Pediatric Head TraumaAPPROACH

TRAUMA AND WOUNDS · 19 SECTIONS

⚲

649 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

Motor Vehicle Collision Evaluation Chest Wall Trauma And Rib Injury Blunt Abdominal Trauma Evaluation Penetrating Trauma Evaluation Pediatric Minor Head Trauma Pediatric Head Trauma Facial Lacerations And Dental Trauma Hand Lacerations With Tendon Injury Concern Puncture Wounds And Retained Foreign Body Concern Electrical Injury Burn Injury Fall Evaluation Assault And Interpersonal Violence Evaluation Eye Trauma And Hyphema Concern

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx88

Mechanism and context

›Injury circumstances

›Time since injury

›Witnessed event

›Unwitnessed event

›Height of fall

›Surface type

›Object strike

›High speed MVC

›Ejection

›Rollover

›Pedestrian struck

›Bicycle collision

›Helmet use

›Sports collision

›Assault

›Suspected non accidental trauma

›Water related injury

›Seizure preceding trauma

›Syncope preceding trauma

Symptoms and neurologic course

›Post injury symptoms

›Loss of consciousness

›Duration of loss of consciousness

›Amnesia

›Vomiting count

›Headache presence

›Headache progression

›Seizure after injury

›Abnormal behavior

›Confusion

›Somnolence

›Irritability

›Poor feeding

›Inconsolable crying

›Visual changes

›Dizziness

›Gait change

›Focal weakness

›Numbness

›Neck pain

OPQRST for headache

›O onset

›Immediate after impact

›Delayed onset after injury

›P provocation and palliation

›Worse with exertion

›Worse with light

›Worse with noise

›Worse with screen use

›Relief with rest

›Relief with acetaminophen

›Q quality

›Pressure

›Throbbing

›Sharp

›Diffuse

›R region and radiation

›Frontal

›Occipital

›Temporal

›Vertex

›Facial pain

›Neck radiation

›S severity

›Pain score 0 to 10

›Functional limitation

›T timing

›Constant

›Intermittent

›Worsening

›Improving

Associated symptoms

›Associated symptoms

›Fever

›Photophobia

›Phonophobia

›Rhinorrhea

›Otorrhea

›Epistaxis

›Neck stiffness

›Back pain

›Chest pain

›Abdominal pain

›Limb pain

Events and care since injury

›Prehospital and interim course

›EMS assessment

›Immobilization used

›Bleeding control

›Medications given

›Interval deterioration

›Return to baseline behavior

02Alarm Features/alarm50

Immediate escalation triggers

›Resuscitation triggers

›Airway compromise

›Apnea

›Hypoventilation

›Hypoxia

›Shock

›Active seizure

›Recurrent seizure

›GCS 12 or less

›Declining mental status

›Unilateral fixed dilated pupil

›Focal neurologic deficit

›Signs of raised intracranial pressure

›Bulging fontanelle

›Cushing response

›Repeated projectile vomiting

›Suspected non accidental trauma with concerning story

High risk exam findings

›High risk findings

›Basilar skull fracture signs

›CSF rhinorrhea

›CSF otorrhea

›Hemotympanum

›Periorbital ecchymosis

›Retroauricular ecchymosis

›Depressed skull fracture

›Large scalp hematoma in infant

›Palpable skull step off

›Persistent altered behavior

›Persistent lethargy

›Cervical spine tenderness

Vital sign danger patterns

›Vital sign dangers

›Hypotension for age

›Bradycardia with hypertension pattern

›Persistent tachycardia unexplained

›SpO2 under 92 percent on room air

›RR depressed for age

›Persistent fever with meningismus

High risk historical triggers

›High risk history

›High impact mechanism

›Prolonged loss of consciousness

›Severe or worsening headache

›Multiple vomiting episodes

›Post traumatic seizure

›Bleeding disorder

›Anticoagulant exposure

›VP shunt

›Known brain tumor

›Prior neurosurgery

›Suspected intoxication

›Inability to observe reliably at home

03Medications/meds23

Current and recent exposures

›Medication exposure

›Anticoagulants

›Antiplatelets

›NSAIDs

›Acetaminophen

›Sedatives

›Stimulants

›Antiseizure medications

›ADHD medications

›Recent anesthesia

›Recent medication changes

Contraindications and interaction traps

›Contraindications

›NSAIDs avoidance with suspected intracranial bleeding

›Sedating medications masking neurologic decline

›Ondansetron QT prolongation risk factors

ED symptom control dosing

›Symptom medication dosing

›Acetaminophen oral 15 mg per kg

›Maximum acetaminophen 75 mg per kg per day

›Ibuprofen oral 10 mg per kg

›Maximum ibuprofen 40 mg per kg per day

›Ondansetron oral 0.15 mg per kg

›Ondansetron IV 0.15 mg per kg

›Maximum single ondansetron dose 8 mg

04Diet/diet10

Intake and hydration

›Intake status

›Last oral intake time

›Poor intake since injury

›Persistent emesis limiting hydration

›Urine output change

Exposures relevant to symptoms

›Exposures

›Caffeine intake

›Energy drinks

›Possible toxin ingestion

›Alcohol exposure in adolescents

05Review of Systems/ros30

Neurologic and concussion symptoms

›Neuro symptoms

›Headache

›Dizziness

›Balance problems

›Vision changes

›Hearing changes

›Sleepiness

›Insomnia

›Irritability

›Emotional lability

›Concentration problems

›Memory problems

›Seizure

Head and neck

›Head and neck symptoms

›Neck pain

›Dysphagia

›Voice change

›Jaw pain

›Dental injury

›Epistaxis

›Rhinorrhea

›Otorrhea

Cardiopulmonary and systemic

›Systemic symptoms

›Chest pain

›Dyspnea

›Palpitations

›Fever

›Syncope

›Abdominal pain

›Limb pain

06Collateral History and Family History/chafh16

Collateral source and reliability

›Collateral

›Caregiver present

›Witness reliability

›Video footage available

›Teacher coach report

›EMS report

Family history relevant to differential

›Family history

›Bleeding disorder

›Seizure disorder

›Sudden cardiac death

›Migraine

Household and safety context

›Environment

›Supervision reliability

›Prior CPS involvement

›Previous unexplained injuries

›Access to safe observation overnight

07Risk Factors/rf19

Patient factors increasing intracranial injury risk

›High risk patient factors

›Age under 2 years

›Bleeding disorder

›Anticoagulant exposure

›VP shunt

›Neurodevelopmental delay

›Prior TBI

›Skull disorder

Injury pattern risks

›Injury pattern risks

›High impact mechanism

›Repeated impacts same day

›Suspected non accidental trauma

›Facial fractures suspicion

›Cervical spine mechanism

Social risks impacting safe discharge

›Discharge reliability risks

›Inability to awaken and observe at home

›Long travel distance to care

›No phone access

›Language barrier without support

08Differential Diagnosis/ddx57

Life threatening

›Life threatening

›Epidural hematoma

›Lucid interval possible

›Skull fracture association

›Subdural hematoma

›Concern for non accidental trauma in infants

›Anticoagulation risk

›Subarachnoid hemorrhage

›Severe sudden headache

›Meningismus

›Cerebral contusion

›Focal deficits possible

›Seizure risk

›Diffuse axonal injury

›Persistent coma

›Often normal initial CT possible

›Herniation syndrome

›Unilateral pupil

›Cushing response

›Cervical spine injury

›Midline tenderness

›Neuro deficit

›Non accidental trauma

›History inconsistent

›Sentinel injuries

Common

›Common

›Concussion mild traumatic brain injury (S06.0X)

