Pediatric Head Injury

Key considerations: Epidural hematoma, Subdural hematoma, Cerebral contusion or hemorrhage

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history: Exact mechanism: height of fall, surface, speed; Loss of consciousness — duration; Vomiting — number of episodes; Behavior change: irritable, sleepy, confused; Amnesia (pre- or post-traumatic); Seizure at time of injury; Age-appropriate: acting normally? Feeding? Playing?; exam: GCS (use pediatric GCS for <2 years); Fontanelle: bulging (increased ICP); Scalp: hematoma (location and size — non-frontal worse in <2yr); Skull palpation: step-off, crepitus, depressed fracture; Pupils: size, symmetry, reactivity; Cerebellar signs, focal deficits; Signs of basilar skull fracture: Battle sign, raccoon eyes, hemotympanum, CSF rhinorrhea/otorrhea; labs: Not routinely needed; Coagulation studies if on anticoagulants or bleeding disorder; imaging: Apply PECARN Head CT rules to determine imaging need; CT head NON-CONTRAST if indicated by PECARN high-risk criteria; Observation alternative for PECARN intermediate-risk with reliable caregivers; bedside: Serial neurological assessments; Continuous monitoring if altered

immediate: ABCs with C-spine precautions if significant mechanism; Elevate head of bed 30 degrees if increased ICP concern; Control active scalp bleeding (can cause significant blood loss in infants); general: Apply PECARN rules for CT decision-making; Serial neuro checks q1h for observation pathway; specific: diagnosis: Concussion; steps: Rest from cognitive and physical activity for 24-48 hours; Gradual return to activity (not all at once); Acetaminophen for headache (avoid NSAIDs acutely); No contact sports until asymptomatic and cleared by physician; Concussion discharge instructions with return precautions; diagnosis: Epidural/subdural hematoma; steps: Emergent neurosurgery consult; If herniating: mannitol 1g/kg IV or hypertonic saline 3% 5mL/kg IV; Intubation with neuroprotective strategy; Elevate head of bed, maintain normothermia; diagnosis: Skull fracture; steps: CT head to evaluate for intracranial injury; Neurosurgery consult for depressed or open fractures; Basilar skull fracture: prophylactic antibiotics controversial, avoid NG tube (use OG)

admit: Intracranial hemorrhage; GCS <15 that does not improve; Skull fracture; Persistent altered mental status or vomiting; Suspected non-accidental trauma (mandatory); Anticoagulated patient with head injury; discharge: PECARN low-risk with normal neurological exam; Concussion with improving symptoms; Reliable caregivers who understand head injury return precautions; Written head injury instructions provided; consults: Neurosurgery for intracranial hemorrhage or depressed skull fracture; Child abuse team if NAT suspected; Sports medicine for concussion follow-up

PECARN rules: <2 years — GCS <15, palpable skull fracture, AMS, non-frontal hematoma, LOC >5sec, severe mechanism, not acting normally → CT
PECARN rules: ≥2 years — GCS <15, signs of basilar skull fracture, AMS, LOC, vomiting, severe mechanism, severe headache → CT
Non-frontal scalp hematomas in infants <2 are associated with higher risk of intracranial injury than frontal hematomas
Scalp lacerations in infants can cause SIGNIFICANT hemorrhage — always check hemoglobin if large laceration and assess for shock

PECARN Head Injury Prediction Rules (Kuppermann et al. Lancet 2009), CDC Pediatric mTBI Guidelines 2018. Last reviewed: 2024-11-01