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

The most appropriate next step is B - Observation for 24 hours. This pediatric patient with loss of consciousness and vomiting following head trauma requires extended monitoring for potential intracranial complications, as these symptoms significantly increase the risk of intracranial injury 1.

Rationale for 24-Hour Observation

This patient meets clear criteria for mandatory observation rather than discharge or immediate specialty consultation. The combination of loss of consciousness and vomiting represents high-risk features that warrant structured monitoring 1.

Key Risk Factors Present

• 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 indicating potential increased intracranial pressure 1
• The patient is now stable, which allows for observation rather than immediate aggressive intervention 2

Why Not Immediate Discharge (Option C)

Patients with transient loss of consciousness who return completely to normal may require observation only, but the addition of vomiting elevates this patient's risk profile 3. Discharging this patient would be inappropriate given the documented risk factors 1.

Why Not Immediate Neurology Consultation (Option A)

The patient's current stability does not warrant immediate specialty consultation 2. The initial management priority is physiological stabilization and interval reassessment, which typically lies between 24 and 72 hours 2. Neurology consultation becomes appropriate if the patient shows neurological improvement during observation or develops concerning features 2.

Observation Protocol

During the 24-hour observation period, implement the following structured approach:

Serial Neurological Assessments

• Perform examinations every 2-4 hours assessing level of consciousness, pupillary response, and motor function 1
• Monitor for worsening headache, repeated vomiting, seizures, or altered mental status 1
• Calculate Glasgow Coma Scale scores at each assessment interval 2

Indications for Escalation During Observation

Any of the following warrant immediate CT imaging:

• Worsening headache 1
• Repeated episodes of vomiting 1
• Seizure activity 1
• Altered mental status or decreased level of consciousness 1
• Development of focal neurological deficits 2

Management of Physiological Stability

The development of physiological instability during observation is common and may require mechanical ventilation or inotropic support, which are appropriate interventions 2. However, if rapid escalation in therapy is required to maintain stability, reassessment of the care plan should occur 2.

Common Pitfalls to Avoid

Do not attribute neurological changes solely to the initial injury without excluding evolving intracranial pathology. Patients with head injuries due to falls have a 90.9% incidence of intracranial hematomas when loss of consciousness is involved, with 81.8% requiring surgical evacuation 4.

Ensure confounders are recognized and treated including drugs, seizure activity, physiological derangement (hypotension, hypoxaemia), and direct cranial nerve injury 2.

Disposition After Observation

• If neurological improvement occurs: Consider repeat imaging, neurophysiological studies, or neurology consultation 2
• If stability is maintained without deterioration: Discharge may be appropriate after the full observation period with close follow-up instructions 5
• If deterioration occurs: Escalate to CT imaging and neurosurgical evaluation as indicated 1