Assessment of Pediatric Head Injury

Initial Clinical Assessment

The American College of Radiology recommends using the PECARN criteria to stratify risk and guide imaging decisions in children with head trauma, as this validated approach minimizes unnecessary radiation while identifying clinically important injuries 1, 2
High-risk features for children ≥2 years old include a Glasgow Coma Scale (GCS) score of 14, signs of altered mental status, and signs of basilar skull fracture, with a 4.3% risk of clinically important injury 2, 3
Intermediate-risk features for children ≥2 years old include a GCS of 15 with normal mental status but history of loss of consciousness, severe headache, or severe mechanism of injury, with a 0.8% risk of clinically important injury 3, 4, 5
High-risk features for children <2 years old include a GCS score of 14, signs of altered mental status, and any palpable skull fracture, with a 4.4% risk of clinically important injury 2, 3
Intermediate-risk features for children <2 years old include a GCS of 15 with normal mental status but loss of consciousness >5 seconds, severe mechanism of injury, or not acting normally per parent, with a 0.9% risk of clinically important injury 3, 4

The American College of Radiology recommends immediate non-contrast CT for high-risk patients, including those with a GCS ≤14, altered mental status, basilar skull fracture signs, or palpable skull fracture in infants 1, 2, 6
CT is the first-line imaging modality because of its rapid acquisition, excellent sensitivity for acute hemorrhage and fractures, and no requirement for sedation 1, 2, 6
Skull radiographs should not be used as they miss up to 50% of intracranial injuries and cannot evaluate brain parenchyma 1, 2, 3
MRI is more sensitive than CT for detecting traumatic lesions and is particularly useful in suspected non-accidental trauma, but is impractical acutely due to length of exam and need for sedation in young children 4, 7, 8

The American College of Radiology recommends maintaining a low threshold for neuroimaging in children <1 year with any concerning findings, or any child with unexplained injuries or inconsistent history, in cases of suspected non-accidental trauma 8
CTA is not routine but should be considered if there is a basilar skull fracture through vascular canal, clinical signs of arterial stroke, or unexplained neurologic deficits 2, 6

The American College of Emergency Physicians recommends providing written warning signs of serious injury, description of expected symptom course, instructions for monitoring postconcussive symptoms, guidance on cognitive and physical rest, clear follow-up instructions, and prevention counseling for low-risk patients discharged without imaging 5, 7, 8

The Pediatric Emergency Care Applied Research Network (PECARN) criteria define a child under 2 years of age as "very low risk" if they have a Glasgow Coma Scale (GCS) = 15 with no palpable skull fracture, nonfrontal scalp hematoma, loss of consciousness ≥5 seconds, severe mechanism of injury, or other signs of altered mental status, with a stable vital signs and normal behavior, according to the American College of Radiology 9, 10.
A child with a forehead hematoma who is laughing and playing with stable vitals and no loss of consciousness falls into the "very low risk" category, as defined by the American College of Radiology 9, 10.
The location of the hematoma is significant, with nonfrontal hematomas carrying a higher risk, as stated by the American College of Radiology 9.

Concerning symptoms that would indicate possible intracranial injury include vomiting, excessive sleepiness, irritability, changes in behavior, seizures, worsening headache, unsteady walking, and unequal pupil size, according to the American College of Radiology 9, 10, 11.
Reassuring signs include return to baseline behavior, no loss of consciousness, and stable vital signs, as indicated by the American College of Radiology 9, 10 and Anaesthesia 12.

The mechanism of injury is not considered severe if it does not involve high-speed motor vehicle accidents or falls from significant heights, as stated by the American College of Radiology 9, 10.

Immediate medical attention should be sought if the child develops persistent vomiting, increasing drowsiness, seizure activity, worsening headache, or new neurological symptoms, according to the American College of Radiology 9, 10, 11.