Mechanism & clinical context (Blunt head injury — fall, sports, MVC, assault; concussion = transient neurologic dysfunction without structural lesion on imaging; minor TBI = GCS 13–15 with brief LOC or amnesia; children <2 yr higher risk of occult injury (ATLS pediatric, AAP concussion, PECARN))
Duration: Once · Non-contrast CT head when PECARN/AAP high-risk features — GCS <15, altered mental status, vomiting, severe headache, seizure, focal deficit, suspected NAI, or high-risk mechanism; radiation risk vs benefit — clinical decision (PECARN, AAP, ATLS)
• **ABCDE primary survey:** airway with C-spine control if indicated; breathing and circulation; disability — GCS, pupils, focal motor/sensory exam; exposure — scalp lacerations, hematoma, Battle sign, raccoon eyes (ATLS pediatric).
• **PECARN CT criteria (≥2 yr):** CT if GCS <15, altered mental status, sign of basilar skull fracture, severe headache, vomiting, or high-risk mechanism; for <2 yr — additional criteria including non-frontal hematoma, LOC >5 s, severe mechanism (PECARN, AAP).
• **Observation criteria:** GCS 15, normal exam, no red flags — observe minimum 4–6 h with serial neuro checks q1–2 h; longer observation if vomiting, headache, or unreliable history (AAP concussion, ATLS).
• **Primary care / ED discharge:** only if low-risk per PECARN, asymptomatic after observation, reliable caregivers; provide written return precautions — worsening headache, repeated vomiting, confusion, seizure, weakness, unequal pupils (AAP concussion).
• **Activity restriction:** cognitive and physical rest 24–48 h after concussion; gradual return-to-play/school per symptom-guided protocol; no same-day return to contact sports (AAP concussion, CDC HEADS UP).
• **ICU/PICU:** GCS ≤8, need for intubation, bilateral fixed pupils, or multisystem trauma — see near_hanging_strangulation card for hypoxic brain injury overlap (ATLS, ERC).
• **Antibiotics:** NOT routine for closed head injury without open fracture or penetrating wound — see open head trauma variant if scalp laceration with galeal violation and exposed bone (ATLS, AAP).
• **Safeguarding:** unexplained injury, inconsistent history, patterned bruising, delay in presentation — mandatory child protection assessment before discharge (AAP).
Clinical notes
• ABCDE first: assess GCS, pupils, focal deficits; C-spine precautions for high-risk mechanism (MVC, fall >1 m, diving, near_hanging_strangulation overlap) — maintain inline stabilization (ATLS pediatric).
• PECARN guides CT: high-risk features mandate imaging; intermediate-risk observe vs CT per shared decision; low-risk may avoid CT with observation (PECARN, AAP).
• Concussion recognition: headache, dizziness, confusion, irritability, sleep disturbance — may be delayed; no same-day return to contact sports (AAP concussion, CDC).
• Return precautions: worsening headache, repeated vomiting, drowsiness, confusion, seizure, weakness, unequal pupils — immediate ED return; educate caregivers in plain language (AAP).
• Cross-reference: concurrent crush_injury or blast_injury — prioritize life-threatening injuries; polytrauma activation per ATLS; do not duplicate crush syndrome management here.
• ATLS — Pediatric head injury and C-spine management (2024)
• AAP — Concussion and sports-related head injury (2024)
• PECARN — Clinical decision rule for pediatric head trauma (2009)
+ 1 more
• ERC — Paediatric life support (traumatic brain injury) (2021)
