Disclosures: Sara Schutzman, MD Nothing to disclose. Richard G Bachur, MD Nothing to disclose. Douglas R Nordli, Jr, MD Grant/Research/Clinical Trial Support: NIH [febrile status, SUDEP]. Consultant/Advisory Boards: Eisai [AED (zonisamide, perampanel)]. James F Wiley, II, MD, MPH Nothing to disclose.
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INTRODUCTION — Head trauma occurs commonly in childhood. Most head trauma in children is minor and not associated with brain injury or long-term sequelae. However, a small number of children who appear to be at low risk after minor head trauma may have a clinically important traumatic brain (ciTBI) injury. (See 'Clinically important traumatic brain injury' below.)
The clinical challenge for evaluating minor head trauma in pediatric patients is to identify those infants and children with ciTBI while limiting unnecessary radiographic imaging and radiation exposure. Neuroimaging, usually with computed tomography (CT), is highly sensitive for identifying brain injury requiring acute intervention. However, individual clinical predictors for ciTBI are often nonspecific, particularly in young children. Thus, evaluation for high-risk findings and the use of a clinical decision rule can provide a balanced approach that identifies almost all infants and children with ciTBI after minor head trauma without overuse of CT.
This topic will discuss the epidemiology of head trauma in infants and children, the incidence of traumatic brain injury (TBI), clinical features of head-injured children with and without ciTBI, and the evaluation of infants and children with mild head trauma.
The management of minor head trauma in children, severe TBI in children and adolescents, concussion and mild head trauma in adolescents, and diagnosis of inflicted head trauma in children are reviewed separately:
Minor head trauma — Because of the difference in mechanisms and presentations, it is best to define minor head trauma differently by age as follows (see 'Mechanism' below and 'Incidence of brain injury' below):
●Children younger than two years of age – Experts define minor head trauma in these patients as a history or physical signs of blunt trauma to the scalp, skull, or brain in an infant or child who is alert or awakens to voice or light touch .
Minor head trauma is generally defined separately in children younger than two years of age for the following reasons [1,2]:
•Clinical assessment is more difficult
•Infants with intracranial injuries are frequently asymptomatic
•Skull fractures or clinically important traumatic brain injury (ciTBI) may occur despite minor trauma
•Inflicted injury occurs more frequently
●Children two years of age and older – The definition of minor head trauma for children two years of age and older has often been based upon the Glasgow Coma Scale (GCS). Some have defined minor head trauma as a GCS score of 15, whereas others have included children with scores ≥13 (table 1) [3,4]. However, the rate of traumatic brain injury in children with a GCS of 13 is as high as 20 percent, which makes computed tomography (CT) of the head indicated for most children with this degree of altered mental status.
Thus, for the purposes of this discussion, we define minor head trauma in previously healthy children two years of age and older as follows:
•GCS of 14 or 15 at the initial examination
•No abnormal or focal findings on neurologic examination
•No physical evidence of skull fracture (eg, no palpable skull defect and no signs of basilar skull fracture such as hemotympanum, CSF oto- or rhinorrhea, or periocular or posterior auricular hematomas)
However, the clinician should regard these patients as having apparently minor head trauma because approximately 5 percent have TBI on neuroimaging, and 1 percent have ciTBI. (See 'Incidence of brain injury' below.)
Mild traumatic brain injury — Mild traumatic brain injury (TBI) is generally associated with symptoms, such as a brief loss of consciousness, disorientation, or vomiting. Like minor head trauma, patients with mild TBI usually have GCS scores of 13 to 15, measured approximately 30 minutes after the injury. In comparison, patients with moderate TBI generally have initial GCS scores between 9 and 12, whereas those with severe injury have GCS scores ≤8 (table 1) . (See 'Clinical features' below.)
Concussion — From a clinical standpoint, concussion can be defined as trauma-induced brain dysfunction without demonstrable structural injury on standard neuroimaging. As such, concussion is a type of mild traumatic brain injury. (See "Concussion in children and adolescents: Clinical manifestations and diagnosis", section on 'Definition' and "Concussion and mild traumatic brain injury", section on 'Definitions'.)
The clinical manifestations, diagnosis, and management of concussion in children and adolescents are discussed in greater detail separately. (See "Concussion in children and adolescents: Clinical manifestations and diagnosis" and "Concussion in children and adolescents: Management" and "Concussion and mild traumatic brain injury".)
Clinically important traumatic brain injury — Several observational studies have been performed to identify infants and children who are at higher risk of intracranial injury (ICI) after minor head trauma . For this topic, we will define clinically important traumatic brain injury (ciTBI) using criteria similar to that established for the largest cohorts studied as follows [7-10]:
●Presence of an ICI (eg, epidural hematoma, subdural hematoma, or cerebral contusion) on CT associated with one or more of the following:
•Neurosurgical intervention (either surgery or invasive intracranial pressure monitoring)
•Endotracheal intubation for the management of head injury
•Hospitalization directly related to the head injury for at least 48 hours
●Depressed skull fracture warranting operative elevation (ie, depressed past the inner table of the skull)
PATHOPHYSIOLOGY — Brain injury can occur following a minor head trauma because rotational acceleration-deceleration of the head generates shearing forces that cause mechanical disruption of nerve fibers, resulting in diffuse axonal injury. This process has been described in association with severe brain injury and occurs in mild traumatic brain injury (TBI) as well. Whether or not this pattern of injury differs in the developing brain is uncertain .
