Pediatric Minor Head TraumaAPPROACH

TRAUMA AND WOUNDS · 19 SECTIONS

⚲

432 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/hx52

Event and mechanism

›Injury context

›Time since injury

›Witnessed event

›Height and distance of fall

›Object impact

›Motor vehicle collision details

›Helmet use

›High speed mechanism

›Ejection or rollover

›Pedestrian or bicyclist struck

Symptoms and course

›Symptom evolution

›Loss of consciousness

›Altered mental status

›Amnesia

›Seizure

›Vomiting episodes

›Headache

›Lethargy

›Irritability

›Poor feeding

›Abnormal behavior by caregiver report

OPQRST headache

›Onset

›Immediate after impact

›Delayed onset

›Provocation and palliation

›Worse with movement

›Worse with light

›Relief with acetaminophen

›Relief with rest

›Quality

›Pressure

›Throbbing

›Region and radiation

›Frontal

›Occipital

›Diffuse

›Severity

›Mild

›Moderate

›Severe

›Timing

›Constant

›Intermittent

›Improving

›Worsening

Prior episodes and baseline

›Baseline function

›Neurodevelopment baseline

›Baseline gait and balance

›Baseline speech

›Baseline school performance

›Baseline sleep pattern

›Baseline behavior pattern

02Alarm Features/alarm34

Immediate escalation triggers

›Resuscitation triggers

›GCS less than 13

›Airway compromise

›Recurrent seizure

›Persistent hypoxia

›Hemodynamic instability

›Rapidly declining mental status

High risk historical features

›High risk history

›Persistent altered mental status

›Prolonged loss of consciousness

›Recurrent vomiting

›Severe headache

›Severe mechanism of injury

›Bleeding disorder

›Anticoagulant exposure

›Ventricular shunt

High risk exam findings

›High risk exam

›Signs of basilar skull fracture

›Hemotympanum

›Periorbital ecchymosis

›Mastoid ecchymosis

›Clear otorrhea

›Clear rhinorrhea

›Palpable skull fracture

›Bulging fontanelle

›Persistent focal neurologic deficit

›Persistent abnormal gait

›Repeatedly abnormal behavior for age

Vital sign danger thresholds

›Concerning vitals

›Bradycardia with hypertension and irregular respirations

›Persistent hypotension

›Persistent tachycardia

›Hypoxia

›Fever with neck stiffness

03Medications/meds18

Current medications and exposures

›Medication list

›Prescription medications

›Over the counter medications

›Supplements

›Herbals

›Recent medication changes

›Medication adherence issues

Bleeding and sedation relevant agents

›High risk medication classes

›Anticoagulants

›Antiplatelets

›NSAIDs

›Sedatives

›Opioids

›Antiseizure medications

Medication interactions and cautions

›ED medication cautions

›Avoid sedating agents that obscure neurologic reassessment when possible

›Avoid NSAIDs if intracranial bleeding concern or significant bleeding risk

›Weight based dosing required for pediatric analgesics and antiemetics

04Diet/diet10

Intake and hydration

›Intake status

›Last oral intake

›Poor intake since injury

›Signs of dehydration

›Ability to tolerate fluids

Relevant exposures

›Exposures

›Caffeine

›Energy drinks

›Alcohol ingestion in adolescents

›Recreational drug exposure in adolescents

05Review of Systems/ros23

Neurologic and cognitive

›Neurologic symptoms

›Headache

›Dizziness

›Confusion

›Memory difficulty

›Vision changes

›Photophobia

›Phonophobia

›Weakness

›Numbness

›Ataxia

GI and systemic

›Systemic symptoms

›Vomiting

›Abdominal pain

›Fever

›Neck pain

›Back pain

Injury survey symptoms

›Other injury symptoms

›Chest pain

›Shortness of breath

›Extremity pain

›Bleeding

›Lacerations

06Collateral History and Family History/chafh15

Collateral source and reliability

›Collateral

›Caregiver identity

›Witness reliability

›Consistency of story over time

›Prior ED visits for injury

Family history and inherited risks

›Family history

›Bleeding disorders

›Seizure disorders

›Early stroke or aneurysm

Safety and maltreatment context

