Overview
Definition:
Pediatric head trauma refers to any injury to the scalp, skull, or brain sustained by a child, ranging from minor contusions to severe intracranial hemorrhages
The Pediatric Emergency Care Applied Research Network (PECARN) developed evidence-based clinical decision rules to guide the management of children with blunt head trauma and identify those who require neuroimaging.
Epidemiology:
Head injuries are a leading cause of unintentional injury-related mortality and morbidity in children globally
In the US, approximately 1.5 million children experience head injuries annually, with 250,000-300,000 requiring emergency department visits
Boys are more frequently affected than girls, and the incidence varies by age group, with toddlers and adolescents being at higher risk.
Clinical Significance:
Accurate assessment of pediatric head trauma is crucial to avoid unnecessary neuroimaging (with its associated radiation exposure and costs) while ensuring timely identification of serious intracranial injuries
The PECARN rules provide a standardized, evidence-based approach to help clinicians make informed decisions regarding CT scanning in pediatric patients with blunt head trauma, thereby optimizing care and resource utilization.
Clinical Presentation
Symptoms:
Chief complaint of head injury
Altered mental status (lethargy, irritability, inconsolable crying)
Vomiting
Headache
Seizures
Loss of consciousness
Amnesia
Neurological deficits (weakness, numbness, speech difficulty).
Signs:
Scalp lacerations or contusions
Skull fracture palpable
Battle's sign (postauricular ecchymosis)
Raccoon eyes (periorbital ecchymosis)
Hemotympanum
Nystagmus
Pupillary abnormalities (anisocoria, sluggish response)
Cranial nerve deficits
Signs of increased intracranial pressure (papilledema, Cushing's triad).
Diagnostic Criteria:
The PECARN decision rules are not diagnostic criteria in themselves but are clinical decision-making tools to guide the need for neuroimaging in children with blunt head trauma
They stratify patients into low-risk and high-risk groups based on specific clinical variables.
Diagnostic Approach
History Taking:
Mechanism of injury (falls, direct blow, motor vehicle accident, abuse)
Height of fall
Surface landed on
Duration and type of loss of consciousness
Amnesia (anterograde, retrograde)
Vomiting (frequency, content)
Seizure activity
Headache severity and characteristics
Irritability or inconsolable crying
Any neurological symptoms
History of prior head trauma or bleeding disorders
Age and developmental status.
Physical Examination:
Thorough head-to-toe examination
Focused neurological assessment including mental status (alertness, orientation), cranial nerves, motor strength, sensation, and reflexes
Detailed examination of the head and neck, including scalp, skull, ears (hemotympanum), nose (rhinorrhea), and orbits (raccoon eyes)
Assessment for signs of meningeal irritation
Vital signs including blood pressure, heart rate, respiratory rate, and oxygen saturation.
Investigations:
Neuroimaging: Head CT scan is the primary modality for identifying intracranial abnormalities
Indications for CT are guided by PECARN rules
MRI may be used for delayed evaluation or specific indications
Skull X-rays are generally not recommended for initial evaluation of head trauma
Laboratory tests are usually not indicated unless there are concerns for coagulopathy or systemic illness.
Differential Diagnosis:
Intracranial hemorrhage (subdural, epidural, subarachnoid, intraparenchymal)
Cerebral contusion
Diffuse axonal injury
Skull fracture (linear, depressed, basilar)
Epidural abscess
Subdural empyema
Meningitis
Hypertensive encephalopathy
Metabolic encephalopathy
Intracranial mass
Non-accidental trauma.
PECARN Decision Rules
Introduction:
The PECARN decision rules are designed to identify children with blunt head trauma who are at low risk for clinically important traumatic brain injury (ciTBI) and can therefore avoid routine head CT scanning.
Low Risk Criteria Age Under 2:
Children < 2 years of age with blunt head trauma are considered low risk for ciTBI if they meet ALL of the following criteria: Normal behavior (when not crying or being examined)
No skull fracture
No signs of a basilar skull fracture
No vomiting
Normal mental status
No scalp hematoma greater than 2 cm in diameter or in a concerning location (e.g., parietal or occipital)
No impact significant for mechanism of injury (e.g., fall > 3 feet or struck by a significant object).