Mild TBI usually occurs with head trauma due to contact and/or acceleration (including translational and rotational acceleration) or deceleration forces. The type of mechanical forces applied to the brain may determine, to some extent, the nature of the resultant injury as follows [12,13]:
●Acceleration occurs when a moving object strikes a stationary head. Linear acceleration is considered the least injurious force and typically is associated with superficial contusions or in rare cases, intracranial hematomas.
●Deceleration results when a moving head strikes a stationary surface. Sudden deceleration is thought to be responsible for most severe brainstem injuries.
●Rotation of the brain occurs when the head is struck in an asymmetric manner or an infant is vigorously shaken. Rotational acceleration-deceleration can induce widespread injury including large subdural hematomas. (See "Intracranial subdural hematoma in children: Epidemiology, anatomy, and pathophysiology", section on 'Pathophysiology'.)
●Epidural hematomas typically arise from a direct blow resulting in a linear fracture that cross middle meningeal arterial branches or dural venous sinuses, but may also occur without an associated fracture in a significant number of children. (See "Intracranial epidural hematoma in children: Epidemiology, anatomy and pathophysiology", section on 'Associated abnormalities'.)
EPIDEMIOLOGY — Head trauma occurs commonly in children. In the United States, among children younger than 14 years of age, traumatic brain injury (TBI) accounts for approximately 500,000 emergency department (ED) visits, 37,000 hospitalizations and over 2000 deaths annually . In developed countries, TBI is the most common cause of death and disability in childhood .
Most children with head trauma are young, male, and have a mild injury. This was demonstrated in a large prospective series that described minor head trauma in 10,965 children in the United Kingdom . Fifty-five percent of children were younger than five years of age, with 28 percent younger than two years of age. Boys accounted for 65 percent of patients, and 98 percent of children had Glasgow Coma Scale (GCS) scores of 15. Other series of children with head trauma have reported lower GCS scores but many of these describe selected populations, such as children with head injury who had neuroimaging performed [17,18].
Mechanism — Falls are the most common mechanism of injury for children sustaining minor head trauma, followed by motor vehicle crashes, pedestrian and bicycle accidents, projectiles, assaults, sports-related trauma, and abuse [7,16]. These mechanisms cause isolated head trauma in the majority of patients .
Infants sustain more falls and are at increased risk for inflicted injury. It is of utmost importance to identify children who have sustained an inflicted head injury, even if the injury is minor. Children who remain in the care of the perpetrator are at significant risk for being injured again. (See "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children" and "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children".)
Incidence of brain injury — The true incidence of clinically important traumatic brain injury (ciTBI) following minor head trauma is unknown. Most studies providing incidence data are from selected populations in which children with moderate to severe injury are overrepresented (eg, including only children who have had computed tomography [CT] or primarily children with nontrivial trauma) [17-20]. Consequently, the risk of ciTBI in these series may be overestimated.
Estimates of the incidence of TBI following head trauma from selected populations are summarized as follows:
●Among children two years of age and older with minor head trauma and a normal neurologic examination, 3 to 7 percent may have a TBI noted on CT scan [7,17-21]. Approximately 1 percent have ciTBI, and 0.1 to 0.6 percent require surgical intervention [8,19,22,23].
●For children younger than two years with minor head trauma and a normal neurologic examination, approximately 3 to 10 percent have a TBI on CT, 1 percent have ciTBI, and 0.2 percent require surgical intervention [7,8,17-19,24]. Many of these younger children have no clinical symptoms of brain injury (19 to 48 percent), although most of these patients have scalp hematomas [7,25,26]. In a prospective series of infants under two years of age, 1 of 14 asymptomatic infants with ciTBI required surgery .
Data from two European populations suggest that the incidence of ciTBI after minor head trauma is much lower (0.6 to 1.2 percent). However, only 2 to 3 percent of patients in these studies underwent neuroimaging [9,27].
Patients with shunts or bleeding disorders — Although the threshold for obtaining neuroimaging after minor head trauma in patients with ventricular shunts or bleeding disorders is lower for many clinicians, it is not clear that clinically important traumatic brain injury (ciTBI) after minor head trauma actually occurs more frequently than in normal children. As an example, in planned secondary analyses of a large multicenter observational study of children with minor head injury, approximately 1 percent of children with either ventricular shunts (98 children) or bleeding disorders (230 children) had a ciTBI (eg, head injury resulting in death, neurosurgery, intubation >24 hours, or hospital admission >2 nights) compared with 0.9 percent of the approximately 40,000 normal children [28-30]. However, with the low numbers of patients in these studies, the true frequency of ciTBI following minor head trauma in children with bleeding disorders or ventricular shunts could be as high as 4 to 5 percent, respectively. Furthermore, the rate of ciTBI seen in children with bleeding disorders occurred despite significantly fewer severe mechanisms of injury when compared with normal children [29,30].
