-weighted imaging (cytotoxic edema, abscess), post-contrast T1 (meningeal/parenchymal enhancement) 1

Diagnostic Workup for Suspected Intracranial Infection

Laboratory Investigations

Obtain immediately: 1, 2

• Blood cultures (before antibiotics if possible, but do not delay treatment) 2
• Complete blood count with differential 1
• C-reactive protein, erythrocyte sedimentation rate 1
• Serum electrolytes, glucose, renal function 1
• Blood gas analysis if altered mental status 1

Lumbar Puncture Considerations

Lumbar puncture is essential for suspected meningitis/encephalitis BUT: 1, 2

• Must obtain CT brain first to exclude mass effect and herniation risk 1, 2
• Contraindications to immediate LP: depressed consciousness, focal neurological signs, signs of increased intracranial pressure, significant brain shift or tight basal cisterns on CT 1
• If LP delayed, initiate empiric antibiotics immediately (within 1 hour of presentation) 2
• Expected CSF findings in bacterial meningitis: neutrophilic pleocytosis, CSF/blood glucose ratio <0.4, elevated protein >45 mg/dL, elevated opening pressure >25 cm H₂O 2

Critical pitfall: Do not perform LP before imaging in patients with meningeal signs or altered consciousness—this risks cerebral herniation if mass effect present 1, 2

Empiric Antibiotic Therapy

If intracranial infection suspected (fever with meningeal signs or altered mental status): 2

• Initiate antibiotics within 1 hour, even before LP if any delay anticipated 2
• Empiric regimen for suspected bacterial meningitis: Ceftriaxone plus vancomycin (for pneumococcal coverage) 2
• Add dexamethasone to reduce mortality and neurological sequelae in bacterial meningitis 2
• Do not delay antibiotics waiting for imaging or LP results—bacterial meningitis mortality is 20-30% and increases with diagnostic delays 2

Supportive Management

Intracranial Pressure Management (if indicated)

If signs of increased ICP develop: 6, 7

• Mannitol 0.25-2 g/kg IV as 15-25% solution over 30-60 minutes for reduction of intracranial pressure 6
• Pediatric dosing: 1-2 g/kg or 30-60 g/m² body surface area over 30-60 minutes 6
• Hyperventilation, temperature control, head elevation 30 degrees 7
• Continuous ICP monitoring if severe head injury with GCS ≤8 7

Symptom Management

For post-traumatic headache and nausea: 3

• Nonopioid analgesics: ibuprofen or acetaminophen (avoid opioids) 3
• Avoid metoclopramide or domperidone—not recommended in pediatric TBI guidelines 3
• Maintain adequate hydration 1

Hospital Admission Criteria

This child requires urgent admission based on: 1

• High-risk features: vomiting after head trauma, headache, fever suggesting infection 1
• Need for neuroimaging and potential neurosurgical intervention 1
• Minimum 24-hour observation for all children with minor head injury due to risk of delayed hematoma 5
• Intensive care consideration if: depressed consciousness, active seizures, respiratory compromise, shock, hypoglycemia, metabolic acidosis 1

Neurosurgical Consultation

Involve neurosurgery immediately if: 1, 5

• CT demonstrates intracranial hemorrhage (epidural, subdural, intracerebral) 5
• Skull fracture with underlying hematoma 5
• Progressive neurological deterioration 8
• Signs of increased intracranial pressure requiring surgical intervention 6, 7

Common intracranial lesions requiring neurosurgical evaluation: epidural hematoma (occurs in 18% with skull fracture, 17% without fracture), subdural hematoma (12% with fracture, 29% without), diffuse brain swelling 5

Monitoring and Follow-Up

During admission: 3, 8

• Serial neurological examinations every 2-4 hours 8
• Cardiovascular and electrolyte monitoring if mannitol administered 6
• Discontinue mannitol if renal, cardiac, or pulmonary status worsens 6
• Monitor for complications: seizures, coagulopathy, pulmonary complications, gastrointestinal bleeding 8

Post-discharge: 3

• Close monitoring for 4-6 weeks essential 3
• Referral for persistent symptoms (headache, cognitive difficulties, vestibular dysfunction) 3
• Gradual return to activity protocols 3

Key Clinical Pitfalls to Avoid

• Do not assume absence of skull fracture rules out intracranial hematoma—29% of subdural hematomas and 17% of epidural hematomas occur without fracture 5
• Do not rely on skull X-ray alone—insufficient to exclude intracranial injury 1, 5
• Do not dismiss fever as unrelated to head injury—delayed fever raises concern for intracranial infection complication 1
• Do not delay antibiotics for diagnostic procedures if bacterial meningitis suspected—treatment within 1 hour critical 2
• Do not perform LP before CT in patients with altered consciousness or focal signs—herniation risk 1, 2