What is the management approach for a pediatric patient under 2 years old with a history of fall and loss of consciousness (LOC)?

Management of Pediatric Patient <2 Years with Fall and Loss of Consciousness

For a child under 2 years old with a fall and loss of consciousness, immediately assess using PECARN criteria to stratify risk: if the child has GCS=15, no palpable skull fracture, no nonfrontal scalp hematoma, LOC ≤5 seconds, no severe mechanism, and is acting normally per parents, they are very low risk and can safely forgo CT imaging; otherwise, proceed with CT head or close observation based on intermediate vs. high-risk features. 1, 2

Immediate Risk Stratification Using PECARN Criteria

Very Low Risk (No CT Required)

Children <2 years are very low risk if ALL of the following are present: 1

• GCS = 15
• No palpable skull fracture
• No nonfrontal scalp hematoma
• LOC ≤5 seconds (or no LOC)
• No severe mechanism of injury
• Acting normally per parents
• No other signs of altered mental status

These children have <0.02% risk of clinically important traumatic brain injury and may safely forgo CT evaluation. 1 This was validated in over 4,000 children with 100% sensitivity and 100% negative predictive value. 1

Intermediate Risk (Consider CT or Close Observation)

Children <2 years are intermediate risk if they have GCS=15 and normal mental status but ANY of: 1

• LOC >5 seconds
• Nonfrontal scalp hematoma (bump on side or back of head)
• Severe mechanism of injury
• Not acting normally per parents

Risk of clinically important brain injury is approximately 0.9%. 1 CT may be considered based on: 1

• Parental preference
• Multiple risk factors present
• Worsening symptoms during observation
• Young infant where observational assessment is challenging

High Risk (CT Head Indicated)

Children <2 years are high risk if they have ANY of: 1, 2

• GCS ≤14
• Altered mental status (agitation, somnolence, repetitive questioning, slow response)
• Palpable skull fracture
• Signs of basilar skull fracture

Risk of clinically important brain injury is approximately 4.4%. 2 CT head without contrast is the imaging modality of choice—it rapidly identifies bleeding and fractures without requiring sedation. 1

Critical Red Flags Requiring Emergency Evaluation

Beyond PECARN criteria, immediately evaluate for: 2

• Altered mental status or decreasing level of consciousness
• Seizure activity
• Focal neurological deficits
• Signs of increased intracranial pressure
• Hemodynamic instability

Observation and Monitoring

For intermediate-risk children not receiving immediate CT: 1, 2

• Close clinical observation for worsening symptoms
• 18% of patients who deteriorate after head injury do so between days 2-7 2
• Educate parents on warning signs requiring immediate return

Warning Signs for Deterioration

Return immediately if: 2

• Worsening or severe headache
• Repeated vomiting
• Increasing confusion or disorientation
• Unusual drowsiness or difficulty waking
• Seizures
• Weakness or numbness
• Unequal pupil size
• Slurred speech
• Significant behavior changes

Important Clinical Pitfalls

Do not routinely obtain skull radiographs—up to 50% of intracranial injuries occur without fracture, and radiographs miss many fractures that CT would detect. 1

Age <2 years is itself a risk factor for more serious injury, making careful evaluation particularly important in this population. 2 Young infants present additional challenges because observational assessment of mental status is more difficult. 1

Isolated LOC (with no other PECARN predictors) carries only 0.5% risk of clinically important brain injury—these children do not routinely require CT. 3 However, this applies only when truly isolated with no other concerning features. 3

Do not use MRI, CTA, MRA, or conventional angiography for initial evaluation—there is no evidence supporting these modalities in acute minor head trauma, and MRI is impractical (requires longer scan time, often needs sedation in young children). 1

Differential Considerations Beyond Trauma

While managing the acute head trauma, consider non-traumatic causes of LOC in this age group: 4

• Breath-holding spells (common in children <2 years)
• Seizures
• Cardiac syncope (rare but life-threatening)
• Non-accidental trauma (always consider in this age group)

If mechanism seems inconsistent with injury severity or history is concerning, maintain high suspicion for abusive head trauma. 1