CLINICAL FEATURES — Similar to reports of the incidence of clinically important traumatic brain injury (ciTBI), some studies that describe clinical features following minor head trauma only included children who underwent head computed tomography (CT). Consequently, these data also likely represent children whose injuries were more severe.
Common findings — Observational studies have identified loss of consciousness, scalp hematoma, vomiting, and headache as common features associated with minor head trauma in children evaluated in emergency departments .
Loss of consciousness — Loss of consciousness (LOC) following minor head trauma occurs in approximately 5 percent of children <2 years of age and up to 13 percent of children ≥2 years of age. It is frequently used to make decisions regarding neuroimaging [7,32]. LOC may be associated with ciTBI depending upon its duration and the presence of other clinical predictors [7,9,32].
However, the risk of TBI in the setting of brief, isolated LOC without any other clinical predictors of TBI, is low . As an example, in one large multicenter, prospective cohort study of 5850 children with LOC after mild head trauma, 0.5 percent of 2780 children with isolated LOC, defined as LOC without any of the age-related PECARN clinical predictors for ciTBI (table 2), had ciTBI compared with 4 percent of 3070 children with LOC and other PECARN clinical predictors . In this study, longer duration of LOC was also associated with ciTBI occurring in 1 percent of 907 children with LOC for <5 seconds and up to 4 percent of 200 children with LOC >5 minutes. (See 'Approach' below.)
Scalp hematoma — Most children with isolated scalp hematomas and no other clinical symptoms do not have ciTBI (eg, injuries resulting in death or requiring hospitalization for >2 days, endotracheal intubation for >24 hours, or neurosurgery).
However, hematomas can be an important indicator of potential TBI when they appear in younger infants, are larger (eg, >3 cm), and are located in nonfrontal regions [33-35]. As an example, in a multicenter observational study of 2998 children younger than 24 months of age with an isolated scalp hematoma, 50 of 570 children (8.8 percent) that underwent CT had TBI (eg, subdural or epidural hematomas, cerebral or subarachnoid hemorrhages, or cerebral contusion). Of 111 patients younger than three months with any hematoma who underwent CT, 21 percent (23 out of 111) had TBI on CT confirming that an isolated scalp hematoma is an important indicator of potential brain injury in neonates and young infants. However, ciTBI occurred in only 12 patients (0.4 percent of all 2998 patients), none of whom died or required neurosurgery . On multivariate analysis, characteristics independently associated with TBI on CT included younger age, larger hematoma size, nonfrontal hematoma location, and more severe mechanisms of injury. A previously validated clinical score incorporates age and hematoma characteristics and may help stratify the risk of TBI in young infants (table 3) . The mechanism of injury is also an important consideration not addressed in this score. (See 'Younger than two years' below.)
Vomiting — At least one episode of vomiting is reported in approximately 13 percent of patients following minor head trauma [7,36]. Most of these children do not have ciTBI [7,8,36]. However, ciTBI is more likely in children who have vomiting and other findings associated with ciTBI (eg, severe mechanism of injury, loss of consciousness, or altered mental status). As an example, of 5557 children evaluated for vomiting after minor head trauma at multiple centers, ciTBI occurred in 0.2 percent (95% CI 0-0.9 percent) of 815 children with isolated vomiting (ie, vomiting alone without other findings of ciTBI) and in 2.5 percent (95% CI 2.1-3.0 percent) of 4577 children with vomiting and other findings of ciTBI . Although the incidence of ciTBI among those with isolated vomiting was low, it was higher than patients without vomiting or other high risk symptoms (0.2 versus 0.04 percent). In a case control study comparing 162 children with mild head injury (as defined by discharge to home from the emergency department [ED]) and vomiting with matched controls, predictors of vomiting included a personal history of vomiting, motion sickness, and headache associated with the injury .
Whether the number of vomiting episodes and the timing of these episodes can help identify patients with ciTBI is unclear. Vomiting two or more times after head trauma was associated with an approximately 37 percent increase in traumatic brain injury in one multicenter observational study . However, increased frequency or later onset of vomiting after head injury did not identify children with ciTBI in another multicenter cohort .
Headache — Headache is a frequent complaint, occurring in up to 46 percent of verbal children with minor blunt head trauma . In preverbal children, irritability may also be an indication of discomfort, including headache [7,9].
When present with other symptoms, headache does modestly increase the risk of ciTBI and is of particular concern if it is persistent or worsening over time . However, in patients with isolated headaches, the incidence of ciTBI is low. As an example, in a planned secondary analysis of a large, multicenter cohort of almost 28,000 verbal children 2 to 18 years of age with minor head trauma, none of the 2462 patients with an isolated headache using an expanded definition, including no scalp findings, had ciTBI compared to 1.6 percent of the 10,105 patients with headache and other symptoms . Among those with isolated headache using PECARN criteria (table 2) only, 3 of 209 patients had ciTBI (1.4 percent, 95% CI 0.3 to 4.1 percent).