›Normal neuroimaging typical

›Symptoms days to weeks

›Scalp hematoma

›Local swelling

›Pain

›Skull fracture

›Palpable step off

›Hematoma over fracture

›Post traumatic headache

›Migraine phenotype possible

›Tension phenotype possible

›Vomiting from pain or vestibular symptoms

›Improves with symptom control

›Persistent vomiting increases risk

Less common and mimics

›Less common

›Meningitis

›Fever

›Neck stiffness

›Intracranial mass incidental

›Progressive symptoms pre injury

›Morning vomiting

›Toxic ingestion

›Unexplained altered mental status

›Pupillary abnormalities

›Cardiac syncope

›Exertional collapse

›Family history sudden death

›Heat illness in sports

›Hyperthermia

›Collapse after exertion

09Past Medical History/pmh20

Neurologic and developmental baseline

›Baseline neuro status

›Prior concussion count

›Prior TBI complications

›Seizure disorder

›Migraine history

›Neurodevelopmental delay

Bleeding and medication related history

›Bleeding risk history

›Known coagulopathy

›Liver disease

›Thrombocytopenia history

›Anticoagulant indication

Devices and surgeries

›Devices and surgeries

›VP shunt

›Prior craniotomy

›Cervical spine surgery

›Cochlear implant

Social and safeguarding history

›Safeguarding

›Prior ED visits for injury

›Prior fractures

›Prior CPS involvement

10Physical Exam/exam55

Vitals and general appearance

›General and vitals

›Mental status level of alertness

›GCS total

›GCS eye

›GCS verbal

›GCS motor

›Work of breathing

›Perfusion

›Temperature pattern

Head and face trauma survey

›Head and face

›Scalp hematoma location

›Scalp hematoma size

›Palpable skull step off

›Lacerations

›Facial tenderness

›Dental injury

›Midface instability

›Orbital tenderness

Basilar skull fracture signs

›Basilar skull fracture

›Hemotympanum

›CSF otorrhea

›CSF rhinorrhea

›Periorbital ecchymosis

›Retroauricular ecchymosis

Pupils and cranial nerves

›Cranial nerve exam

›Pupils size symmetry

›Pupils reactivity

›Extraocular movements

›Visual fields gross

›Facial symmetry

›Gag and voice

Neurologic exam

›Neuro exam

›Speech quality

›Strength symmetry

›Tone

›Sensation gross

›Coordination

›Gait

›Pronator drift

Cervical spine and spine

›Spine exam

›Midline cervical tenderness

›Range of motion limitation

›Neurologic symptoms with movement

›Thoracolumbar tenderness

Skin and safeguarding findings

›Bruising and injury pattern

›Bruises in non mobile infant

›Bruising on torso ears neck

›Patterned bruising

›Multiple injuries different ages

Reassessment loop

›Reassessment loop

›Neuro checks frequency based on risk

›Repeat GCS trend

›Repeat vitals trend

›Repeat vomiting count

›New focal deficit trigger escalation

11Lab Studies/labs18

Point of care and immediate labs

›Immediate labs

›Glucose for altered mental status

›Pregnancy test in post menarche patients

›CBC for significant trauma or bleeding concern

›Electrolytes for vomiting dehydration

Coagulation and bleeding evaluation

›Coagulation labs

›INR for bleeding disorder or anticoagulant exposure

›aPTT for suspected coagulopathy

›Fibrinogen if severe trauma

Severe TBI and multisystem trauma labs

›Severe injury labs

›Type and screen if potential transfusion

›VBG or ABG for ventilation status

›Lactate for shock

›LFT for abdominal injury screening local protocol dependent

Toxicology when indicated

›Toxicology

›Ethanol if suspected intoxication

›Acetaminophen level if overdose concern

›Urine drug screen if altered mental status unexplained

12Imaging/img99

Scoring Systems

›Decision tools

›PECARN minor head trauma

›When to use

›Blunt head trauma

›GCS 14 to 15

›Presentation within 24 hours

›When not to use

›Penetrating trauma

›Known brain tumor

›Bleeding disorder with concerning presentation

›Neuroimaging already performed