›Non accidental trauma concern

›Inconsistent mechanism with developmental stage

›Unexplained delay in presentation

›Prior concerning injuries

›Household violence exposure

›Unsafe supervision concerns

07Risk Factors/rf18

Patient factors increasing ciTBI risk

›Pediatric risk modifiers

›Age younger than 2 years

›Large non frontal scalp hematoma

›Known neurologic disorder

›Ventricular shunt

›Prior neurosurgery

Bleeding and anticoagulation risks

›Hemorrhage risks

›Hemophilia

›Von Willebrand disease

›Thrombocytopenia

›Anticoagulant exposure

›Antiplatelet exposure

Environmental and mechanism risks

›Mechanism risks

›High height fall

›High speed collision

›Struck by vehicle

›Head strike with high energy object

›Suspected abusive head trauma

08Differential Diagnosis/ddx55

Life threatening

›Cannot miss diagnoses

›Epidural hematoma

›Skull fracture association

›Possible lucid interval

›Subdural hematoma

›Higher risk with abusive head trauma

›Higher risk with bleeding disorder

›Traumatic subarachnoid hemorrhage

›Severe headache

›Meningismus

›Cerebral contusion

›Focal deficit

›Worsening mental status

›Diffuse cerebral edema

›Declining GCS

›Cushing physiology features

›Depressed skull fracture

›Palpable step off

›Overlying laceration

›Cervical spine injury

›Neck pain

›Neurologic deficit

›Abusive head trauma

›Inconsistent history

›Retinal hemorrhage

Common

›Common diagnoses

›Concussion and mild traumatic brain injury (S06.0X0)

›Headache

›Dizziness

›Cognitive symptoms

›Scalp hematoma and contusion

›Local swelling

›Local tenderness

›Facial laceration

›External bleeding

›Wound contamination

›Vomiting from pain or anxiety

›Normal neuro exam

›Improving course

Less common

›Less common and mimics

›Migraine triggered by injury

›Prior migraine history

›Photophobia

›Syncope leading to fall

›Prodrome

›Exertional collapse

›Seizure leading to fall

›Postictal confusion

›Tongue bite

›Toxic ingestion

›Pupillary abnormalities

›Unexplained sedation

›Metabolic cause

›Hypoglycemia

›Electrolyte abnormality

09Past Medical History/pmh15

Relevant conditions

›Chronic conditions

›Prior traumatic brain injury

›Prior concussion

›Seizure disorder (G40.909)

›Bleeding disorder

›Hydrocephalus with shunt

›Autism spectrum disorder (F84.0)

Procedures and devices

›Procedures and devices

›Ventricular shunt

›Cochlear implant

›Prior craniotomy

Baseline function and supports

›Baseline and supports

›Developmental delays

›Special education needs

›Caregiver capacity for observation at home

10Physical Exam/exam35

Initial impression and vitals

›General assessment

›Toxic appearance

›Level of alertness

›Age appropriate interaction

›Vital sign trend

›Pain assessment

Neurologic exam

›Neurologic exam

›GCS components

›Mental status

›Speech and language for age

›Pupils

›Extraocular movements

›Facial symmetry

›Motor strength

›Sensation

›Coordination

›Gait for age

Head and neck exam

›Head and neck findings

›Scalp hematoma location

›Scalp hematoma size

›Skull step off

›Battle sign

›Raccoon eyes

›Hemotympanum

›Nasal septal hematoma

›Oral trauma

›Fontanelle fullness

Cervical spine and trauma survey

›Trauma survey

›Midline neck tenderness

›Range of motion limitations

›Chest wall tenderness

›Abdominal tenderness

›Long bone tenderness

›Bruising pattern

›Petechiae or purpura

11Lab Studies/labs10

Labs when indicated

›Targeted labs

›Point of care glucose for altered mental status

›CBC for significant bleeding concern

›INR and PT for suspected coagulopathy or anticoagulant exposure

›Type and screen for major trauma or expected transfusion

›Pregnancy test in post menarchal patients when imaging or meds may be affected

Interpretation and limitations

›Pitfalls

›Normal labs do not exclude intracranial injury

›Coagulation tests may be needed before invasive procedures or reversal decisions