Seizures — Among unselected populations of children with head trauma, immediate posttraumatic seizures occurred in ≤0.6 percent [9,27]. In smaller series, seizures have been reported in approximately 3 to 8 percent of patients [4,19,39]. In one large cohort, the frequency of seizures after minor head trauma was 4 percent with approximately half occurring at the time of impact .
Skull fractures — Skull fractures occur in up to 10 percent of children younger than two years of age following minor head trauma [3,35]. Most skull fractures in this population are linear. Among children with linear skull fractures, 15 to 30 percent have associated intracranial injuries [2,19,20,26,40,41].
Most children with skull fractures will also have overlying scalp hematomas. However, most children with scalp hematomas, outside of infancy, do not have a skull fracture. In infants younger than one year of age, large scalp hematoma size, younger age, and/or nonfrontal location (highest risk with temporal or parietal), suggest a higher incidence of skull fracture. However, in one prospective series of 422 children, no infant with a frontal hematoma had an intracranial injury .
Other findings of skull fracture include a palpable skull defect, cerebrospinal fluid rhinorrhea or otorrhea, posterior auricular hematoma (Battle’s sign) (picture 1), hemotympanum (picture 2), and periorbital hematomas (“raccoon eyes”) (picture 3).
The evaluation and management of skull fractures in children are discussed in greater detail separately. (See "Skull fractures in children".)
Other findings — Transient cortical defects, such as cortical blindness and acute confusional states, have been reported rarely in association with minor head trauma [42-44]. These deficits are thought to be secondary to vascular hyperreactivity and may be trauma-induced, migraine-equivalent phenomena. Although rare, there are also case reports of ischemic or thrombotic stroke following mild head trauma in children [45,46].
EVALUATION — The priority for the evaluation of children with apparently minor head trauma is to identify those patients with traumatic brain injury (TBI) who may require immediate intervention (eg, an expanding epidural hematoma), admission for monitoring (eg, small stable epidural hematomas or cerebral contusions) or close follow-up (eg, skull fracture without intracranial injury), while limiting unnecessary neuroimaging.
In addition, children who may have sustained an inflicted injury must be identified. The evaluation of abusive head trauma is discussed in detail elsewhere. (See "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children" and "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children".)
Features of the history and physical examination, along with selective neuroimaging, generally identify children who have sustained a brain injury with acute management implications.
History — Historical features that may suggest an increased risk of clinically important traumatic brain include the following:
●Caregiver concern that a child younger than two years of age is not acting normally
●Seizure, confusion, or loss of consciousness
●Severe or worsening headache
●High-risk mechanism, such as a fall from greater than 3 to 5 feet (depending on age), significant motor vehicle collision, penetrating injury, inflicted injury, or unknown mechanism (which may represent inflicted injury)
●Preexisting conditions that place the child at risk for intracranial hemorrhage, such as arteriovenous malformation or a bleeding disorder (see 'Patients with shunts or bleeding disorders' above)
Physical examination — The clinician should perform a thorough head and neurological examination (including mental status). Vital signs and evidence of associated extracranial injury, such as neck or abdominal tenderness, also warrant careful evaluation.
The presence of the following specific findings is significant:
●Scalp abnormalities, such as hematoma, tenderness, or depression
●In infants, bulging anterior fontanelle
●Abnormal mental status
●Focal neurologic abnormality
Predictors of traumatic brain injury — The approach to neuroimaging in children with suspected abusive head trauma is discussed separately; however, any child with concerns for abusive head trauma should undergo neuroimaging. (See "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'Imaging'.)
In children with minor head trauma, no combination of clinical findings is both highly sensitive and specific for clinically important traumatic brain injuries (ciTBI). However, clinical findings can help stratify a patient’s risk of ciTBI as high, intermediate, or low as follows:
●High risk – Observational reports from selected populations have consistently described the following findings as significant predictors of ciTBI in children [9,21,27,47-49]:
•Focal neurologic examination
•Altered mental status (persistent Glasgow score ≤14)
•Findings indicating a skull fracture, such as a palpable skull defect, cerebrospinal fluid rhinorrhea or otorrhea, posterior auricular hematoma (Battle’s sign) (picture 1), hemotympanum (picture 2), and periorbital hematomas (“raccoon eyes”) (picture 3)
●Intermediate risk – Variable significance has been reported for each of the following findings [7,21,27,47-51]:
•Loss of consciousness
•Age less than two years
•Nonfrontal scalp hematoma in children younger than one year of age
•Persistent or worsening headache
•Significant trauma mechanism (eg, bicycle-related injury, falls from >0.9 to 1.5 m [3 to 5 feet], serious motor vehicle collision)
●Low risk – Patients with none of the above findings (low mechanism of injury, normal exam except frontal hematoma, no symptoms) are considered low risk and should typically not undergo neuroimaging.
Neuroimaging — An approach to neuroimaging of children with minor head trauma that is based upon risk of ciTBI is provided below. (See 'Approach' below.)
Most children with minor head trauma do not need computed tomography (CT) of the head CT to exclude ciTBI. The decision to obtain a head CT should be made using clinical predictors to determine risk of ciTBI. (See 'Approach' below.)
The approach to neuroimaging in children with suspected abusive head trauma is discussed separately. (See "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'Imaging'.)