›Age under 2 years high risk features

›GCS 14

›Palpable skull fracture

›Altered mental status

›Age under 2 years intermediate risk features

›Non frontal scalp hematoma

›Loss of consciousness 5 seconds or more

›Severe mechanism

›Not acting normally per parent

›Age 2 years and older high risk features

›GCS 14

›Signs of basilar skull fracture

›Altered mental status

›Age 2 years and older intermediate risk features

›History of loss of consciousness

›History of vomiting

›Severe headache

›Severe mechanism

›Application notes

›Observation pathway option for intermediate risk

›Shared decision making for CT in intermediate risk

›CATCH2 local protocol dependent

›Population

›Minor head injury with symptoms

›GCS 13 to 15

›Use case

›Alternative when PECARN not used

›Local practice standard

›CHALICE local protocol dependent

›Population

›Pediatric head injury broad

›ED triage support

›Use case

›Alternative when PECARN not used

›Local practice standard

MRI

›MRI brain

›Indications

›Persistent neurologic deficits with nondiagnostic CT

›Suspected diffuse axonal injury

›Subacute symptoms with concern for shear injury

›Suspected abusive head trauma with CT equivocal

›Contraindications and limitations

›Unstable patient

›Metal implants not MRI safe

›Need for sedation in young children

›Interpretation pearls

›DWI for diffuse axonal injury

›Susceptibility sequences for microhemorrhage

›CT head noncontrast

›Indications

›GCS 13 or less

›Focal neurologic deficit

›Signs of basilar skull fracture

›Palpable skull fracture

›Persistent altered mental status

›Post traumatic seizure with concerning features

›Worsening headache

›Recurrent vomiting with high risk features

›Suspected non accidental trauma

›Protocol and safety

›Pediatric dose reduction protocol

›Radiation risk discussion for low risk patients

›Interpretation pearls

›Epidural lens shape

›Subdural crescent shape

›Midline shift measurement

›Basal cistern effacement

›Limitations

›Early diffuse axonal injury may be missed

›Symptoms can precede imaging changes

›CT cervical spine local protocol dependent

›Indications

›Neuro deficit

›Midline cervical tenderness

›High risk mechanism with concerning exam

›Limitations

›Radiation exposure

›Prefer plain radiographs when appropriate

Ultrasound

›POCUS

›FAST exam in multisystem trauma

›Hemoperitoneum screen

›Pericardial effusion screen

›Ocular ultrasound local protocol dependent

›Optic nerve sheath diameter as raised ICP adjunct

›Not a standalone rule out test

›Skull fracture ultrasound local protocol dependent

›Adjunct in infants with scalp hematoma

›Does not exclude intracranial injury

13Special Tests/spec13

Bedside neurologic and vestibular assessment

›Bedside concussion tools

›Symptom inventory

›Balance testing

›Oculomotor screening

›Limitations in young children

Cervical spine clearance

›C spine clearance

›Clinical clearance criteria local protocol dependent

›Immobilization continuation triggers

›Imaging selection based on age and exam

Abuse evaluation adjuncts

›Abusive head trauma evaluation

›Skeletal survey in children under 2 years local protocol dependent

›Dilated retinal exam local protocol dependent

›Social work involvement

14ECG/ecg12

When relevant

›ECG indications

›Syncope preceding injury

›Palpitations

›Chest pain

›Suspected ingestion

›QT risk with antiemetics

High risk findings

›ECG red flags

›Long QT

›Brugada pattern

›Wolff Parkinson White pattern

›High grade AV block

›Ventricular arrhythmia

15Assessment/ax29

Severity and risk stratification

›Severity stratification

›Severe TBI (S06) with GCS 8 or less

›Airway protection likely required

›Neurosurgery emergent involvement

›Moderate TBI (S06) with GCS 9 to 12

›CT head typically indicated

›Observation or admission common

›Mild TBI concussion (S06.0X)

