Head trauma (peds)

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This page is for pediatric patients. For adult patients, see: head trauma (main)

Background

  • TBI in the pediatric population is rare, occuring in 0.9% of the 42,412 PECARN population
  • The primary ED question is whether or not to perform a head CT to assess for intracranial hemorrhage
    • Cranial ultrasound is a poor screening tool for bleeding[1]
  • The PECARN rule has become standard of care to determine which patients need CT imaging
    • In patients <2 yrs the aid is 100% sensitive with NPV of 100%
    • In patient >2 yrs the aid is 96.8% sensitive with NPV of 99.95% (with validation studies showing sensitivity of 100% for TBI and injury requiring neurosurgery

Pediatric GCS[2][3]

Eye Opening Verbal Motor
6: Normal spontaneous movement
5: Smiles, coos, babbles 5: Withdraws to touch
4: Opens eyes spontaneously 4: Irritable, crying (but consolable) 4: Withdraws to pain
3: Opens eyes to speech only 3:Inconsolable crying or crying only in response to pain 3: Abnormal flexion to pain (Decorticate response)
2: Opens eyes to pain only 2: Moans in response to pain 2: Abnormal extension to pain (Decerebrate response)
1: Does not open eyes 1: No response 1: No response

Note:

  • For Motor score 4, pain is defined flat, fingernail pressure (often performed with the barrel of a pencil).
  • For Motor scores 2 and 3, pain is defined by pressing hard on the supraorbital notch. If this unsuccessful, sternal pressure may also be attempted.

Clinical Features

Differential Diagnosis

Head trauma

Evaluation

Work-Up

Rules below are according to the of PECARN Head CT Study[4]

<2 years old

PECARN Under Age 2

Any 1 of the following?

Then obtain a Non-Con Brain CT (4.4% risk of cTBI)

1 or more of the following?

  • Non-frontal scalp hematoma
  • LOC ≥ 5 seconds
  • Severe injury mechanism
    • pedestrian or bicyclist without helmet struck by motorized vehicle
    • fall >1m or 3ft
    • head struck by high-impact object
  • Abnormal activity per parents

Then consider a Non-Con Brain CT or Observation (0.9% risk of cTBI)

≥2 years old - 18 years

PECARN Age 2 and Up

Any 1 of the following?

Then obtain a Non-Con Brain CT (4.3% risk of cTBI)

1 or more of the following?

  • History of vomiting^
  • LOC
  • Severe injury mechanism
    • Pedestrian or bicyclist without helmet struck by motorized vehicle
    • Fall >2m or 5ft
    • Head struck by high-impact object
  • Severe headache

Then consider a Non-Con Brain CT or Observation (0.9% risk of cTBI)

^Consider observation in place of imaging in children with isolated vomiting (no other indication) as the sole risk factor (0.2% risk of cTBI)[5]

Management

Dependent on diagnosis, see:

Disposition

  • Discharge if:
    • Asymptomatic after 2-4hr obs (not vomiting, nl neuro exam, nl mental status)
    • Head CT normal (delayed deterioration after normal CT is near zero)
  • Consider discharge if:
    • Nondisplaced fracture with out intracranial injury (in consultation with neurosx)

See Also

General/Adult

Pediatric

Calculators

PECARN Pediatric Head Injury

PECARN — Pediatric Head CT Decision Rule
Age Group Select One
Patient Age 1 <2 years    ≥2 years
Age <2 Years — Risk Factors
Criteria No Yes
GCS <15 (altered mental status) 1
Palpable skull fracture 1
Occipital/parietal/temporal scalp hematoma 1
Loss of consciousness ≥5 seconds 1
Not acting normally per parent 1
Severe mechanism of injury (MVC with ejection/rollover/fatality, pedestrian/cyclist without helmet struck by motorized vehicle, fall >3 feet, head struck by high-impact object) 1
Risk Factors (<2y) / 6
Age ≥2 Years — Risk Factors
Criteria No Yes
GCS <15 (altered mental status) 1
Signs of basilar skull fracture (hemotympanum, raccoon eyes, Battle sign, CSF otorrhea/rhinorrhea) 1
Vomiting 1
Loss of consciousness 1
Severe headache 1
Severe mechanism of injury (MVC with ejection/rollover/fatality, pedestrian/cyclist without helmet struck by motorized vehicle, fall >5 feet, head struck by high-impact object) 1
Risk Factors (≥2y) / 6
Interpretation (for selected age group)
0 Very low risk — ciTBI risk <0.02% (<2y) or <0.05% (≥2y). CT not recommended.
1 (intermediate*) Low risk — ciTBI risk ~0.9% (<2y) or ~0.8% (≥2y). Observation vs. CT. *Only if GCS=15 and no skull fracture/AMS. Consider observation for 4-6 hours.
GCS<15 or skull fx High risk — ciTBI risk 4.4% (<2y) or 4.3% (≥2y). CT recommended.
References
  • Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374:1160-1170. PMID 19758692.

External Links

References

  1. ↑ Elkhunovich, M., Sirody, J., McCormick, T., Goodarzian, F., & Claudius, I. (2018). The Utility of Cranial Ultrasound for Detection of Intracranial Hemorrhage in Infants. Pediatric Emergency Care, 34(2), 96–101.
  2. ↑ Holmes JF, Palchak MJ, MacFarlane T, et al. Performance of the pediatric glasgow coma scale in children with blunt head trauma. Acad Emerg Med. 2005 Sep;12(9):814-9.
  3. ↑ James HE. Neurologic evaluation and support in the child with an acute brain insult. Pediatr Ann. 1986 Jan;15(1):16-22.
  4. ↑ PECARN Rule Kupperman N, Holmes JF, Dayan PS, et al: Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 374(9696): 1160, 2009
  5. ↑ Dayan PS, et al. "Association of Traumatic Brain Injuries with Vomiting in Children with Blunt Head Trauma. June 2014. Annals of EM. 63(6):657-665
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