A 16-year-old boy is brought to the emergency department after loss of consciousness. The patient was riding his bicycle when he lost his balance and fell, hitting his head on the ground. The fall was witnessed by several friends who report that the boy lost consciousness for approximately 1 minute. There were no seizures following the event. The boy vomited twice in the ambulance and has a mild headache. He has no other medical conditions and takes no medications. Blood pressure is 121/67 mm Hg and pulse is 78/min. The patient is awake and alert. Examination shows a small bruise and an abrasion over the right temporal region. Neurological examination shows intact cranial nerves. Strength is 5/5 bilaterally. Sensations are intact and reflexes are equal. Gait examination shows no abnormalities. Romberg test is negative. Which of the following is the most appropriate next step in management of this patient?
Pediatric traumatic brain injury (PECARN rule) | |
High-risk features |
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High-risk features |
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Management |
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CSF = cerebrospinal fluid; MVC = motor vehicle collision. | |
Minor head trauma is common in children and adolescents and usually does not lead to any long-term complications. However, a minority of patients can have life-threatening traumatic brain injury (eg, intracranial hemorrhage). To avoid unnecessary radiation exposure from imaging overuse, management of minor head trauma is based on risk for intracranial injury.
High-risk features of head trauma in children age ≥2 include:
Head CT scan without contrast is the preferred imaging modality to evaluate for an intracranial bleed (eg, subdural hematoma) when high-risk features are present, as in this patient with both LOC and vomiting after a fall. Alternatively, observation for 4-6 hours in the emergency department may be an option for patients with isolated or mild/improved high-risk features (eg, brief LOC, resolved vomiting) but normal mental status and no signs of a basilar skull fracture. Head CT scan is warranted if symptoms worsen during the observation period.
(Choice A) Patients with no high-risk features of intracranial injury can typically be discharged with instructions on when to seek re-evaluation (eg, severe headache). This patient with LOC and vomiting could be discharged only after a normal CT scan or if symptoms improve during observation.
(Choice B) After head imaging, electroencephalography may be performed in a trauma patient with seizure activity, not seen here.
(Choice D) Skull radiographs are sometimes used to evaluate for a fracture in an infant with an uncertain history of trauma (eg, child abuse) but are not indicated for known head trauma because they cannot detect intracranial injury.
(Choice E) Urgent neurosurgical evaluation is appropriate if an intracranial bleed is detected on neuroimaging or in an unstable, altered patient with head trauma.
Educational objective:
Head CT scan without contrast is indicated for minor head trauma with high-risk features for intracranial injury (ie, altered mental status, loss of consciousness, severe mechanism of injury, vomiting or severe headache, signs of a basilar skull fracture). Observation for 4-6 hours may be an alternative option if mental status is normal and there are no signs of a basilar skull fracture.