Immediate Management of 2-Year-Old with Face-First Fall on Tile Floor
For a 2-year-old who fell face-first on tile while running, immediately assess using PECARN criteria to determine if imaging is needed—if the child has a GCS of 15, is acting normally per parents, has no loss of consciousness >5 seconds, no palpable skull fracture, no severe mechanism, and no altered mental status, they are very low risk (<0.02% chance of serious brain injury) and can be safely observed at home without CT scan. 1
Risk Stratification Using PECARN Criteria
For children under 2 years of age, assess the following high-risk features that would require immediate CT imaging 1:
High-Risk Features (4.4% risk of serious injury):
Intermediate-Risk Features (0.9% risk of serious injury):
- Loss of consciousness >5 seconds 1
- Severe mechanism of injury (high-speed motor vehicle accident, fall from significant height—not a simple fall while running) 2
- Not acting normally per parent 1
- Nonfrontal scalp hematoma 1
Very Low-Risk Features (<0.02% risk):
- GCS = 15 with normal mental status 1
- No palpable skull fracture 1
- No nonfrontal scalp hematoma 2
- Loss of consciousness ≤5 seconds 1
- No severe mechanism of injury 1
- Acting normally per parents 1
Critical Assessment Points
Examine specifically for:
- Mental status: Is the child alert, interactive, and behaving normally? 2
- Skull palpation: Feel carefully for step-offs or depressions indicating fracture 1
- Scalp hematoma location: Frontal hematomas are lower risk than occipital, parietal, or temporal 2
- Loss of consciousness: Ask parents if child had any period of unresponsiveness, even brief 1
- Mechanism: Running and falling on tile is NOT considered a severe mechanism (unlike falls from >3 feet or from caregiver's arms) 2, 3
Imaging Decision
Do NOT obtain CT scan if all very low-risk criteria are met (100% sensitivity, 100% negative predictive value validated in over 4,000 children) 1. This avoids unnecessary radiation exposure in children who can be safely observed 4.
Obtain immediate non-contrast head CT if:
- Any high-risk features are present 4, 2
- Multiple intermediate-risk features are present 4
- Clinical deterioration occurs during observation 4
Consider CT versus observation if:
- Single intermediate-risk feature present (shared decision-making with parents) 2
Home Observation Instructions
If discharging without imaging, instruct parents to return immediately for: 5
- Persistent or worsening vomiting 5
- Increasing drowsiness or difficulty waking 5
- Seizure activity 5
- Worsening headache 5
- Excessive irritability or significant behavior changes 5
- Unsteady walking or coordination problems 5
- Unequal pupil size 5
Expected normal symptoms that may occur: 5
- Mild headache 5
- Brief crying episode immediately after fall 2
- Small forehead bump or bruise 2
- Transient fussiness that resolves 5
Special Consideration: Non-Accidental Trauma
Maintain low threshold for imaging if: 1
- History inconsistent with injury pattern 1
- Unexplained injuries elsewhere 1
- Facial injury in child <2 years (high-risk marker for abuse) 1
- Delay in seeking care 1
Running and falling face-first is a common accidental mechanism in toddlers learning to run, but if the story doesn't match the injury or there are other concerning features, consider non-accidental trauma and obtain neuroimaging even with normal examination 1.
Common Pitfalls to Avoid
- Do not obtain skull X-rays—they miss up to 50% of intracranial injuries and provide no information about brain parenchyma 4, 2
- Do not use MRI acutely—it requires longer examination time and often sedation in this age group 4, 2
- Do not scan very low-risk patients—this exposes them to unnecessary radiation without clinical benefit 4
- Do not assume forehead location means no imaging needed—assess all PECARN criteria, not just hematoma location 2