›Vomiting related dehydration may alter electrolytes

12Imaging/img29

Scoring Systems

›Decision instruments for CT avoidance and observation

›PECARN pediatric head trauma rule

›Age younger than 2 years pathway

›Age 2 years and older pathway

›Use for blunt head trauma within 24 hours with GCS 14 to 15

›Not for penetrating trauma

›Not for known bleeding disorder without individualized assessment

›CATCH2 rule

›Canadian context

›Alternative to PECARN in some settings

›CHALICE rule

›UK derived rule

›Alternative to PECARN in some settings

MRI

›MRI options

›Rapid MRI protocols local protocol dependent

›Consider when CT avoidance desired and MRI available without unsafe delay

›Consider for persistent symptoms with normal CT when alternative pathology suspected

›Contraindications include non compatible implanted devices

›CT head non contrast

›Indications aligned to PECARN and local pediatric head injury pathways

›Immediate CT for GCS less than 13 or signs of basilar skull fracture or palpable skull fracture

›Weigh radiation risk especially in younger children

›Sedation risk and monitoring requirements when needed

›Interpretation pitfalls include very early bleed and motion artifact

Ultrasound

›Point of care ultrasound

›Skull fracture detection adjunct when trained operator available

›Not a rule out for intracranial injury

›Consider for infants with scalp hematoma when CT decision uncertain

›False negatives with small fractures or poor windows

13Special Tests/spec16

Observation and serial exams

›ED observation pathway

›Serial neurologic exams

›Serial vital signs

›Symptom trajectory over 4 to 6 hours from injury time local protocol dependent

›Escalate to CT for worsening symptoms

Concussion focused tools

›Concussion assessment tools

›Symptom checklist for headache dizziness nausea sleep changes

›Balance testing for age

›Vestibular ocular screening when symptomatic

›SCAT6 for ages 13 years and older when sport related

Child maltreatment evaluation

›Abusive head trauma workup triggers

›Inconsistent history with injuries

›Sentinel bruising in non mobile infant

›Multiple injuries in different stages

›Consider skeletal survey local protocol dependent

›Consider ophthalmology exam for retinal hemorrhage local protocol dependent

14ECG/ecg10

Indications when mechanism unclear

›ECG indications

›Syncope preceding fall

›Exertional collapse

›Palpitations

›Family history sudden death

High risk patterns

›ECG red flags

›Long QT

›Brugada pattern

›Wolff Parkinson White pattern

›High grade AV block

15Assessment/ax18

Working diagnosis and risk level

›Problem representation

›Minor blunt head trauma with GCS 14 to 15

›Suspected concussion and mild traumatic brain injury (S06.0X0)