Children who have minor head trauma and who are at an increased risk for ciTBI that may require neurosurgical intervention or intensive care or monitoring should be initially imaged with unenhanced CT. Head CT identifies essentially all ciTBI . It can be rapidly obtained in most hospitals. Skull radiography is of little or no added value if a head CT is performed. (See "Approach to neuroimaging in children", section on 'CT applications' and "Approach to neuroimaging in children", section on 'Plain radiographs'.)
The decision to obtain a head CT for children with minor head trauma must balance the importance of identifying a significant, but rare ciTBI with the estimated risks of late onset malignancy associated with radiation exposure from CT. The risk of death or major disability if a ciTBI is missed is considerable and immediate. Furthermore, evidence suggests that a clinician’s ability to predict the presence of such an injury in patient without high-risk findings (eg, altered mental status, focal neurologic examination, or signs of basilar skull fracture) is poor .
On the other hand, the estimated lifetime risk of cancer mortality from a head CT is substantially higher for children than for adults because of a longer subsequent lifetime and the greater sensitivity of some developing organs (eg, brain or bone marrow) to radiation. Estimates suggest that the lifetime risk of death due to cancer caused by radiation from one head CT is 1 in 1500 in a one year old infant and 1 in 5000 in a 10 year old child . However, the latency period for development of cancer may be decades. (See "Approach to neuroimaging in children", section on 'Radiation'.)
Thus, the probability of ciTBI as determined by clinical findings is a key factor for identifying the optimal approach in individual patients. As an example, in a clinical decision analysis of the optimal neuroimaging strategy that weighed the risk of ciTBI with the risk of radiation exposure from head CT and subsequent malignancy for children younger than two years of age with minor head trauma, no imaging was the best strategy when the probability of ciTBI was about 0.9 percent and head CT was the preferred strategy only for patients at higher risk .
Clinical decision rules — Clinical decision rules are not intended to replace clinical judgment. Based upon existing evidence, they assist rather than completely direct the clinician’s approach to neuroimaging of children with minor head trauma.
For infants and children with minor head trauma, absence of high-risk signs or symptoms of ciTBI, we suggest that management decisions, especially the performance of neuroimaging and observation, be guided by the use of the Pediatric Emergency Care Applied Research Network (PECARN) low-risk clinical decision rules (table 2) rather than other rules because it was derived in the largest cohort and is the only rule to be validated. (See 'Neuroimaging' above and 'Approach' below.)
This recommendation is based upon the following evidence:
●The PECARN rule was derived and validated in large pediatric cohorts (33,785 and 8627 patients, respectively) at multiple centers including pediatric and general emergency departments and consists of six low-risk predictors in two age groups (table 2) . The goal of this decision rule is to identify children who are at low risk for ciTBI and do not need neuroimaging.
In prospective validation, high sensitivities for the detection of ciTBI (100 percent for children <2 years [95% CI 86-100 percent] and 97 percent for children ≥2 years [95% CI 89-100 percent]) and high negative predictive values (100 percent for children <2 years [95% CI 99.7-100 percent] and 99.95 percent [95% CI 99.81-100 percent] or children ≥2 years) were achieved . The prevalence of ciTBI was approximately 1 percent in both the derivation and validation cohorts.
Not all children who do not meet these low-risk criteria require neuroimaging (as this would likely increase imaging rates) so the authors defined high and intermediate-risk groups . Those with altered mental status and signs of fracture were considered high risk which corresponded to a 4 percent incidence of ciTBI. The investigators felt that all such patients warranted neuroimaging.
Patients who did not meet low-risk criteria, other than altered mental status or signs of fracture (table 2), were considered at intermediate risk which corresponded to a 0.9 percent incidence of ciTBI . These children accounted for approximately 30 percent of all patients. Imaging or observation was suggested, based upon other factors, such as clinician experience, with a lower threshold to image children with multiple, more severe, or worsening signs or symptoms. (See 'Approach' below.)
●Implementation of the PECARN rule in the management of 356 children (46 percent under two years of age) in a separate setting from its original derivation or validation was associated with the following findings :
•High clinician satisfaction with the rule (96 percent)
•High adherence to the rule (94 percent)
•Identification of all three children with a ciTBI at the first visit
•A marginal increase in the rate of head CT after implementation from 7 to 8 percent that was not statistically significant
●In a decision analysis model that utilized characteristics of the PECARN public use dataset, application of the PECARN rules were projected to result in more ciTBI being missed but fewer computer tomographs (CT) of the head, fewer radiation-induced cancers, lower net quality-adjusted-life-years (QALYS) lost, and lower costs when compared to usual care in the United States . Overall, the model indicated that the PECARN rules were better than usual care because they were more effective (less QALYS lost) and less costly.
●Several other clinical decision rules for children with minor head trauma have been derived [6,31]. Of these, CHALICE (table 4) and CATCH (table 5) were derived in the largest and most heterogeneous cohorts. However, no other clinical decision rule, including CHALICE or CATCH, has either been validated or achieved similar results during implementation .
