Management of Toddler Head Injury Without Loss of Consciousness

Risk Stratification Using PECARN Criteria

The American College of Radiology recommends using PECARN criteria to determine if CT imaging is needed for a toddler with head injury and no loss of consciousness, with a risk of clinically important brain injury of <0.02% for very low-risk children under 2 years 1, 2
For children under 2 years, the PECARN criteria include a GCS score of 15, normal mental status, no palpable skull fracture, no nonfrontal scalp hematoma, no severe mechanism, and acting normally per parents, with a risk of clinically important brain injury of <0.02% 1, 2
For children 2 years and older, the PECARN criteria include a GCS score of 15, normal mental status, no signs of basilar skull fracture, no vomiting, no severe headache, and no severe injury mechanism, with a risk of clinically important brain injury of <0.05% 2
The presence of vomiting, severe mechanism of injury, or nonfrontal scalp hematoma in children under 2 years increases the risk of significant injury to 0.8-0.9% 5, 1

The American College of Radiology recommends CT head without contrast as the imaging modality of choice when indicated, as it rapidly identifies bleeding and fractures, does not require sedation, and has excellent sensitivity for acute intracranial hemorrhage 4, 5
The use of skull radiographs is not recommended, as up to 50% of intracranial injuries occur without fracture, and radiographs miss many fractures that CT would detect 5, 1, 2
Advanced imaging such as CTA, MRA, MRI, or conventional angiography is not recommended for initial evaluation of minor head trauma in children 5, 1, 2