›ciTBI risk stratification using PECARN

›Alternative diagnoses considered based on symptoms and exam

Complications to exclude

›Complications

›Intracranial hemorrhage

›Clinically important traumatic brain injury

›Skull fracture

›Cervical spine injury

Supporting features and uncertainty

›Key data synthesis

›Mechanism severity

›Mental status abnormalities

›Vomiting pattern

›Headache severity

›Scalp hematoma characteristics

›Exam signs of basilar skull fracture

›Social reliability for home observation

16Plan/plan26

First 5 minutes

›Early workflow

›Continuous pulse oximetry for altered mental status

›Cardiorespiratory monitoring for GCS less than 15 or sedation risk

›IV access for persistent vomiting or dehydration or concerning exam

›Glucose check for altered mental status

›Cervical spine precautions for concerning mechanism or neck pain

Imaging and observation decision pathway

›PECARN based pathway

›Immediate CT for high risk criteria

›Observation option for intermediate risk criteria

›No CT for very low risk criteria with reliable follow up

›Shared decision making with caregiver when intermediate risk and stable

Symptom control

›Medications

›Acetaminophen PO 15 mg per kg

›Maximum 75 mg per kg per day

›Ondansetron ODT 0.15 mg per kg

›Maximum single dose 8 mg

›Avoid routine opioids

Reassessment loop

›Reassessment timing

›Repeat neuro exam every 30 to 60 minutes during observation

›Recheck vitals after analgesia and fluids

›Escalate to CT for worsening headache or repeated vomiting or new deficit

Consultation and safeguarding

›Consult triggers

›Neurosurgery for intracranial hemorrhage or depressed skull fracture

›Trauma team for multi system injury

›Child protection team for suspected abuse

›Social work for unsafe discharge environment

17Disposition/dispo18

Admission and higher level care

›Admit criteria

›Abnormal head CT

›Persistent altered mental status

›Uncontrolled vomiting

›Seizure after injury

›Suspicion for abusive head trauma

›Unsafe home observation

Observation pathway

›ED or short stay observation

›Intermediate risk by PECARN with stable exam

›Symptom improvement required for discharge

›Reliable caregiver required

Discharge criteria

›Discharge requirements

›Normal or improving mental status

›No new neurologic deficit

›Able to tolerate oral fluids

›Pain controlled with non opioid medications

›Caregiver understands return precautions

›Follow up plan established

18Discharge Instructions/di24

Copy discharge instructions

›Home care summary

›Today you were seen for a head injury and symptoms consistent with a concussion

›Most children improve over days to weeks

›Rest for the first 24 to 48 hours with light activity as tolerated

›Gradual return to school with breaks if symptoms worsen

›No sports or high risk activity until cleared by a clinician

›Medicines

›Acetaminophen as directed for headache

›Avoid aspirin

›Avoid sedating medicines unless prescribed

›Return to the emergency department now for

›Worsening headache

›Repeated vomiting

›Increasing sleepiness or hard to wake

›Confusion or behavior that is not normal for your child

›Seizure

›Weakness or trouble walking

›Unequal pupils

›Clear fluid from the nose or ears

›New vision changes

›Follow up

›Primary care or concussion clinic follow up in 1 to 3 days

›Earlier follow up if symptoms worsen

›School note and return to learn plan if needed

19References/r6

Guidelines and landmark evidence

›Core sources

›NICE guideline NG232 Head injury assessment and early management 2023

›Kuppermann et al PECARN prediction rules for ciTBI The Lancet 2009

›CDC Pediatric mild traumatic brain injury clinical guidance updated 2025

›Canadian Paediatric Society Management of the paediatric patient with acute head trauma 2025

›American Academy of Pediatrics Sport related concussion in children and adolescents 2018