›GCS 14 to 15

›Imaging guided by decision tools

Working problem list

›Problem list

›Head injury with risk of intracranial hemorrhage

›Decision tool category documented

›Observation versus CT rationale

›Cervical spine injury risk

›Clearance status documented

›Imaging rationale if obtained

›Vomiting and dehydration risk

›PO tolerance status

›Antiemetic response

›Safeguarding concern if present

›History consistency

›Injury pattern consistency

Complications to rule out

›Complications

›Intracranial hemorrhage

›Skull fracture

›Cervical spine injury

›Seizure recurrence

›Raised intracranial pressure

16Plan/plan45

First 5 minutes and stabilization

›Critical workflow

›Airway positioning and suction readiness

›Oxygen for SpO2 under 92 percent

›Cardiorespiratory monitoring

›IV access criteria

›Two IV lines for shock or severe TBI

›Glucose check for altered mental status

›C spine immobilization when indicated

Neuroprotective targets for severe TBI

›Neuroprotection

›Head of bed 30 degrees if hemodynamically stable

›Normoxia target SpO2 94 to 98 percent

›Normocapnia target EtCO2 35 to 40 mmHg

›Avoid hypotension for age

›Treat hypoglycemia promptly

›Treat hyperthermia

Hyperosmolar therapy for impending herniation

›Hyperosmolar

›Hypertonic saline 3 percent IV 2 mL per kg bolus

›Repeat bolus based on response local protocol dependent

›Mannitol IV 0.5 g per kg local protocol dependent

›Avoid mannitol with hypotension

Seizure management

›Seizure plan

›Lorazepam IV 0.1 mg per kg

›Maximum lorazepam single dose 4 mg

›Levetiracetam IV 20 to 60 mg per kg local protocol dependent

›Fosphenytoin IV 20 mg PE per kg local protocol dependent

Symptom control for mild injury

›Symptom control

›Acetaminophen dosing per weight

›Ibuprofen dosing per weight if low bleed concern

›Ondansetron dosing per weight

›Oral hydration trial after antiemetic

Observation pathway

›ED observation

›Serial neuro checks interval local protocol dependent

›Repeat exam prior to discharge

›Worsening symptoms trigger CT

Consultation and escalation

›Consultation

›Neurosurgery for intracranial hemorrhage

›Trauma team for multisystem trauma

›PICU for severe TBI or airway needs

›Child protection team for suspected abuse

Reassessment triggers and time windows

›Reassessment triggers

›New vomiting after initial stability

›Increasing headache severity

›New confusion or somnolence

›New focal deficit

›Seizure recurrence

17Disposition/dispo30

ICU and high acuity care

›ICU criteria

›GCS 8 or less

›Intubation required

›Need for hyperosmolar therapy

›Refractory seizures

›Hemodynamic instability

›Significant intracranial hemorrhage with mass effect

Inpatient admission criteria

›Admission criteria

›Abnormal CT findings without ICU need

›Persistent altered mental status

›Persistent vomiting with dehydration

›Concerning social situation

›Suspected non accidental trauma

Observation unit criteria

›Observation criteria

›Intermediate risk decision tool category

›Symptoms improving with ED treatment

›Normal neuro exam

›Reliable reassessment possible

Discharge criteria

›Discharge criteria

›Normal mental status at baseline

›Normal neuro exam

›No concerning exam findings

›Tolerating oral intake

›Pain and nausea controlled

›Reliable caregiver observation available

›Clear return precautions understood

Follow up timing

›Follow up

›Primary care within 2 to 3 days for concussion symptoms

›Concussion clinic referral if symptoms over 2 weeks

›Neurosurgery follow up if skull fracture or hemorrhage

18Discharge Instructions/di29

Copy discharge instructions

›Copy discharge instructions

›Diagnosis

›Head injury with concussion symptoms possible

›Expected course

›Headache dizziness nausea tiredness can last days to weeks

›Activity

›Rest for 24 to 48 hours

›Gradual return to school and activity as tolerated

›No sports until cleared by a clinician

›Medications

›Acetaminophen as directed for headache

›Avoid sedating medicines unless prescribed

›Hydration

›Small frequent fluids

›Return to ED now if

›Worsening headache

›Repeated vomiting

›Confusion

›Trouble waking up

›Seizure

›Weakness or numbness

›Unequal pupils

›Slurred speech

›Neck pain with neurologic symptoms

›Any caregiver concern about deterioration

›Special instructions

›Wake checks overnight only if advised by clinician

›Avoid alcohol and recreational drugs in adolescents

›Limit screens if they worsen symptoms

19References/r6

Guidelines and decision tools

›References

›PECARN pediatric head trauma clinical prediction rules (2009)

›CDC pediatric mild traumatic brain injury guideline (2018)

