What is the most appropriate next step for a pediatric patient with no past medical history who presented to the emergency room (ER) after a fall, loss of consciousness, and vomiting, and is now stable?

Management of Pediatric Head Injury with Loss of Consciousness and Vomiting

This child requires observation for at least 24 hours (Option B) given the combination of loss of consciousness and vomiting following head trauma, which are high-risk features that warrant close monitoring for potential intracranial complications. 1

Rationale for 24-Hour Observation

Loss of consciousness and vomiting are critical red flags that significantly increase the risk of intracranial injury and require extended monitoring. 1

• Loss of consciousness occurs in less than 10% of concussions but is an important sign that may herald the need for further imaging and intervention 1
• Vomiting is a key symptom in the postconcussion symptom scale and indicates potential increased intracranial pressure 1
• The combination of these two features places this patient in a higher-risk category requiring hospital observation rather than immediate discharge 2, 3

Risk Stratification Based on Clinical Features

This patient falls into an intermediate-risk category based on established head injury protocols:

• Group Beta/Gamma classification: Patients with transient loss of consciousness AND vomiting require CT scanning and observation, not immediate discharge 2
• Multivariate analysis demonstrates that loss of consciousness/amnesia and nausea/vomiting are significantly correlated with CT abnormalities in mild head injury 3
• The patient is now "stable" but this does not eliminate the risk of delayed deterioration, which can occur in the first 24-48 hours 4

Why Not Immediate Neurosurgery Consultation (Option A)?

Neurosurgery consultation is not the immediate next step unless specific high-risk features are present:

• The patient is currently stable without ongoing altered mental status, focal neurological deficits, or signs of herniation 2
• Neurosurgical intervention is indicated for patients with abnormal Glasgow Coma Scale, persistent neurological deficits, or signs of basilar/depressed skull fracture 4
• Only 0.66-0.97% of mild head injury patients ultimately require surgical treatment 3, 4

Why Not Discharge (Option C)?

Immediate discharge is inappropriate and potentially dangerous for this patient:

• Patients with history of loss of consciousness or vomiting should NOT be discharged without observation unless they have completely normal examination and no risk factors 2, 4
• The risk of delayed intracranial hemorrhage (epidural or subdural hematoma) exists within the first 24-48 hours 5
• Even patients who appear stable initially can deteriorate, with 3.9% developing early post-traumatic seizures and 1.4-1.6% developing delayed hematomas 4

Observation Protocol During 24-Hour Period

During the observation period, the following monitoring is essential:

• Serial neurological examinations every 2-4 hours assessing level of consciousness, pupillary response, and motor function 1, 5
• Vital sign monitoring for Cushing's triad (bradycardia, hypertension, irregular respirations) which indicates rising intracranial pressure 5
• Assessment for worsening headache, repeated vomiting, seizures, or altered mental status—any of which warrant immediate CT imaging 1, 3
• CT scan should be obtained if any deterioration occurs or if the patient has persistent symptoms 2, 3

Common Pitfalls to Avoid

• Do not assume "stable" means safe for discharge—delayed deterioration is well-documented in pediatric head injury 4
• Do not skip observation based on normal initial examination—intracranial lesions can be present even with GCS 15 2
• Do not discharge without ensuring a competent observer at home—if adequate home observation cannot be guaranteed, hospital observation is mandatory 4

Indications for CT Imaging During Observation

CT scan should be obtained if any of the following develop:

• Persistent or worsening headache 3, 4
• Repeated episodes of vomiting 2, 3
• Any decline in level of consciousness 3, 4
• Development of focal neurological signs 4
• Post-traumatic seizure 4