Management of Pediatric Head Trauma Due to Fall

Initial Risk Stratification

The American College of Radiology recommends using the PECARN clinical decision rules to guide all imaging decisions in pediatric head trauma, as they have been prospectively validated in over 40,000 children with 99.9-100% negative predictive value 1, 2
Children under 2 years of age can safely avoid CT imaging if they have a Glasgow Coma Scale (GCS) score of 15, normal mental status, no palpable skull fracture, no nonfrontal scalp hematoma, loss of consciousness ≤5 seconds, no severe mechanism of injury, and are acting normally per parents' report, with a risk of clinically important traumatic brain injury of <0.02% 1, 2, 3, 4
Children 2 years and older can safely avoid CT imaging if they have a GCS score of 15, normal mental status, no signs of basilar skull fracture, no vomiting, no severe headache, and no severe mechanism of injury, with a risk of clinically important traumatic brain injury of <0.05% 1, 2, 3

The American College of Radiology recommends obtaining urgent non-contrast head CT for children with GCS ≤13, altered mental status, signs of basilar skull fracture, palpable skull fracture, post-traumatic seizure, or focal neurological deficits, with a risk of clinically important injury ranging from 4.3-16% 1, 2, 3
Children with intermediate-risk features, such as loss of consciousness >5 seconds, severe mechanism of injury, or nonfrontal scalp hematoma, should undergo either CT or careful observation, with a risk of clinically important injury of 0.8-0.9% 1, 3, 4

The American Academy of Pediatrics recommends immediate intubation with spine protection, maintenance of normocapnia, prevention of hypotension, and urgent CT head and cervical spine for children with severe head trauma (GCS ≤8) 2, 3
The American College of Radiology recommends using non-contrast CT as initial imaging, implementing pediatric-specific reduced-dose protocols, and obtaining multiplanar and 3D reconstructions to increase sensitivity for fractures and small hemorrhages 3

The American Academy of Pediatrics recommends maintaining a high index of suspicion for non-accidental trauma in children under 2 years, and obtaining either non-contrast CT or MRI regardless of clinical presentation, with a risk of clinically important injury ranging from 4.3-16% 1, 2, 3
Common pitfalls to avoid include obtaining CT in very low-risk patients, delaying imaging when high-risk features are present, using skull radiographs instead of CT, and attempting MRI in the acute setting 3, 4

The American Academy of Pediatrics recommends providing comprehensive discharge instructions, educating parents on expected symptom course, and giving specific monitoring instructions for children discharged without imaging, with follow-up for persistent postconcussive symptoms beyond 2 weeks 3, 5
Children requiring admission should undergo early rehabilitation planning, with physical, occupational, cognitive, speech, and play therapy as needed, and a goal of returning the child to full, age-appropriate function 2, 3, 4