›Brain Trauma Foundation guidelines for pediatric severe traumatic brain injury (latest version local protocol dependent)

›NICE head injury assessment and early management guideline (latest version local protocol dependent)

›Canadian Paediatric Society guidance on concussion and return to play return to school (local protocol dependent)

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Pediatric Head TraumaAPPROACH

TRAUMA AND WOUNDS · 19 SECTIONS

⚲

649 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx88

Mechanism and context

›Injury circumstances

›Time since injury

›Witnessed event

›Unwitnessed event

›Height of fall

›Surface type

›Object strike

›High speed MVC

›Ejection

›Rollover

›Pedestrian struck

›Bicycle collision

›Helmet use

›Sports collision

›Assault

›Suspected non accidental trauma

›Water related injury

›Seizure preceding trauma

›Syncope preceding trauma

Symptoms and neurologic course

›Post injury symptoms

›Loss of consciousness

›Duration of loss of consciousness

›Amnesia

›Vomiting count

›Headache presence

›Headache progression

›Seizure after injury

›Abnormal behavior

›Confusion

›Somnolence

›Irritability

›Poor feeding

›Inconsolable crying

›Visual changes

›Dizziness

›Gait change

›Focal weakness

›Numbness

›Neck pain

OPQRST for headache

›O onset

›Immediate after impact

›Delayed onset after injury

›P provocation and palliation

›Worse with exertion

›Worse with light

›Worse with noise

›Worse with screen use

›Relief with rest

›Relief with acetaminophen

›Q quality

›Pressure

›Throbbing

›Sharp

›Diffuse

›R region and radiation

›Frontal

›Occipital

›Temporal

›Vertex

›Facial pain

›Neck radiation

›S severity

›Pain score 0 to 10

›Functional limitation

›T timing

›Constant

›Intermittent

›Worsening

›Improving

Associated symptoms

›Associated symptoms

›Fever

›Photophobia

›Phonophobia

›Rhinorrhea

›Otorrhea

›Epistaxis

›Neck stiffness

›Back pain

›Chest pain

›Abdominal pain

›Limb pain

Events and care since injury

›Prehospital and interim course

›EMS assessment

›Immobilization used

›Bleeding control

›Medications given

›Interval deterioration

›Return to baseline behavior

02Alarm Features/alarm50

Immediate escalation triggers

›Resuscitation triggers

›Airway compromise

›Apnea

›Hypoventilation

›Hypoxia

›Shock

›Active seizure

›Recurrent seizure

›GCS 12 or less

›Declining mental status

›Unilateral fixed dilated pupil

›Focal neurologic deficit

›Signs of raised intracranial pressure

›Bulging fontanelle

›Cushing response

›Repeated projectile vomiting

›Suspected non accidental trauma with concerning story

High risk exam findings

›High risk findings

›Basilar skull fracture signs

›CSF rhinorrhea

›CSF otorrhea

›Hemotympanum

›Periorbital ecchymosis

›Retroauricular ecchymosis

›Depressed skull fracture

›Large scalp hematoma in infant

›Palpable skull step off

›Persistent altered behavior

›Persistent lethargy

›Cervical spine tenderness

Vital sign danger patterns

›Vital sign dangers

›Hypotension for age

›Bradycardia with hypertension pattern

›Persistent tachycardia unexplained

›SpO2 under 92 percent on room air

›RR depressed for age

›Persistent fever with meningismus

High risk historical triggers

›High risk history

›High impact mechanism

›Prolonged loss of consciousness

›Severe or worsening headache

›Multiple vomiting episodes

›Post traumatic seizure

›Bleeding disorder

›Anticoagulant exposure

›VP shunt

›Known brain tumor

›Prior neurosurgery

›Suspected intoxication

›Inability to observe reliably at home

03Medications/meds23

Current and recent exposures

›Medication exposure

›Anticoagulants

›Antiplatelets

›NSAIDs

›Acetaminophen

›Sedatives

›Stimulants

›Antiseizure medications

›ADHD medications

›Recent anesthesia

›Recent medication changes

Contraindications and interaction traps

›Contraindications

›NSAIDs avoidance with suspected intracranial bleeding

›Sedating medications masking neurologic decline

›Ondansetron QT prolongation risk factors

ED symptom control dosing

›Symptom medication dosing

›Acetaminophen oral 15 mg per kg

›Maximum acetaminophen 75 mg per kg per day

›Ibuprofen oral 10 mg per kg

›Maximum ibuprofen 40 mg per kg per day

›Ondansetron oral 0.15 mg per kg

›Ondansetron IV 0.15 mg per kg

›Maximum single ondansetron dose 8 mg

04Diet/diet10

Intake and hydration

›Intake status

›Last oral intake time

›Poor intake since injury

›Persistent emesis limiting hydration

›Urine output change

Exposures relevant to symptoms

›Exposures

›Caffeine intake

›Energy drinks

›Possible toxin ingestion

›Alcohol exposure in adolescents

05Review of Systems/ros30

Neurologic and concussion symptoms

›Neuro symptoms

›Headache

›Dizziness

›Balance problems

›Vision changes

›Hearing changes

›Sleepiness

›Insomnia

›Irritability

›Emotional lability

›Concentration problems

›Memory problems

›Seizure

Head and neck

›Head and neck symptoms

›Neck pain

›Dysphagia

›Voice change

›Jaw pain

›Dental injury

›Epistaxis

›Rhinorrhea

›Otorrhea

Cardiopulmonary and systemic

›Systemic symptoms

›Chest pain

›Dyspnea

›Palpitations

›Fever

›Syncope

›Abdominal pain

›Limb pain

06Collateral History and Family History/chafh16

Collateral source and reliability

›Collateral

›Caregiver present

›Witness reliability

›Video footage available

›Teacher coach report

›EMS report

Family history relevant to differential

›Family history

›Bleeding disorder

›Seizure disorder

›Sudden cardiac death

›Migraine

Household and safety context

›Environment

›Supervision reliability

›Prior CPS involvement

›Previous unexplained injuries

›Access to safe observation overnight

07Risk Factors/rf19

Patient factors increasing intracranial injury risk

›High risk patient factors

›Age under 2 years

›Bleeding disorder

›Anticoagulant exposure

›VP shunt

›Neurodevelopmental delay

›Prior TBI

›Skull disorder

Injury pattern risks

›Injury pattern risks

›High impact mechanism

›Repeated impacts same day

›Suspected non accidental trauma

›Facial fractures suspicion

›Cervical spine mechanism

Social risks impacting safe discharge

›Discharge reliability risks

›Inability to awaken and observe at home

›Long travel distance to care

›No phone access

›Language barrier without support

08Differential Diagnosis/ddx57

Life threatening

›Life threatening

›Epidural hematoma

›Lucid interval possible

›Skull fracture association

›Subdural hematoma

›Concern for non accidental trauma in infants

›Anticoagulation risk

›Subarachnoid hemorrhage

›Severe sudden headache

›Meningismus

›Cerebral contusion

›Focal deficits possible

›Seizure risk

›Diffuse axonal injury

›Persistent coma

›Often normal initial CT possible

›Herniation syndrome

›Unilateral pupil

›Cushing response

›Cervical spine injury

›Midline tenderness

›Neuro deficit

›Non accidental trauma

›History inconsistent

›Sentinel injuries

Common

›Common

›Concussion mild traumatic brain injury (S06.0X)