Unlike PECARN, which sought to identify children at low risk who would not require imaging, the CHALICE rule, derived from a prospective study of 22,772 patients, has identified 14 high-risk criteria for ciTBI (table 4) that serve as indicators for head CT. During derivation, the rule had a sensitivity of 98 percent (95% CI 96-100 percent) and a specificity of 87 percent . However, evidence suggests that the CHALICE rule may increase the rate of head CT without improved detection of ciTBI as follows:
•In a retrospective analysis of the application of the CHALICE rule in 1065 children, use of this rule would have increased the rate of head CT from 6.5 to 10 percent with only seven additional skull fractures or intracranial injuries identified during initial evaluation . Furthermore, had the CHALICE rule been applied to these patients and head CT obtained at the initial evaluation, the outcomes probably would not have been different.
•In a retrospective observational study of 1091 head injured patients evaluated in one pediatric emergency department (ED), application of the CHALICE rule would have been associated with an increase in the rate of head CT from 19 to 46 percent . In addition, six patients with intracranial injuries would have been missed, including one requiring neurosurgery.
CATCH is also a high-risk decision rule for ciTBI consisting of four high-risk factors and three additional medium-risk factors (table 5) . During derivation in almost 4000 children, including those with a Glasgow Coma Scale (GCS) score of 13, it achieved high sensitivity (98 percent for intermediate-risk factors and 100 percent for high-risk factors). However, it would require that 52 percent of patients undergo CT. In addition, CATCH has not been prospectively validated.
●In a prospective, single center observational study of physician judgment and clinical decision rules in which PECARN, CHALICE, and CATCH decision rules were all applied to 1009 children with minor head injury (2 percent with ciTBI and 19 percent undergoing CT), only physician practice (sensitivity 100 percent, 95% CI 84-100 percent) and the PECARN rule (sensitivity 100 percent, 95% CI 84-100 percent) identified all ciTBI, including four patients requiring neurosurgical intervention . Both CATCH and CHALICE misclassified a small number of patients with ciTBI as low risk. Both rules also missed one injury that warranted neurosurgical intervention.
Taken together, the evidence suggests that the PECARN rule provides a sensitive means of identifying children with ciTBI at an acceptable cost when applied to patients who have sustained more than trivial head trauma but who do not have obvious indications for neuroimaging.
Although not prospectively validated, the CHALICE rule has been implemented in the United Kingdom , and other investigators have suggested use of the CHALICE rule instead of the PECARN rule for the following reasons:
●In two separate analyses, investigators determined, based upon theoretical estimates, that implementation of the PECARN rule would increase the amount of neuroimaging to a greater extent than the CHALICE rule [6,31]. However, as noted above, actual implementation of the PECARN rule in one emergency department (ED) with a low rate of head CT only marginally increased the number of head CTs while identifying all children with ciTBI . Given the low pre-implementation imaging rate, however, the lack of increase may have been due to the preponderance of low-risk patients at this center.
●In a decision analysis that compared the CHALICE and PECARN rules and assigned costs based upon the United Kingdom National Health Service experience, CHALICE was the optimal strategy for evaluating children with minor head trauma . However, all decision rules evaluated in this study had similar costs and outcomes. Specifically, the PECARN rule achieved quality of life estimates similar to the CHALICE rule while costing about ₤75 (approximately USD $125) more per patient. This difference in cost is likely within the margin of error for the model.
Approach — Although there is not uniformity regarding risk factors derived from the large, multicenter observational studies, there are many consistencies particularly for the high and low-risk groups that permit a suggested approach to neuroimaging in children with minor head trauma [7-10,49]. This approach is largely consistent with guidelines for evaluation and management of minor head trauma in children previously proposed by expert consensus .
Younger than two years — Because children younger than two years of age are more difficult to assess, may be asymptomatic despite having a ciTBI, are at risk for abusive head trauma, and are more prone to skull fractures than older children, we suggest the following criteria for neuroimaging (see 'Minor head trauma' above and "Minor head trauma in infants and children: Management", section on 'Minor head trauma'):
●Perform neuroimaging – Infants and children younger than two years of age with high risk for intracranial injury or with suspected skull fracture should have a head CT [1,7,60].
High-risk patients have one or more of the following signs or symptoms:
•Suspicion of child abuse
•Focal neurologic findings
•Acute skull fracture, including depressed or basilar fracture
•Altered mental status change (eg, lethargy or irritability)
•Persistent vomiting (see 'Vomiting' above)
•Seizure following injury
●Observe or perform neuroimaging – Intermediate-risk patients may be managed with close observation for four to six hours after the injury (with imaging obtained for any worsening condition during this period), or they may be evaluated immediately by head CT.
Patient at intermediate-risk have any one or more of the following signs or symptoms:
•Vomiting that is self-limited
•Loss of consciousness that is uncertain, or isolated and very brief (less than a few seconds) (see 'Loss of consciousness' above)
•History of lethargy or irritability, now resolved
•Behavioral change reported by caregiver
•Injury caused by high-risk mechanism of injury (eg, fall more than three feet, patient ejection, death of a passenger, rollover, high-impact head injury)
•Scalp hematoma (particularly nonfrontal)
•Skull fracture more than 24 hours old (nonacute)
•Unwitnessed trauma of concern (eg, fall heard in adjacent room with possible loss of consciousness)
•Age younger than three months with nontrivial trauma
The clinician should have a lower threshold for imaging if symptoms are multiple, worsening or severe, if vomiting is persistent, and for the youngest patients with nontrivial trauma [7,11,21].
