In a pediatric patient with head trauma, how should I assess severity, determine need for computed tomography (CT) imaging using Pediatric Emergency Care Applied Research Network (PECARN) criteria, and manage based on the findings?

Pediatric Head Injury Assessment and Management

Initial Risk Stratification Using PECARN Criteria

Use the validated PECARN clinical decision rules to stratify all pediatric head trauma patients by age and risk factors, which will determine whether CT imaging is needed, observation is appropriate, or the child can be safely discharged without imaging. 1, 2

For Children ≥2 Years of Age

High-Risk Criteria (CT Required):

• GCS of 14 or other signs of altered mental status 1, 2
• Signs of basilar skull fracture (hemotympanum, periorbital ecchymosis, Battle's sign, CSF otorrhea/rhinorrhea) 1, 2
• Risk of clinically important traumatic brain injury: approximately 4.3% 1

Intermediate-Risk Criteria (CT vs. Observation):

• GCS of 15 with normal mental status and no basilar skull fracture, BUT with any of the following: 3, 2
  • History of loss of consciousness 1
  • Vomiting 1
  • Severe mechanism of injury 2
  • Severe headache 1
• Risk of clinically important injury: approximately 0.8% 3, 2

Very Low-Risk Criteria (No Imaging Needed):

• GCS of 15 1
• Normal mental status 1
• No basilar skull fracture 1
• No vomiting 1
• No severe mechanism of injury 1
• No severe headache 1
• Sensitivity: 100%, can safely forgo CT 3

For Children <2 Years of Age

High-Risk Criteria (CT Required):

• GCS of 14 or other signs of altered mental status 4, 2
• Palpable skull fracture 4, 2
• Risk of clinically important intracranial injury: approximately 4.4% 4, 2

Intermediate-Risk Criteria (CT vs. Observation):

• GCS of 15 with normal mental status and no palpable skull fracture, BUT with any of the following: 4, 2
  • Loss of consciousness >5 seconds 4, 2
  • Severe mechanism of injury 4, 2
  • Not acting normally per parent 4, 2
  • Nonfrontal scalp hematoma 2
• Risk of significant injury: approximately 0.9% 3, 4

Very Low-Risk Criteria (No Imaging Needed):

• GCS of 15 4
• Normal mental status 4
• No palpable skull fracture 4
• No nonfrontal scalp hematoma 4
• Loss of consciousness ≤5 seconds 4
• No severe mechanism of injury 4
• Acting normally per parents 4
• Risk of clinically important traumatic brain injury: <0.02% with 100% sensitivity and 100% negative predictive value 3, 4

Special Clinical Scenarios Requiring Immediate CT

Post-traumatic seizures are a high-risk criterion requiring immediate CT imaging regardless of other factors, with reported incidence of intracranial injury ranging from 2.4% in mild TBI to 28-83% in severe TBI. 1

Any clinical deterioration during observation warrants immediate CT imaging, even if the initial examination was normal. 1

Management of Intermediate-Risk Patients

For intermediate-risk patients, CT may be considered instead of observation in the following situations: 3, 2

• Parental preference for definitive imaging 3, 2
• Multiple risk factors present 3, 2
• Worsening clinical symptoms or signs during observation 3, 2
• Young infants where observational assessment is challenging 3, 2

Every additional hour of emergency department observation is associated with decreased CT utilization without delaying diagnosis of significant traumatic brain injury. 1, 2

CT Imaging Protocol Specifications

Perform non-contrast CT head using dedicated pediatric-specific, reduced-dose protocols following the ALARA principle ("as low as reasonably achievable"). 1, 2

Multiplanar and 3D-reconstructed images should ideally be performed to increase sensitivity for fractures and small hemorrhages. 1, 2

IV contrast is not indicated initially as it may obscure subtle hemorrhages. 1

Why CT Remains the Gold Standard

CT provides rapid acquisition time, excellent sensitivity for acute intracranial hemorrhage and fractures, requires no sedation, and can be performed in unstable patients. 4, 2

MRI is impractical in the acute setting due to longer examination times, need for safety screening, and potential requirement for sedation in younger children. 3, 1

Critical Pitfalls to Avoid

Do not obtain CT in very low-risk patients meeting all PECARN criteria, as this exposes them to unnecessary radiation without clinical benefit. 4, 2

Do not rely on skull radiographs, as they miss up to 50% of intracranial injuries and provide no information about brain parenchyma. 3, 4, 2

Do not use ultrasound to exclude intracranial injury in infants, even when the fontanelle is open, as it lacks sensitivity for small subdural hematomas (particularly in the posterior fossa) and other small extra-axial hemorrhages. 4

Up to 50% of intracranial injuries occur without skull fracture, so the presence or absence of fracture alone cannot predict intracranial injury. 4, 2

Do not apply PECARN criteria to suspected abusive head trauma cases; these children require either CT or MRI regardless of clinical presentation. 1, 2

Do not delay imaging for prolonged observation when high-risk features are present, as this represents a clear indication for immediate CT. 1