›Normal neuroimaging typical

›Symptoms days to weeks

›Scalp hematoma

›Local swelling

›Pain

›Skull fracture

›Palpable step off

›Hematoma over fracture

›Post traumatic headache

›Migraine phenotype possible

›Tension phenotype possible

›Vomiting from pain or vestibular symptoms

›Improves with symptom control

›Persistent vomiting increases risk

Less common and mimics

›Less common

›Meningitis

›Fever

›Neck stiffness

›Intracranial mass incidental

›Progressive symptoms pre injury

›Morning vomiting

›Toxic ingestion

›Unexplained altered mental status

›Pupillary abnormalities

›Cardiac syncope

›Exertional collapse

›Family history sudden death

›Heat illness in sports

›Hyperthermia

›Collapse after exertion

09Past Medical History/pmh20

Neurologic and developmental baseline

›Baseline neuro status

›Prior concussion count

›Prior TBI complications

›Seizure disorder

›Migraine history

›Neurodevelopmental delay

Bleeding and medication related history

›Bleeding risk history

›Known coagulopathy

›Liver disease

›Thrombocytopenia history

›Anticoagulant indication

Devices and surgeries

›Devices and surgeries

›VP shunt

›Prior craniotomy

›Cervical spine surgery

›Cochlear implant

Social and safeguarding history

›Safeguarding

›Prior ED visits for injury

›Prior fractures

›Prior CPS involvement

10Physical Exam/exam55

Vitals and general appearance

›General and vitals

›Mental status level of alertness

›GCS total

›GCS eye

›GCS verbal

›GCS motor

›Work of breathing

›Perfusion

›Temperature pattern

Head and face trauma survey

›Head and face

›Scalp hematoma location

›Scalp hematoma size

›Palpable skull step off

›Lacerations

›Facial tenderness

›Dental injury

›Midface instability

›Orbital tenderness

Basilar skull fracture signs

›Basilar skull fracture

›Hemotympanum

›CSF otorrhea

›CSF rhinorrhea

›Periorbital ecchymosis

›Retroauricular ecchymosis

Pupils and cranial nerves

›Cranial nerve exam

›Pupils size symmetry

›Pupils reactivity

›Extraocular movements

›Visual fields gross

›Facial symmetry

›Gag and voice

Neurologic exam

›Neuro exam

›Speech quality

›Strength symmetry

›Tone

›Sensation gross

›Coordination

›Gait

›Pronator drift

Cervical spine and spine

›Spine exam

›Midline cervical tenderness

›Range of motion limitation

›Neurologic symptoms with movement

›Thoracolumbar tenderness

Skin and safeguarding findings

›Bruising and injury pattern

›Bruises in non mobile infant

›Bruising on torso ears neck

›Patterned bruising

›Multiple injuries different ages

Reassessment loop

›Reassessment loop

›Neuro checks frequency based on risk

›Repeat GCS trend

›Repeat vitals trend

›Repeat vomiting count

›New focal deficit trigger escalation

11Lab Studies/labs18

Point of care and immediate labs

›Immediate labs

›Glucose for altered mental status

›Pregnancy test in post menarche patients

›CBC for significant trauma or bleeding concern

›Electrolytes for vomiting dehydration

Coagulation and bleeding evaluation

›Coagulation labs

›INR for bleeding disorder or anticoagulant exposure

›aPTT for suspected coagulopathy

›Fibrinogen if severe trauma

Severe TBI and multisystem trauma labs

›Severe injury labs

›Type and screen if potential transfusion

›VBG or ABG for ventilation status

›Lactate for shock

›LFT for abdominal injury screening local protocol dependent

Toxicology when indicated

›Toxicology

›Ethanol if suspected intoxication

›Acetaminophen level if overdose concern

›Urine drug screen if altered mental status unexplained

12Imaging/img99

Scoring Systems

›Decision tools

›PECARN minor head trauma

›When to use

›Blunt head trauma

›GCS 14 to 15

›Presentation within 24 hours

›When not to use

›Penetrating trauma

›Known brain tumor

›Bleeding disorder with concerning presentation

›Neuroimaging already performed

