What is the appropriate management for a toddler with a head injury and no loss of consciousness (LOC)?

Management of Toddler Head Injury Without Loss of Consciousness

For a toddler with head injury and no loss of consciousness, use PECARN criteria to determine if CT imaging is needed—if the child meets very low-risk criteria (GCS 15, normal mental status, no palpable skull fracture, no nonfrontal scalp hematoma, no severe mechanism, acting normally per parents), they can safely forgo CT imaging and be managed with observation alone. 1

Risk Stratification Using PECARN Criteria

Very Low Risk (No CT Needed)

For children under 2 years, all of the following must be present to safely avoid CT: 1

• GCS score of 15
• No altered mental status
• No palpable skull fracture
• No nonfrontal scalp hematoma (bumps on side or back of head)
• No severe mechanism of injury
• Acting normally per parents
• Risk of clinically important brain injury: <0.02% 1

For children 2 years and older, all of the following must be present: 1

• GCS score of 15
• Normal mental status
• No signs of basilar skull fracture
• No vomiting
• No severe headache
• No severe injury mechanism
• Risk of clinically important brain injury: <0.05% 1

Critical caveat: The absence of loss of consciousness does NOT rule out intracranial injury—research shows 16% of children with GCS 15 and no LOC can still have intracranial injury including subdural hematoma, epidural hematoma, or brain contusion. 2 This is why the complete PECARN criteria assessment is essential, not just LOC status.

Intermediate Risk (Consider CT or Close Observation)

If the child has GCS 15 and normal mental status but has ANY of the following: 1

• Vomiting (especially multiple episodes)
• Severe mechanism of injury
• Not acting normally per parent (but still alert)
• Nonfrontal scalp hematoma (in children <2 years)
• Risk of significant injury: 0.8-0.9% 1

For intermediate-risk children, CT may be considered based on: 1

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

Observation Protocol

For Very Low-Risk Children (No CT Performed)

Provide detailed discharge instructions including: 3

• Written and verbal instructions at 6th-7th grade reading level, font size ≥12 points
• Expected postconcussive symptoms: dizziness, nausea, vision problems, sensitivity to noise/light, mood changes, irritability, sleep disturbances
• Critical warning: 18% of patients who deteriorate do so between days 2-7 4, 3

Red Flags Requiring Immediate Return

Instruct parents to return immediately for: 4

• 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

Imaging Considerations

When CT is Indicated

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

CT head without contrast is the imaging modality of choice when indicated because it: 4

• Rapidly identifies bleeding and fractures
• Does not require sedation
• Has excellent sensitivity for acute intracranial hemorrhage

Advanced Imaging NOT Recommended

There is no evidence supporting use of CTA, MRA, MRI, or conventional angiography for initial evaluation of minor head trauma in children. 1

Special Considerations for Toddlers

Age under 2 years is itself a risk factor for more serious injury, making careful evaluation particularly important. 4 In this age group: 5

• Clinical signs of brain injury are insensitive indicators of intracranial injury
• Only 52% of infants with intracranial injury had clinical symptoms or signs of brain injury
• Significant scalp hematomas (especially nonfrontal) are particularly important to identify, as 93% of asymptomatic infants with intracranial injury had scalp hematomas

Common pitfall: Do not rely solely on absence of LOC or normal neurologic exam to rule out intracranial injury—neither LOC nor mild altered mentation is a sensitive indicator for selecting patients for CT scanning. 2 Always use the complete PECARN criteria assessment.