What should be done for a patient, likely a child, who fell off a bed, has a knot on their head, a bruised jaw, and a gum injury?

Immediate Assessment and Management of Pediatric Fall with Head and Oral Injuries

The child should be evaluated immediately for signs of serious head injury, and if any concerning features are present (altered mental status, severe headache, vomiting, loss of consciousness, or visible skull deformity), they need emergency department evaluation with head CT imaging rather than urgent care. 1

Initial Risk Stratification

The decision to seek emergency care versus observation depends on specific clinical features:

High-Risk Features Requiring Emergency Department Evaluation:

• Glasgow Coma Scale (GCS) score of 14 or less 1
• Any altered mental status (confusion, excessive sleepiness, difficulty staying awake) 1
• Signs of basilar skull fracture (bruising behind ears, raccoon eyes, clear fluid from nose/ears) 1
• Loss of consciousness at time of injury 1
• Severe or worsening headache 1
• Repeated vomiting 1
• Seizure activity 1

If any of these features are present, the child needs immediate ED evaluation with non-contrast head CT, as the risk of clinically important intracranial injury is approximately 4.3-4.4%. 1

Moderate-Risk Features (Consider ED Evaluation):

• Palpable skull fracture (a "knot" that feels like a step-off or depression in the skull) 1
• Significant scalp hematoma (large, boggy swelling) 1
• Mechanism concerning for significant impact 1

Assessment of the Oral Injuries

The gum injury ("bit a chunk out of their gums") requires specific evaluation:

Immediate Oral Examination Should Assess:

• Whether any teeth are loose, displaced, or missing 1
• Depth and extent of the gum laceration 2
• Active bleeding from the wound 2
• Whether the child can bite teeth together normally (check occlusion) 1

Management Based on Dental Findings:

For gum lacerations without tooth involvement:

• Most heal spontaneously without intervention 2
• Clean gently with water or saline 3
• Soft diet for 10 days (avoid hard, sharp, or irritating foods) 2
• Gentle oral hygiene with warm saline rinses after meals 3
• Watch for signs of infection (increased swelling, pain, fever, purulent drainage) 2

For loose or displaced teeth:

• If primary (baby) teeth are loose but not avulsed, no immediate treatment is needed - observe for spontaneous repositioning 1
• If teeth are significantly displaced and interfering with bite, immediate dental referral is required 1
• If a tooth is completely knocked out (avulsed), do NOT replant primary teeth 1

Child Abuse Screening

This injury pattern warrants consideration of non-accidental trauma, as the American Academy of Pediatrics recommends assessing for child abuse in children younger than 5 years with trauma affecting the lips, gingiva, tongue, and palate. 2 Key questions include:

• Is the mechanism of injury consistent with the child's developmental stage? 2
• Are there other unexplained injuries? 1
• Does the history change or seem inconsistent? 1

Recommended Action Plan

Based on the described injuries (knot on head, bruised jaw, gum injury), the appropriate course is:

1. Immediately assess for high-risk features listed above - if ANY are present, go to the emergency department, not urgent care 1

2. If no high-risk features but the "knot" feels like a skull deformity or step-off, go to ED 1

3. If the knot is simply a soft tissue hematoma (swelling) without skull deformity, and the child is acting normally with no concerning symptoms, home observation may be appropriate 1

4. For the oral injuries, if teeth are stable and bleeding has stopped, home care with soft diet and oral hygiene is sufficient 2, 3

5. Seek immediate dental evaluation if:

   • Multiple teeth are loose or displaced 2
   • Extensive gingival or facial swelling develops 2
   • Signs of infection appear 2

Home Observation Instructions (If No ED Visit Required)

Monitor closely for 24-48 hours for:

• Changes in mental status or behavior 1
• Severe or worsening headache 1
• Repeated vomiting 1
• Difficulty walking or speaking 1
• Increasing swelling at injury sites 2
• Fever or signs of infection 2

Any of these warrant immediate medical evaluation. 1, 2

Common Pitfall

The most critical error is dismissing a seemingly minor fall in a young child. Falls from beds can cause significant intracranial injury, particularly in children under 2 years of age, and clinicians should have a low threshold for neuroimaging in young children with any concerning features. 1 The absence of loss of consciousness does not exclude serious injury. 1