›Age under 2 years high risk features

›GCS 14

›Palpable skull fracture

›Altered mental status

›Age under 2 years intermediate risk features

›Non frontal scalp hematoma

›Loss of consciousness 5 seconds or more

›Severe mechanism

›Not acting normally per parent

›Age 2 years and older high risk features

›GCS 14

›Signs of basilar skull fracture

›Altered mental status

›Age 2 years and older intermediate risk features

›History of loss of consciousness

›History of vomiting

›Severe headache

›Severe mechanism

›Application notes

›Observation pathway option for intermediate risk

›Shared decision making for CT in intermediate risk

›CATCH2 local protocol dependent

›Population

›Minor head injury with symptoms

›GCS 13 to 15

›Use case

›Alternative when PECARN not used

›Local practice standard

›CHALICE local protocol dependent

›Population

›Pediatric head injury broad

›ED triage support

›Use case

›Alternative when PECARN not used

›Local practice standard

MRI

›MRI brain

›Indications

›Persistent neurologic deficits with nondiagnostic CT

›Suspected diffuse axonal injury

›Subacute symptoms with concern for shear injury

›Suspected abusive head trauma with CT equivocal

›Contraindications and limitations

›Unstable patient

›Metal implants not MRI safe

›Need for sedation in young children

›Interpretation pearls

›DWI for diffuse axonal injury

›Susceptibility sequences for microhemorrhage

›CT head noncontrast

›Indications

›GCS 13 or less

›Focal neurologic deficit

›Signs of basilar skull fracture

›Palpable skull fracture

›Persistent altered mental status

›Post traumatic seizure with concerning features

›Worsening headache

›Recurrent vomiting with high risk features

›Suspected non accidental trauma

›Protocol and safety

›Pediatric dose reduction protocol

›Radiation risk discussion for low risk patients

›Interpretation pearls

›Epidural lens shape

›Subdural crescent shape

›Midline shift measurement

›Basal cistern effacement

›Limitations

›Early diffuse axonal injury may be missed

›Symptoms can precede imaging changes

›CT cervical spine local protocol dependent

›Indications

›Neuro deficit

›Midline cervical tenderness

›High risk mechanism with concerning exam

›Limitations

›Radiation exposure

›Prefer plain radiographs when appropriate

Ultrasound

›POCUS

›FAST exam in multisystem trauma

›Hemoperitoneum screen

›Pericardial effusion screen

›Ocular ultrasound local protocol dependent

›Optic nerve sheath diameter as raised ICP adjunct

›Not a standalone rule out test

›Skull fracture ultrasound local protocol dependent

›Adjunct in infants with scalp hematoma

›Does not exclude intracranial injury

13Special Tests/spec13

Bedside neurologic and vestibular assessment

›Bedside concussion tools

›Symptom inventory

›Balance testing

›Oculomotor screening

›Limitations in young children

Cervical spine clearance

›C spine clearance

›Clinical clearance criteria local protocol dependent

›Immobilization continuation triggers

›Imaging selection based on age and exam

Abuse evaluation adjuncts

›Abusive head trauma evaluation

›Skeletal survey in children under 2 years local protocol dependent

›Dilated retinal exam local protocol dependent

›Social work involvement

14ECG/ecg12

When relevant

›ECG indications

›Syncope preceding injury

›Palpitations

›Chest pain

›Suspected ingestion

›QT risk with antiemetics

High risk findings

›ECG red flags

›Long QT

›Brugada pattern

›Wolff Parkinson White pattern

›High grade AV block

›Ventricular arrhythmia

15Assessment/ax29

Severity and risk stratification

›Severity stratification

›Severe TBI (S06) with GCS 8 or less

›Airway protection likely required

›Neurosurgery emergent involvement

›Moderate TBI (S06) with GCS 9 to 12

›CT head typically indicated

›Observation or admission common

›Mild TBI concussion (S06.0X)