The risk for fracture and TBI with scalp hematomas can be stratified using a validated scalp score (table 3) . Younger patients, larger hematomas, and nonfrontal hematomas (temporal-parietal more concerning than occipital) have the highest risk. As an example, in a large multicenter, cohort study, 8 out of 16 patients younger than three months of age with large temporal/parietal hematomas who underwent imaging had TBI on CT . If a scalp hematoma is the only finding, evidence from this study indicates that there is approximately a 0.4 percent risk of ciTBI, and a 1.7 percent risk of TBI on CT.
For patients for whom the sole criterion is a high-risk mechanism for injury, the risk of ciTBI is 0.3 percent [7,61].
If immediate CT is deferred for intermediate-risk patients, we suggest observation for at least four to six hours after injury to ensure no progression of clinical findings that warrant CT.
Preliminary evidence suggests that observation of selected children younger than two years of age at intermediate risk reduces the number of head CTs without missing a ciTBI. As an example, in an observational study of 1318 children evaluated for minor head trauma at a single pediatric ED, including 509 children younger than two years of age, the rate of head CT among children who were chosen for observation was 5 percent [62,63]. The adjusted time dependent decrease in CT rate for children at intermediate risk according to the PECARN decision rule was 72 percent and their median time of observation was three hours. None of the intermediate-risk children were subsequently found to have a ciTBI.
Skull radiographs may occasionally be useful to screen for fracture and avoid the risk of radiation and sedation from CT in selected asymptomatic patients 3 to 24 months of age with concerning scalp hematomas . However, skull radiographs should only be performed if a radiologist with pediatric expertise is available to provide an interpretation because physicians with pediatric emergency expertise may have limited accuracy in correctly identifying skull fractures in young children . If a screening skull radiograph shows a fracture, then a head CT should be performed. (See 'Skull radiographs' below.)
●Do not perform neuroimaging – Imaging studies should be avoided in children <2 years of age at very low risk for brain injury. These patients should have a normal neurologic examination (including a normal fontanelle), no history of seizure, and no persistent vomiting. The clinician should also have no suspicion for abuse.
•Normal mental status
•No parietal, occipital or temporal scalp hematoma
•No loss of consciousness >5 seconds (see 'Loss of consciousness' above)
•No evidence of skull fracture
•Normal behavior according to the routine caregiver
•No high-risk mechanism of injury (severe mechanisms: fall >0.9 m [3 feet]; head struck by high impact object; motor vehicle collision with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by a motorized vehicle)
The risk for clinically important traumatic brain injury is less than 0.02 percent in these patients .
Two years and older — Criteria to guide decisions about neuroimaging in children two years of age and older are derived from several large multicenter observational studies [7,9,21] and a metaanalysis of observational studies .
We suggest the following approach:
●Perform neuroimaging – Children ≥2 years of age with one or more of the following signs and symptoms appear to be at the highest risk for ciTBI and should have CT of the head performed [7,9,21,47]:
•Focal neurologic findings
•Skull fracture, especially findings of basilar skull fracture
•Persistent altered mental status (eg, agitation, lethargy, repetitive questioning, or slow response to verbal questioning)
•Prolonged loss of consciousness (LOC) (see 'Loss of consciousness' above)
Multiple observational studies have found these individual findings to be highly associated with ciTBI in children .
●Observe or perform neuroimaging – For children with signs and symptoms that have been variably associated with intracranial injury, close observation for four to six hours after the injury (with imaging obtained for any worsening symptoms or concerns during this period) is an alternative to immediate CT of the head. The clinician should have a lower threshold for imaging for severe, persistent, worsening, or multiple clinical findings. These signs and symptoms include:
•Vomiting (see 'Vomiting' above)
•Questionable or brief loss of consciousness (LOC)
•Injury caused by high-risk mechanism of injury
The risk of ciTBI is approximately 1 percent in patients with at least one of these criteria and 0.6 percent if the sole criterion is a high-risk mechanism for injury [7,61]. Patients with isolated LOC that is brief have a low risk of ciTBI. Most of these patients do not require neuroimaging . Multiple or worsening symptoms or signs likely puts the child at greater risk than an isolated finding [7,11,21].
Evidence suggests that observation of patients with these signs and symptoms may decrease the utilization of head CT without missing clinically important traumatic brain injury as follows:
•In a multicenter, prospective observational study, children (median age five years) who were observed had a lower rate of head CT use than those who were not (31 versus 35 percent, respectively, difference -4 percent [95% CI -5 to -3 percent]) . The observed patients had a similar rate of clinically important traumatic brain injury (0.8 versus 0.9 percent). In this study, most observed children were older than two years of age.
