Based upon the child’s history/physical examination it was felt they had a minor head injury. This patient was risk stratified for important intracranial injury using the PECARN (Pediatric Emergency Care Applied Research Network) head injury criteria (Kuppermann N, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009; 374:1160-1170.). For children <2 y.o. these criteria are: normal mental status, no scalp hematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 sec, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents. For children >2 y.o. these criteria are: (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache).
We discussed the risk of radiation from CT scanning of the head, including cognitive effects and lifetime cancer risks. We also spoke of the low risk of an intracranial injury requiring intervention based upon the low risk stratification by the PECARN rules and the patient’s overall clinical status. The parent/guardian of this child chose to observe and closely monitor the child and hold on CT scanning at this time.
We spoke with the parent/guardian of the child concerning observation instructions. I stated that the child should be kept under observation for the next 24 hours. If any concern arises that he/she is developing a problem, they should return to the ED and if necessary, contact 911. Symptoms to return to the ED include (but are not limited to): increasing drowsiness or confusion, persisting new or recurrent severe headache, vomiting, weakness of one or more limbs, difficulty in seeing or breathing, discharge or bleeding from ear, nose or mouth, seizures, or any other abnormal behavior or concerns.
Check your child every hour for the next 4 hours, then every 2 hours twice, then every 4 hours twice. Make sure he is acting normally, not throwing up, and his eyes look normal as well. Return to the ED if you have further concerns about how he is acting or you cannot wake him up.