›GCS 14 to 15

›Imaging guided by decision tools

Working problem list

›Problem list

›Head injury with risk of intracranial hemorrhage

›Decision tool category documented

›Observation versus CT rationale

›Cervical spine injury risk

›Clearance status documented

›Imaging rationale if obtained

›Vomiting and dehydration risk

›PO tolerance status

›Antiemetic response

›Safeguarding concern if present

›History consistency

›Injury pattern consistency

Complications to rule out

›Complications

›Intracranial hemorrhage

›Skull fracture

›Cervical spine injury

›Seizure recurrence

›Raised intracranial pressure

16Plan/plan45

First 5 minutes and stabilization

›Critical workflow

›Airway positioning and suction readiness

›Oxygen for SpO2 under 92 percent

›Cardiorespiratory monitoring

›IV access criteria

›Two IV lines for shock or severe TBI

›Glucose check for altered mental status

›C spine immobilization when indicated

Neuroprotective targets for severe TBI

›Neuroprotection

›Head of bed 30 degrees if hemodynamically stable

›Normoxia target SpO2 94 to 98 percent

›Normocapnia target EtCO2 35 to 40 mmHg

›Avoid hypotension for age

›Treat hypoglycemia promptly

›Treat hyperthermia

Hyperosmolar therapy for impending herniation

›Hyperosmolar

›Hypertonic saline 3 percent IV 2 mL per kg bolus

›Repeat bolus based on response local protocol dependent

›Mannitol IV 0.5 g per kg local protocol dependent

›Avoid mannitol with hypotension

Seizure management

›Seizure plan

›Lorazepam IV 0.1 mg per kg

›Maximum lorazepam single dose 4 mg

›Levetiracetam IV 20 to 60 mg per kg local protocol dependent

›Fosphenytoin IV 20 mg PE per kg local protocol dependent

Symptom control for mild injury

›Symptom control

›Acetaminophen dosing per weight

›Ibuprofen dosing per weight if low bleed concern

›Ondansetron dosing per weight

›Oral hydration trial after antiemetic

Observation pathway

›ED observation

›Serial neuro checks interval local protocol dependent

›Repeat exam prior to discharge

›Worsening symptoms trigger CT

Consultation and escalation

›Consultation

›Neurosurgery for intracranial hemorrhage

›Trauma team for multisystem trauma

›PICU for severe TBI or airway needs

›Child protection team for suspected abuse

Reassessment triggers and time windows

›Reassessment triggers

›New vomiting after initial stability

›Increasing headache severity

›New confusion or somnolence

›New focal deficit

›Seizure recurrence

17Disposition/dispo30

ICU and high acuity care

›ICU criteria

›GCS 8 or less

›Intubation required

›Need for hyperosmolar therapy

›Refractory seizures

›Hemodynamic instability

›Significant intracranial hemorrhage with mass effect

Inpatient admission criteria

›Admission criteria

›Abnormal CT findings without ICU need

›Persistent altered mental status

›Persistent vomiting with dehydration

›Concerning social situation

›Suspected non accidental trauma

Observation unit criteria

›Observation criteria

›Intermediate risk decision tool category

›Symptoms improving with ED treatment

›Normal neuro exam

›Reliable reassessment possible

Discharge criteria

›Discharge criteria

›Normal mental status at baseline

›Normal neuro exam

›No concerning exam findings

›Tolerating oral intake

›Pain and nausea controlled

›Reliable caregiver observation available

›Clear return precautions understood

Follow up timing

›Follow up

›Primary care within 2 to 3 days for concussion symptoms

›Concussion clinic referral if symptoms over 2 weeks

›Neurosurgery follow up if skull fracture or hemorrhage

18Discharge Instructions/di29

Copy discharge instructions

›Copy discharge instructions

›Diagnosis

›Head injury with concussion symptoms possible

›Expected course

›Headache dizziness nausea tiredness can last days to weeks

›Activity

›Rest for 24 to 48 hours

›Gradual return to school and activity as tolerated

›No sports until cleared by a clinician

›Medications

›Acetaminophen as directed for headache

›Avoid sedating medicines unless prescribed

›Hydration

›Small frequent fluids

›Return to ED now if

›Worsening headache

›Repeated vomiting

›Confusion

›Trouble waking up

›Seizure

›Weakness or numbness

›Unequal pupils

›Slurred speech

›Neck pain with neurologic symptoms

›Any caregiver concern about deterioration

›Special instructions

›Wake checks overnight only if advised by clinician

›Avoid alcohol and recreational drugs in adolescents

›Limit screens if they worsen symptoms

19References/r6

Guidelines and decision tools

›References

›PECARN pediatric head trauma clinical prediction rules (2009)

›CDC pediatric mild traumatic brain injury guideline (2018)

›Brain Trauma Foundation guidelines for pediatric severe traumatic brain injury (latest version local protocol dependent)

›NICE head injury assessment and early management guideline (latest version local protocol dependent)

›Canadian Paediatric Society guidance on concussion and return to play return to school (local protocol dependent)

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.