•In a single center prospective observational study previously discussed, the rate of head CT in children who were chosen to be observed was 5 percent and the median time for observation was 2.5 hours . Overall, 20 percent of children received a head CT. The adjusted time dependent decrease in CT rate overall was 69 percent (odds ratio [OR] 0.31, 95% CI 0.25-0.37). Most observed patients were intermediate risk by the PECARN decision rule and two years of age or older. All eight children with ciTBI had an immediate head CT although clinical follow-up was confined to electronic medical record review.
Thus, observation appears to be a safe and effective approach for selected children two years of age and older who are at an intermediate risk of ciTBI based upon the PECARN decision rule.
●Do not perform neuroimaging – Imaging studies should be avoided in children ≥2 years of age at very low risk for ciTBI. These patients should have a normal neurologic examination, no physical evidence suggesting a skull fracture, and no preexisting condition that might increase the risk of intracranial hemorrhage (eg, bleeding disorder) .
•Normal mental status
•No LOC (see 'Loss of consciousness' above)
•No vomiting (see 'Vomiting' above)
•No signs of basilar skull fracture
•No severe headache
•No high-risk mechanism of injury (severe mechanisms: fall >1.5 m [5 feet]; head struck by high impact object; motor vehicle collision with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without a helmet struck by a motorized vehicle)
The risk for clinically important traumatic brain injury is less than 0.05 percent if none of these findings are present .
Skull radiographs — Because plain skull radiographs give no direct information about intracranial injury, they are rarely performed as the initial imaging study. Instances in which skull radiographs may assist the clinician in deciding whether or not to perform CT of the head include the following:
●When the history of trauma is uncertain (eg, skeletal survey in the evaluation of suspected abuse)
●To rapidly evaluate for the location of a radiopaque foreign body (eg, whether a projectile is intracranial or not)
●In rare instances, to screen for fractures in selected asymptomatic patients 3 to 24 months of age with concerning scalp hematomas
However, skull radiographs should only be performed if a radiologist with pediatric expertise is available to provide an interpretation because physicians with pediatric emergency expertise may have limited accuracy in correctly identifying skull fractures in young children .
If a screening skull radiograph shows a fracture, then a head CT should be performed. If a screening skull radiograph shows no fracture, the risk of a ciTBI may be lower, but the clinician should understand that it may still be present. (See "Skull fractures in children", section on 'Radiologic evaluation' and 'Incidence of brain injury' above.)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient information: Head injury in children and adolescents (The Basics)")
●Beyond the Basics topic (see "Patient information: Head injury in children and adolescents (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●In infants, minor head trauma refers to patients who are alert or awaken to voice or light touch but have a history or physical signs of blunt trauma to the scalp, skull, or brain. In children two years of age or older, this topic defines minor head trauma as children who have sustained head trauma but have a Glasgow Coma Scale (GCS) score of 14 to 15, normal physical examination, and no physical evidence of a skull fracture. (See 'Definitions' above and 'Epidemiology' above and "Minor head trauma in infants and children: Management", section on 'Definitions'.)
●Although associated clinically important traumatic brain injury (ciTBI), (ie, intracranial injury requiring neurosurgical intervention, intensive monitoring and supportive care, prolonged hospitalization; a depressed skull fracture requiring elevation; or a basilar skull fractures) occurs in a small percentage of children and infants who have a normal neurologic examination at presentation, it must be recognized in order to prevent deterioration and subsequent morbidity or mortality. In addition, abusive head trauma must also be identified because it often results in serious intracranial injury and carries a significant risk of recurrence. (See 'Clinically important traumatic brain injury' above and 'Incidence of brain injury' above and "Minor head trauma in infants and children: Management", section on 'Definitions'.)
●Features of the history and physical examination along with careful observation in children with equivocal findings usually identify children who have sustained a ciTBI and warrant neuroimaging. (See 'History' above and 'Physical examination' above and 'Predictors of traumatic brain injury' above.)
●Those who are at an increased risk for ciTBI that may require neurosurgical intervention or intensive care or monitoring should be initially imaged with unenhanced computed tomography (CT). Skull radiography is of little or no added value if a head CT is performed. (See 'Neuroimaging' above and 'Skull radiographs' above.)
●The probability of ciTBI as determined by clinical findings is a key factor for identifying the optimal approach in individual patients. Patients at high risk for ciTBI should undergo prompt neuroimaging. Those at intermediate risk may undergo neuroimaging or observation with performance of imaging if persistent, worsening or new symptoms occur during observation. Infants and children at low risk for ciTBI should not undergo neuroimaging. Clinical decision rules can assist the clinician in determining the level of risk and need for neuroimaging but should not replace clinical judgment. (See 'Clinical decision rules' above.)
●For infants and children with minor head trauma and absence of high-risk physical findings of ciTBI, we suggest that management decisions, especially the performance of neuroimaging or emergency department (ED) observation, be guided by the use of the Pediatric Emergency Care Applied Research Network (PECARN) low-risk clinical decision rules (table 2) rather than other rules. (See 'Clinical decision rules' above.)
●An approach to neuroimaging of infants and children with minor head trauma that differs by age and is based upon the PECARN low-risk clinical decision rules and known additional findings that predict a higher risk for ciTBI is provided. (See 'Younger than two years' above and 'Two years and older' above.)
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