II. Indications

  1. Pediatric Head Trauma decision tool on whether to perform neuroimaging

III. General

  1. CT Head in all moderate and Severe Head Trauma
    1. CT Head has a higher Test Sensitivity for Intracranial Hemorrhage than MRI Head
  2. Guidelines below apply to minor Head Trauma only
    1. Blunt Head Trauma
    2. Patient remains awake and alert
  3. Delayed Intracranial Hemorrhage following minor head injuries is rare beyond 6 hours in children
    1. Hamilton (2010) Pediatrics 126(1): e33-9 [PubMed] (or open in [QxMD Read])

IV. Cause: Severe Mechanism of Injury (used in criteria below)

  1. Motor vehicle crash with ejection
  2. Death of another passenger
  3. Rollover
  4. Fall greater than 3 feet (>5 feet if over age 2 years)
  5. Unhelmeted pedestrian
  6. Bicyclist struck by motorized vehicle
  7. Head struck by high impact object (e.g. baseball)

V. Protocol: Age <2 years old

  1. CT Head indications (4.4% risk of clinically important TBI)
    1. GCS 14 or less or other signs of Altered Level of Consciousness
      1. Agitation or Somnolence or
      2. Repetitive questions or slow response to questions
    2. Palpable Skull Fracture
  2. Additional CT Head Indications or Observation for 4-6 hours (0.9% risk of clinically important TBI)
    1. Occipital, parietal or temporal scalp hematoma or
    2. History of loss of consciousness of 5 seconds or more or
    3. Severe Mechanism of injury or
    4. Not acting normally per parent
  3. Additional features which may warrant CT Head (not part of PECARN guidelines)
    1. Worsening symptoms or signs in the emergency department or
    2. Age <3 months
      1. Younger children are less likely to be symptomatic
    3. Bulging Fontanelle
    4. Three to four episodes of Vomiting after injury
    5. Seizure
  4. Interpretation if all criteria negative
    1. Risk of missed clinically important TBI: <0.02%

VI. Protocol: Age 2 or more years old

  1. CT Head indications (4.3% risk of clinically important TBI)
    1. GCS 14 or less or other Altered Level of Consciousness signs or
    2. Basilar Skull Fracture
  2. Additional CT Head Indications or Observation for 4-6 hours (0.9% risk of clinically important TBI)
    1. Loss of consciousness or
    2. History of Vomiting or
    3. Severe Mechanism of injury or
    4. Severe Headache
  3. Additional features which may warrant CT Head (not part of PECARN guidelines)
    1. Worsening symptoms or signs in the emergency department
    2. Seizure
  4. Interpretation if all criteria negative
    1. Risk of missed clinically important TBI: <0.05%

VII. Precautions

  1. Difficult balance between risk of missing a clinically important TBI and ionizing radiation exposure
    1. Positive PECARN indications for Head CT have a 1% risk of clinically important TBI
    2. Single Head CT in children and adolescents has an associated cancer risk of 0.025%
    3. ED Observation for 2-3 hours is a reliable and safe strategy for children with low and moderate risk head injuries
      1. Schonfeld (2013) Ann Emerg Med 62(6): 597-603 [PubMed] (or open in [QxMD Read])
  2. Skull Fracture is associated with an intracranial injury in 15-30%
    1. Scalp hematoma predicts Fracture (>80% sensitivity)
    2. Higher risk Fractures
      1. Depressed Skull Fracture
      2. Basilar Skull Fracture
      3. New Skull Fracture <24 hours

VIII. References

  1. Kuppermann (2009) Lancet 374(9696):1160-70
  2. Schutzman (2001) Pediatrics 107:983-93 [PubMed] (or open in [QxMD Read])

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