PECARN Pediatric Head Injury/Trauma Algorithm

In the pediatric population (age 18 years or younger), CT imaging of the head is thought to be associated with an increased risk of lethal malignancy over the life of the patient, with the risk decreasing with age. The estimated risk of lethal malignancy from a head CT in one year is 1 in 1000-1500. The risk decreases to 1 in 5000 once the patient is 10 years old. The Pediatric Emergency Care Applied Research Network (PECARN) conducted the largest study to derive and validate clinical prediction rules to identify children with very low risk of Clinically Important Traumatic Brain Injury (ciTBI) following blunt head trauma who do not need imaging. As a result, the PECARN Pediatric Head Injury Prediction Rule can assist providers in determining which pediatric patients they can safely discharge without obtaining a head CT. Of note, the PECARN study results suggest overall TBI in children is rare with low rates of TBI on head CT (5.2%) and even lower rates of ciTBI (0.9%).

The PECARN Pediatric Head Injury Prediction Rule is a well-validated clinical decision aid. The criteria allow clinicians to safely rule out the presence of clinically important traumatic brain injuries among pediatric head injury patients without the need for CT imaging.

¹Glascow Coma Scale (GCS)

²Other signs of altered mental status (AMS): Agitation, somnolence, repetitive questioning, or slow response to verbal communication.

³Loss of Consciousness (LOC)

⁴Severe mechanism:

• Motor vehicle crash (MVC) with patient ejection
• MVC with death of another passenger or rollover
• Pedestrian or bicyclist w/o helmet struck by motorized vehicle
• Fall from > 3 ft (0.9 m)
• Head struck by high-impact object

⁵Other clinical factors include:

• Clinician experience
• Multiple versus isolated findings⁶
• Worsening symptoms or signs after emergency department observation
• Age < 3 months
• Parental preference

⁶Isolated findings:

• Isolated Loss of Consciousness
• Isolated headache
• Isolated vomiting
• Certain types of isolated scalp hematomas in infants > 3 months

⁷Definition of clinically important traumatic brain injury (ciTBI)

  (any of the following)

• Death from traumatic brain injury (TBI)
• Neurosurgical intervention for TBI
• Intubation of more than 24 hours for TBI
• Hospital Admission of 2 nights or more for the TBI in association with TBI on CT^

^Definition of TBI on CT (any of the following):

• Intracranial hemorrhage or contusion
• Cerebral edema
• Traumatic infarction
• Diffuse axonal injury
• Shearing injury
• Sigmoid sinus thrombosis
• Midline shift of intracranial contents or signs of brain herniation
• Diastasis of the skull
• Pneumocephalus
• Skull fracture depressed by at least the width of the table of the skull

Management Considerations:

• Clinical judgement also plays a key role in work-up and disposition. For example, judgement may be based on:
  • If the event was witnessed or historical reliability
  • Patient age
  • Parental preference
  • Clinical deterioration
  • Patient co-morbidities
• For those with suspected or radiologically-confirmed traumatic brain injury (TBI):
  • First assess ABC's and consider neurosurgical/ICU consultation 
  • Consult institutional protocols on, for example: 
    • Fluid management
    • Seizure prophylaxis
    • Hypertonic saline or mannitol
    • Admission or disposition
• For those not imaged, observation for 4-6 hours to monitor changes in clinical status.
• For those discharged
  • Reassurance, education and strict return precautions. 
  • Follow-up with primary care or neurologist.
  • If concussion suspected, return to play or school anticipatory guidance.
    • Concussion awareness, diagnosis and treatment (AAFP) resources.

The evaluation only applies to children with a Glascow Coma Scale of ≥ 14.