Mechanism & risk stratification (Document **fall height**, surface (concrete vs carpet), body part struck first, loss of consciousness, vomiting, behavior change; **low-risk** mechanisms in well-appearing children often allow clinical observation without CT — apply validated head-injury rules (PECARN, CATCH, CHALICE) per age (ATLS pediatric, AAP head injury, NICE NG232))
Initial assessment (ABCDE) (ABCDE primary survey · GCS/AVPU · pupils · fontanelle tension in infants · scalp hematoma location/size · skull fracture signs · neuro exam serially · assess for non-accidental injury (NAI) red flags — inconsistent history, delay in care, patterned injuries (ATLS, AAP, safeguarding))
Duration: ED / observation · Apply age-appropriate **clinical decision rule** for minor head injury · Serial neuro exams · Observation pathway if rule-negative and well-appearing · CT head only per rule-positive or high-risk features · C-spine immobilization only if mechanism + exam warrant (ATLS pediatric, AAP, NICE)
• **Red flags — immediate CT and/or admission:** GCS <15 or declining · focal neuro deficit · seizure post-injury · persistent vomiting · severe/worsening headache · bulging fontanelle · signs of skull fracture (palpable step, Battle sign, hemotympanum) · LOC >5 s or amnesia · high-risk mechanism with concerning exam (ATLS, PECARN, AAP).
• **PECARN (≥2 years):** CT if any high-risk: altered mental status, palpable skull fracture, vomiting, severe headache, or ≥2 mod-risk (non-frontal hematoma, LOC, severe mechanism) — rule-negative well-appearing children often safe for observation (PECARN, AAP).
• **Infants <2 years:** lower threshold — skull fracture risk higher with short falls; apply PECARN <2y or CHALICE; admit/observe infants with scalp hematoma, irritability, or unreliable exam (AAP, CHALICE).
• **C-spine:** immobilize if high-risk mechanism (fall >1 m/3 ft, axial load, diving-equivalent, neck pain, neuro deficit, GCS <15, intoxication, unreliable exam) — clinical clearance protocols in cooperative children per ATLS pediatric; imaging if criteria met.
• **Discharge criteria:** rule-negative, normal serial exams 4–6 h, reliable caregivers, written return precautions (vomiting, lethargy, seizure, unequal pupils, behavior change) — primary care documents mechanism and safeguarding assessment (AAP, NICE).
Duration: As indicated · Admit for observation 12–24 h if intermediate risk, social concerns, unreliable caregivers, or evolving symptoms — CT per clinical deterioration; social work if NAI suspected (AAP, ATLS)
• **Admit for observation:** intermediate-risk head injury per local rule · unreliable exam (young infant, developmental delay) · home environment concerns · new symptoms during ED stay · coagulopathy or VP shunt (AAP, ATLS).
• **CT head indications:** rule-positive features · declining GCS · focal deficit · seizure · persistent vomiting · suspected NAI with head injury (AAP, PECARN, safeguarding).
• **Safeguarding:** falls from windows/balconies, stairs in toddlers, or inconsistent mechanism — assess for NAI; document height, supervision, injury pattern; involve social work per local policy (AAP child abuse pediatrics).
• **What NOT to do:** routine CT for all minor falls · discharge without return precautions · ignore scalp hematoma in infants <2 years · clear c-spine without clinical criteria (ATLS, AAP).
• **Cross-reference:** isolated head injury details → see **head_trauma** card; chest/abdominal impact from fall → see **chest_trauma**, **abdominal_trauma** if focal symptoms develop.
Clinical notes
• ABCDE + mechanism: document fall height, surface, first body part struck, LOC, vomiting, behavior change; apply PECARN/CATCH/CHALICE for CT decisions — avoid routine imaging in low-risk well-appearing children (ATLS, AAP, NICE NG232).
• Red flags: GCS <15 or declining, focal neuro deficit, post-injury seizure, persistent vomiting, skull fracture signs, bulging fontanelle — CT and admission; infants <2 years have lower threshold (PECARN, CHALICE, AAP).
• C-spine: selective immobilization per ATLS pediatric — high-risk mechanism, neck pain, neuro deficit, GCS <15; clinical clearance in cooperative children when criteria met.
• Discharge: rule-negative with normal serial exams, reliable caregivers, return precautions for vomiting, lethargy, seizure, behavior change; assess safeguarding if mechanism inconsistent (AAP, ATLS).
• Cross-links: focal head injury → **head_trauma**; thoracic/abd impact symptoms → **chest_trauma**, **abdominal_trauma**; crush component if trapped under object → **crush_injury**.
• ATLS — Pediatric trauma and cervical spine management (2024)
• AAP — Minor head injury and clinical decision rules (2024)
• PECARN — Pediatric head injury prediction rules (2009)
+ 2 more
• NICE NG232 — Head injury assessment in children (2023)
• WHO — Pocket Book of Hospital Care for Children (head injury) (2022)