Low Risk Criteria Age 2 To 18:
Children 2 to 18 years of age with blunt head trauma are considered low risk for ciTBI if they meet ALL of the following criteria: Normal behavior (when not crying or being examined)
No headache
No vomiting
No signs of a basilar skull fracture
No neurological signs (focal deficit, occipital scalp tenderness, temporal scalp tenderness, posterior neck tenderness).
High Risk Criteria:
Any child with blunt head trauma who does NOT meet the low-risk criteria is considered to be at higher risk for ciTBI and should be considered for head CT scanning
These include children with altered mental status, signs of skull fracture (especially basilar), significant vomiting, focal neurological deficits, and specific mechanisms of injury or concerning scalp findings.
Application And Validation:
These rules were derived from large prospective cohort studies and have demonstrated high sensitivity and specificity in identifying children with ciTBI, aiming to reduce the number of unnecessary CT scans while maintaining safety
They have been validated in multiple pediatric emergency departments.
Management
Initial Management:
ABC assessment (Airway, Breathing, Circulation)
Maintain cervical spine precautions if mechanism is concerning
Control external bleeding with direct pressure
Provide oxygen if hypoxic
Establish intravenous access if necessary
Monitor vital signs closely.
Medical Management:
Primarily supportive
Management of seizures with benzodiazepines
Analgesia for headache
Anti-emetics for vomiting
Avoidance of sedatives that may obscure neurological assessment unless absolutely necessary
Observation is key for low-risk patients.
Surgical Management:
Indicated for significant intracranial hemorrhage requiring surgical evacuation (e.g., epidural hematoma, large subdural hematoma) or for depressed skull fractures requiring elevation
Neurosurgical consultation is essential for patients identified with severe intracranial injuries.
Supportive Care:
Continuous neurological monitoring
Strict fluid management
Pain and nausea control
Prevention of secondary brain injury (e.g., avoiding hypoxia, hypotension)
Education of caregivers regarding warning signs and follow-up.
Complications
Early Complications:
Epidural hematoma
Subdural hematoma
Subarachnoid hemorrhage
Intraparenchymal hemorrhage
Diffuse axonal injury
Skull fractures
Seizures
Intracranial hypertension
Herniation syndromes
Cerebrospinal fluid leak.
Late Complications:
Post-traumatic seizures
Cognitive deficits (attention, memory, executive function)
Behavioral changes
Academic difficulties
Chronic headaches
Post-concussive syndrome
Hydrocephalus
Post-traumatic epilepsy.
Prevention Strategies:
Use of appropriate safety restraints (car seats, seat belts)
Wearing helmets during sports and recreational activities
Childproofing homes to prevent falls
Education on safe play environments
Prompt evaluation and appropriate management of head injuries to prevent secondary complications.
Prognosis
Factors Affecting Prognosis:
Severity of the initial injury (GCS score, presence and type of intracranial injury)
Age of the child
Presence of pre-existing medical conditions
Timeliness and appropriateness of medical and surgical management
Development of complications.
Outcomes:
Most children with mild head trauma and no intracranial injuries recover fully with minimal or no long-term sequelae
However, children with moderate to severe head injuries, especially those with significant intracranial pathology, may experience a range of long-term deficits affecting cognitive, behavioral, and physical functions.
Follow Up:
Follow-up is guided by the severity of the injury and the presence of any neurological deficits or symptoms
Children with mild head trauma may require only brief follow-up or symptom-based management
Those with moderate to severe injuries require comprehensive neurodevelopmental assessments, rehabilitation services, and ongoing monitoring by pediatric neurologists, neuropsychologists, and other specialists.
Key Points
Exam Focus:
Understand the PECARN criteria for both age groups (<2 years and 2-18 years) meticulously
Be able to identify the specific signs and symptoms that place a child at high risk for ciTBI
Know when CT is indicated and when it can be safely avoided.
Clinical Pearls:
Always assess for non-accidental trauma in young children with head injuries, especially if the history is inconsistent with the findings
In younger children, irritability and inconsolable crying can be signs of altered mental status
Be thorough in your physical exam to detect subtle signs of basilar skull fracture or concerning scalp hematomas.
Common Mistakes:
Over-reliance on mechanism of injury alone without considering clinical presentation
Missing subtle signs of basilar skull fracture
Failing to correctly apply the PECARN criteria, leading to either unnecessary imaging or missed significant injuries
Not adequately reassessing altered mental status in a child who initially appeared well.