What is the initial management for a 2.5-year-old child with an accidental head injury and soft tissue injury?

Initial Management of Head Injury with Soft Tissue Injury in a 2.5-Year-Old Child

For a 2.5-year-old with accidental head trauma and soft tissue injury, immediately assess risk stratification using PECARN criteria to determine need for CT imaging, while simultaneously managing the soft tissue wound and monitoring for neurological deterioration. 1

Immediate Risk Stratification (PECARN Criteria)

Your first priority is determining the child's risk category, which dictates imaging and disposition decisions:

Very Low Risk (No CT needed) 1

• GCS 15 AND
• No altered mental status AND
• No palpable skull fracture AND
• No nonfrontal scalp hematoma AND
• Loss of consciousness <5 seconds (if any) AND
• No severe mechanism of injury AND
• Acting normally per parents

Children meeting ALL these criteria can safely forgo CT imaging with >99% sensitivity and 100% negative predictive value for clinically important traumatic brain injury. 1

Intermediate Risk (CT may be considered) 1

• GCS 15 with normal mental status AND
• No palpable skull fracture BUT
• History of loss of consciousness >5 seconds OR
• Severe mechanism of injury OR
• Not acting normally per parent

The likelihood of significant injury is approximately 0.9% in this age group. 1 CT may be considered based on parental preference, multiple risk factors, worsening symptoms during observation, or difficulty with observational assessment in young children. 1

High Risk (CT strongly recommended) 1

• GCS ≤14 OR
• Other signs of altered mental status OR
• Signs of palpable skull fracture

Risk of clinically significant intracranial injury is approximately 4.4%, making imaging strongly recommended. 1

Hemodynamic Management

Maintain mean arterial pressure (MAP) 50-90 mmHg for ages 1-5 years to ensure adequate cerebral perfusion. 1 Target MAP at least 10 mmHg above the normal range to account for potential increased intracranial pressure. 1

• Monitor blood glucose closely, as young children are prone to hypoglycemia 1
• Maintain normoglycemia using isotonic saline with 5-10% glucose as maintenance fluid (with 50-60% restriction on standard administration rates) 1

Soft Tissue Injury Management

Wound Assessment and Care 2

• Examine for depth of injury—determine if superficial or penetrating beyond subcutaneous tissue 2
• Assess for associated injuries to underlying structures (skull fracture palpation is part of PECARN criteria) 1
• Facial soft tissue injuries require attention to surgical alignment and symmetry to prevent poor cosmesis, as revisions may be needed as the child grows 2

Delayed Presentation Consideration

If the child presents >24 hours after injury with only scalp swelling and is neurologically nonfocal, the risk of requiring surgical intervention or neurologic decline is extremely low. 3 However, CT imaging may still be indicated based on PECARN criteria and to evaluate for non-accidental trauma. 3

Observation and Disposition

For Very Low Risk Patients 1

• Discharge with clear return precautions
• No imaging required

For Intermediate Risk Patients 1

• Consider observation period of 4-6 hours if CT not performed
• Perform CT if symptoms worsen, multiple risk factors present, or parental preference
• Admit if CT shows any intracranial injury

For High Risk Patients 1

• Obtain CT head immediately 1
• Admit for neurological observation with serial examinations 4
• Consider repeat CT at 6-12 hours if initial examination shows intracranial injury 4

Critical Pitfalls to Avoid

Never discharge a child with signs of basilar skull fracture (Battle's sign, raccoon eyes, hemotympanum, CSF otorrhea/rhinorrhea) without CT imaging and adequate observation, even if GCS is 15. 4 These findings place the child in high-risk category regardless of other factors. 4

Do not assume delayed scalp swelling alone requires surgical intervention—in children ≤24 months presenting in delayed fashion with isolated scalp swelling and nonfocal examination, no patients in a 2-year cohort required surgery or experienced neurologic decline. 3

Consider non-accidental trauma in any child <2 years with head injury, especially if mechanism is unclear or inconsistent with developmental capabilities. 1