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 Minor Head TraumaAPPROACH

TRAUMA AND WOUNDS · 19 SECTIONS

⚲

432 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/hx52

Event and mechanism

›Injury context

›Time since injury

›Witnessed event

›Height and distance of fall

›Object impact

›Motor vehicle collision details

›Helmet use

›High speed mechanism

›Ejection or rollover

›Pedestrian or bicyclist struck

Symptoms and course

›Symptom evolution

›Loss of consciousness

›Altered mental status

›Amnesia

›Seizure

›Vomiting episodes

›Headache

›Lethargy

›Irritability

›Poor feeding

›Abnormal behavior by caregiver report

OPQRST headache

›Onset

›Immediate after impact

›Delayed onset

›Provocation and palliation

›Worse with movement

›Worse with light

›Relief with acetaminophen

›Relief with rest

›Quality

›Pressure

›Throbbing

›Region and radiation

›Frontal

›Occipital

›Diffuse

›Severity

›Mild

›Moderate

›Severe

›Timing

›Constant

›Intermittent

›Improving

›Worsening

Prior episodes and baseline

›Baseline function

›Neurodevelopment baseline

›Baseline gait and balance

›Baseline speech

›Baseline school performance

›Baseline sleep pattern

›Baseline behavior pattern

02Alarm Features/alarm34

Immediate escalation triggers

›Resuscitation triggers

›GCS less than 13

›Airway compromise

›Recurrent seizure

›Persistent hypoxia

›Hemodynamic instability

›Rapidly declining mental status

High risk historical features

›High risk history

›Persistent altered mental status

›Prolonged loss of consciousness

›Recurrent vomiting

›Severe headache

›Severe mechanism of injury

›Bleeding disorder

›Anticoagulant exposure

›Ventricular shunt

High risk exam findings

›High risk exam

›Signs of basilar skull fracture

›Hemotympanum

›Periorbital ecchymosis

›Mastoid ecchymosis

›Clear otorrhea

›Clear rhinorrhea

›Palpable skull fracture

›Bulging fontanelle

›Persistent focal neurologic deficit

›Persistent abnormal gait

›Repeatedly abnormal behavior for age

Vital sign danger thresholds

›Concerning vitals

›Bradycardia with hypertension and irregular respirations

›Persistent hypotension

›Persistent tachycardia

›Hypoxia

›Fever with neck stiffness

03Medications/meds18

Current medications and exposures

›Medication list

›Prescription medications

›Over the counter medications

›Supplements

›Herbals

›Recent medication changes

›Medication adherence issues

Bleeding and sedation relevant agents

›High risk medication classes

›Anticoagulants

›Antiplatelets

›NSAIDs

›Sedatives

›Opioids

›Antiseizure medications

Medication interactions and cautions

›ED medication cautions

›Avoid sedating agents that obscure neurologic reassessment when possible

›Avoid NSAIDs if intracranial bleeding concern or significant bleeding risk

›Weight based dosing required for pediatric analgesics and antiemetics

04Diet/diet10

Intake and hydration

›Intake status

›Last oral intake

›Poor intake since injury

›Signs of dehydration

›Ability to tolerate fluids

Relevant exposures

›Exposures

›Caffeine

›Energy drinks

›Alcohol ingestion in adolescents

›Recreational drug exposure in adolescents

05Review of Systems/ros23

Neurologic and cognitive

›Neurologic symptoms

›Headache

›Dizziness

›Confusion

›Memory difficulty

›Vision changes

›Photophobia

›Phonophobia

›Weakness

›Numbness

›Ataxia

GI and systemic

›Systemic symptoms

›Vomiting

›Abdominal pain

›Fever

›Neck pain

›Back pain

Injury survey symptoms

›Other injury symptoms

›Chest pain

›Shortness of breath

›Extremity pain

›Bleeding

›Lacerations

06Collateral History and Family History/chafh15

Collateral source and reliability

›Collateral

›Caregiver identity

›Witness reliability

›Consistency of story over time

›Prior ED visits for injury

Family history and inherited risks

›Family history

›Bleeding disorders

›Seizure disorders

›Early stroke or aneurysm

Safety and maltreatment context

›Non accidental trauma concern

›Inconsistent mechanism with developmental stage

›Unexplained delay in presentation

›Prior concerning injuries

›Household violence exposure

›Unsafe supervision concerns

07Risk Factors/rf18

Patient factors increasing ciTBI risk

›Pediatric risk modifiers

›Age younger than 2 years

›Large non frontal scalp hematoma

›Known neurologic disorder

›Ventricular shunt

›Prior neurosurgery

Bleeding and anticoagulation risks

›Hemorrhage risks

›Hemophilia

›Von Willebrand disease

›Thrombocytopenia

›Anticoagulant exposure

›Antiplatelet exposure

Environmental and mechanism risks

›Mechanism risks

›High height fall

›High speed collision

›Struck by vehicle

›Head strike with high energy object

›Suspected abusive head trauma

08Differential Diagnosis/ddx55

Life threatening

›Cannot miss diagnoses

›Epidural hematoma

›Skull fracture association

›Possible lucid interval

›Subdural hematoma

›Higher risk with abusive head trauma

›Higher risk with bleeding disorder

›Traumatic subarachnoid hemorrhage

›Severe headache

›Meningismus

›Cerebral contusion

›Focal deficit

›Worsening mental status

›Diffuse cerebral edema

›Declining GCS

›Cushing physiology features

›Depressed skull fracture

›Palpable step off

›Overlying laceration

›Cervical spine injury

›Neck pain

›Neurologic deficit

›Abusive head trauma

›Inconsistent history

›Retinal hemorrhage

Common

›Common diagnoses

›Concussion and mild traumatic brain injury (S06.0X0)

›Headache

›Dizziness

›Cognitive symptoms

›Scalp hematoma and contusion

›Local swelling

›Local tenderness

›Facial laceration

›External bleeding

›Wound contamination

›Vomiting from pain or anxiety

›Normal neuro exam

›Improving course

Less common

›Less common and mimics

›Migraine triggered by injury

›Prior migraine history

›Photophobia

›Syncope leading to fall

›Prodrome

›Exertional collapse

›Seizure leading to fall

›Postictal confusion

›Tongue bite

›Toxic ingestion

›Pupillary abnormalities

›Unexplained sedation

›Metabolic cause

›Hypoglycemia

›Electrolyte abnormality

09Past Medical History/pmh15

Relevant conditions

›Chronic conditions

›Prior traumatic brain injury

›Prior concussion

›Seizure disorder (G40.909)

