What is the appropriate management for a child with head trauma due to a fall, considering age, symptoms, and past medical history?

Management of Pediatric Head Trauma Due to Fall

Initial Risk Stratification Using PECARN Criteria

The PECARN clinical decision rules should guide all imaging decisions in pediatric head trauma, as they have been prospectively validated in over 40,000 children with 99.9-100% negative predictive value and represent the most evidence-based approach to avoid unnecessary CT scans while maintaining safety. 1, 2

For Children Under 2 Years of Age

The child can safely avoid CT imaging if ALL of the following are present 1, 2, 3:

• Glasgow Coma Scale (GCS) score of 15
• Normal mental status (alert, interactive, age-appropriate behavior)
• No palpable skull fracture on examination
• No nonfrontal scalp hematoma (frontal hematomas are lower risk)
• Loss of consciousness ≤5 seconds (if any)
• No severe mechanism of injury (motor vehicle crash with ejection, death of another passenger, or rollover; pedestrian/bicyclist struck by vehicle; fall >3 feet; head struck by high-impact object)
• Acting normally per parents' report

Risk of clinically important traumatic brain injury in this very low-risk group is <0.02%. 3, 4

For Children 2 Years and Older

The child can safely avoid CT imaging if ALL of the following are present 1, 3:

• GCS score of 15
• Normal mental status
• No signs of basilar skull fracture (hemotympanum, raccoon eyes, Battle sign, CSF otorrhea/rhinorrhea)
• No vomiting
• No severe headache
• No severe mechanism of injury

Risk of clinically important traumatic brain injury in this very low-risk group is <0.05%. 3

When CT Imaging is Mandatory

High-Risk Features Requiring Immediate CT 2, 3

Obtain urgent non-contrast head CT (rated 9/9 appropriateness by ACR) for any of the following 1, 3:

• GCS ≤13 (moderate to severe head trauma)
• GCS of 14 or other altered mental status (risk of clinically important injury ~4.3%)
• Signs of basilar skull fracture (risk ~4.3%)
• Palpable skull fracture in children <2 years (risk ~4.4%)
• Post-traumatic seizure (risk 16% for traumatic brain injury requiring hospitalization)
• Focal neurological deficits (including transient visual disturbance)

Intermediate-Risk Features: Consider CT or Observation 1, 3, 4

For children with GCS 15 and normal mental status but with the following features, either obtain CT or implement careful observation (risk ~0.8-0.9%) 3:

In children <2 years:

• Loss of consciousness >5 seconds
• Severe mechanism of injury
• Not acting normally per parent
• Nonfrontal scalp hematoma

In children ≥2 years:

• Vomiting (especially if multiple episodes)
• Severe headache
• History of loss of consciousness

Clinical observation for several hours before deciding on CT is an effective strategy to reduce unnecessary radiation exposure, with every additional hour of emergency department observation associated with decreased CT utilization without delaying diagnosis of significant injury. 3

Critical Management Principles

Severe Head Trauma (GCS ≤8) 2

1. Immediate intubation with spine protection (decreases mortality)
2. Maintain normocapnia: PaCO₂ 35-40 mmHg (or EtCO₂ 30-35 mmHg)
3. Prevent hypotension: Maintain systolic BP >110 mmHg in older children
4. Urgent CT head and cervical spine without delay
5. Immediate neurosurgical consultation
6. ICP monitoring if GCS ≤8 with abnormal CT, targeting ICP <20 mmHg (lower thresholds for younger children)
7. Transfer to pediatric trauma center with dedicated PICU capabilities

Imaging Technical Specifications 3

• Use non-contrast CT as initial imaging (IV contrast may obscure subtle hemorrhages)
• Implement pediatric-specific, reduced-dose protocols following ALARA principles
• Obtain multiplanar and 3D reconstructions to increase sensitivity for fractures and small hemorrhages
• Never use skull radiographs as they miss up to 50% of intracranial injuries and provide no information about brain parenchyma

Special Populations and Pitfalls 1, 2, 3

Suspected non-accidental trauma (children <2 years): 2, 3

• Maintain high index of suspicion
• Do NOT apply PECARN criteria
• Obtain either non-contrast CT or MRI regardless of clinical presentation
• Follow state reporting requirements

Common pitfalls to avoid: 3

• Obtaining CT in very low-risk patients who meet all PECARN criteria (unnecessary radiation exposure)
• Delaying imaging when high-risk features are present
• Using skull radiographs instead of CT
• Attempting MRI in acute setting (longer examination times, potential sedation requirement)
• Routine "pan-scan" whole-body CT (use selective region-specific scanning based on clinical prediction)

Disposition and Follow-Up 1, 2

For children discharged without imaging: 1

• Provide comprehensive discharge instructions including warning signs of deterioration
• Educate on expected symptom course
• Give specific monitoring instructions for parents
• Ensure follow-up for persistent postconcussive symptoms beyond 2 weeks

For children requiring admission: 2

• Early rehabilitation planning for neurologic injuries
• Physical, occupational, cognitive, speech, and play therapy as needed
• Goal of returning child to full, age-appropriate function