Pediatric Head Injury Assessment

Introduction to PECARN Criteria

The American College of Radiology and American Academy of Pediatrics recommend using the PECARN criteria to assess pediatric head injuries, with different risk criteria for children under 2 years and older children 1, 2
The PECARN criteria are not designed for suspected abuse cases, which require a different evaluation approach with a lower threshold for imaging 1, 3

Children can be stratified into risk categories based on the PECARN criteria, with the following criteria:

Age	Criteria	Risk Category
< 2 years	Normal mental status, no scalp hematoma, no loss of consciousness, non-severe injury mechanism	Low
< 2 years	Abnormal mental status, scalp hematoma, loss of consciousness, severe injury mechanism	Intermediate/High
≥ 2 years	Normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture	Low
≥ 2 years	Abnormal mental status, loss of consciousness, vomiting, severe injury mechanism, signs of basilar skull fracture	Intermediate/High

Children meeting very low risk PECARN criteria can safely avoid CT scans due to a <0.05% risk of clinically important traumatic brain injury (ciTBI) 1

The American College of Radiology recommends CT imaging for children under 2 years old with altered mental status, palpable skull fracture, vomiting, loss of consciousness, severe mechanism of injury, or abnormal behavior, as these factors increase the risk of traumatic brain injury 2, 1
Planned observation reduces CT use by 3.9% with no increase in missed injuries, and each additional hour of observation is associated with decreased CT utilization without missing significant injuries, with a recommended 4-6 hour observation period for children meeting PECARN very low risk criteria before discharge 4
Patients can be safely discharged after the observation period if they meet all criteria, including no deterioration in neurological status, no development of concerning symptoms, normal behavior according to parents, and reliable caregivers who can monitor the child at home, with instructions to return if the child develops persistent vomiting, severe or worsening headache, difficulty waking up or staying awake, confusion or unusual behavior, seizures, weakness or numbness in arms or legs, or difficulty walking or talking 1, 4

Infants under 12 months have a higher risk of clinically significant traumatic brain injury even with minor mechanisms 2
A thorough medical history should include questions about the timing of the injury, past medical history, medication history, home environment, and risk assessment, as these factors can contribute to the overall assessment of suspected child abuse, with documentation of the history using the caregiver's exact words when possible, avoiding value judgments or interpretations of body language, and documenting any discrepancies in the history without accusatory language, as recommended by the American Academy of Pediatrics and American College of Radiology 5, 6
The presence of concerning social factors, such as a history of previous injuries or ED visits for trauma, inappropriate responses from caregivers, and evasive answers to direct questions, should be assessed and documented as they may indicate an increased risk of child abuse 5
The American Academy of Pediatrics notes that CT imaging carries radiation risks that must be balanced against the low probability of clinically important traumatic brain injury in very low-risk patients 2