›Bleeding disorder

›Hydrocephalus with shunt

›Autism spectrum disorder (F84.0)

Procedures and devices

›Procedures and devices

›Ventricular shunt

›Cochlear implant

›Prior craniotomy

Baseline function and supports

›Baseline and supports

›Developmental delays

›Special education needs

›Caregiver capacity for observation at home

10Physical Exam/exam35

Initial impression and vitals

›General assessment

›Toxic appearance

›Level of alertness

›Age appropriate interaction

›Vital sign trend

›Pain assessment

Neurologic exam

›Neurologic exam

›GCS components

›Mental status

›Speech and language for age

›Pupils

›Extraocular movements

›Facial symmetry

›Motor strength

›Sensation

›Coordination

›Gait for age

Head and neck exam

›Head and neck findings

›Scalp hematoma location

›Scalp hematoma size

›Skull step off

›Battle sign

›Raccoon eyes

›Hemotympanum

›Nasal septal hematoma

›Oral trauma

›Fontanelle fullness

Cervical spine and trauma survey

›Trauma survey

›Midline neck tenderness

›Range of motion limitations

›Chest wall tenderness

›Abdominal tenderness

›Long bone tenderness

›Bruising pattern

›Petechiae or purpura

11Lab Studies/labs10

Labs when indicated

›Targeted labs

›Point of care glucose for altered mental status

›CBC for significant bleeding concern

›INR and PT for suspected coagulopathy or anticoagulant exposure

›Type and screen for major trauma or expected transfusion

›Pregnancy test in post menarchal patients when imaging or meds may be affected

Interpretation and limitations

›Pitfalls

›Normal labs do not exclude intracranial injury

›Coagulation tests may be needed before invasive procedures or reversal decisions

›Vomiting related dehydration may alter electrolytes

12Imaging/img29

Scoring Systems

›Decision instruments for CT avoidance and observation

›PECARN pediatric head trauma rule

›Age younger than 2 years pathway

›Age 2 years and older pathway

›Use for blunt head trauma within 24 hours with GCS 14 to 15

›Not for penetrating trauma

›Not for known bleeding disorder without individualized assessment

›CATCH2 rule

›Canadian context

›Alternative to PECARN in some settings

›CHALICE rule

›UK derived rule

›Alternative to PECARN in some settings

MRI

›MRI options

›Rapid MRI protocols local protocol dependent

›Consider when CT avoidance desired and MRI available without unsafe delay

›Consider for persistent symptoms with normal CT when alternative pathology suspected

›Contraindications include non compatible implanted devices

›CT head non contrast

›Indications aligned to PECARN and local pediatric head injury pathways

›Immediate CT for GCS less than 13 or signs of basilar skull fracture or palpable skull fracture

›Weigh radiation risk especially in younger children

›Sedation risk and monitoring requirements when needed

›Interpretation pitfalls include very early bleed and motion artifact

Ultrasound

›Point of care ultrasound

›Skull fracture detection adjunct when trained operator available

›Not a rule out for intracranial injury

›Consider for infants with scalp hematoma when CT decision uncertain

›False negatives with small fractures or poor windows

13Special Tests/spec16

Observation and serial exams

›ED observation pathway

›Serial neurologic exams

›Serial vital signs

›Symptom trajectory over 4 to 6 hours from injury time local protocol dependent

›Escalate to CT for worsening symptoms

Concussion focused tools

›Concussion assessment tools

›Symptom checklist for headache dizziness nausea sleep changes

›Balance testing for age

›Vestibular ocular screening when symptomatic

›SCAT6 for ages 13 years and older when sport related

Child maltreatment evaluation

›Abusive head trauma workup triggers

›Inconsistent history with injuries

›Sentinel bruising in non mobile infant

›Multiple injuries in different stages

›Consider skeletal survey local protocol dependent

›Consider ophthalmology exam for retinal hemorrhage local protocol dependent

14ECG/ecg10

Indications when mechanism unclear

›ECG indications

›Syncope preceding fall

›Exertional collapse

›Palpitations

›Family history sudden death

High risk patterns

›ECG red flags

›Long QT

›Brugada pattern

›Wolff Parkinson White pattern

›High grade AV block

15Assessment/ax18

Working diagnosis and risk level

›Problem representation

›Minor blunt head trauma with GCS 14 to 15

›Suspected concussion and mild traumatic brain injury (S06.0X0)

›ciTBI risk stratification using PECARN

›Alternative diagnoses considered based on symptoms and exam

Complications to exclude

›Complications

›Intracranial hemorrhage

›Clinically important traumatic brain injury

›Skull fracture

›Cervical spine injury

Supporting features and uncertainty

›Key data synthesis

›Mechanism severity

›Mental status abnormalities

›Vomiting pattern

›Headache severity

›Scalp hematoma characteristics

›Exam signs of basilar skull fracture

›Social reliability for home observation

16Plan/plan26

First 5 minutes

›Early workflow

›Continuous pulse oximetry for altered mental status

›Cardiorespiratory monitoring for GCS less than 15 or sedation risk

›IV access for persistent vomiting or dehydration or concerning exam

›Glucose check for altered mental status

›Cervical spine precautions for concerning mechanism or neck pain

Imaging and observation decision pathway

›PECARN based pathway

›Immediate CT for high risk criteria

›Observation option for intermediate risk criteria

›No CT for very low risk criteria with reliable follow up

›Shared decision making with caregiver when intermediate risk and stable

Symptom control

›Medications

›Acetaminophen PO 15 mg per kg

›Maximum 75 mg per kg per day

›Ondansetron ODT 0.15 mg per kg

›Maximum single dose 8 mg

›Avoid routine opioids

Reassessment loop

›Reassessment timing

›Repeat neuro exam every 30 to 60 minutes during observation

›Recheck vitals after analgesia and fluids

›Escalate to CT for worsening headache or repeated vomiting or new deficit

Consultation and safeguarding

›Consult triggers

›Neurosurgery for intracranial hemorrhage or depressed skull fracture

›Trauma team for multi system injury

›Child protection team for suspected abuse

›Social work for unsafe discharge environment

17Disposition/dispo18

Admission and higher level care

›Admit criteria

›Abnormal head CT

›Persistent altered mental status

›Uncontrolled vomiting

›Seizure after injury

›Suspicion for abusive head trauma

›Unsafe home observation

Observation pathway

›ED or short stay observation

›Intermediate risk by PECARN with stable exam

›Symptom improvement required for discharge

›Reliable caregiver required

Discharge criteria

›Discharge requirements

›Normal or improving mental status

›No new neurologic deficit

›Able to tolerate oral fluids

›Pain controlled with non opioid medications

›Caregiver understands return precautions

›Follow up plan established

18Discharge Instructions/di24

Copy discharge instructions

›Home care summary

›Today you were seen for a head injury and symptoms consistent with a concussion

›Most children improve over days to weeks

›Rest for the first 24 to 48 hours with light activity as tolerated

›Gradual return to school with breaks if symptoms worsen

›No sports or high risk activity until cleared by a clinician

›Medicines

›Acetaminophen as directed for headache

›Avoid aspirin

›Avoid sedating medicines unless prescribed

›Return to the emergency department now for

›Worsening headache

›Repeated vomiting

›Increasing sleepiness or hard to wake

›Confusion or behavior that is not normal for your child

›Seizure

›Weakness or trouble walking

›Unequal pupils

›Clear fluid from the nose or ears

›New vision changes

›Follow up

›Primary care or concussion clinic follow up in 1 to 3 days

›Earlier follow up if symptoms worsen

›School note and return to learn plan if needed

19References/r6

Guidelines and landmark evidence

›Core sources

›NICE guideline NG232 Head injury assessment and early management 2023

›Kuppermann et al PECARN prediction rules for ciTBI The Lancet 2009

›CDC Pediatric mild traumatic brain injury clinical guidance updated 2025

›Canadian Paediatric Society Management of the paediatric patient with acute head trauma 2025

›American Academy of Pediatrics Sport related concussion in children and adolescents 2018

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.