Minor Head Trauma (< 18 years)
Signs of basiler skull fracture
- Periorbital ecchymosis (“raccoon eyes”)
- Battle's sign
- Hemotympanum
- Cerebrospinal fluid otorrhea
- Cerebrospinal fluid rhinorrhea
>2 years?
Meets discharge criteria?
Meets discharge criteria?
< 3 months?
Meets discharge criteria?
Worsening signs/symptoms during 2 - 6 hour observation?
Consider admission and neurology consult
Consult neurosurgery if appropriate
Consider admission and neurology consult
1 or more factors present?
- GCS 14
- Signs of altered mental status
- Palpable or other signs of skull fracture
- Focal neurologic findings
- Seizure after injury
- Persistent vomiting
- Suspicion of abuse
- Bulging fontanelle
Evaluate secondary factors:
- Occipital, parietal or temporal scalp hematoma
- Loss of consciousness >= 5 sec
- Severe mechanism
- Not acting normally per parent
Discharge with PMD follow up within 24 hours
Consider neurology or neurosurgery consult
Discharge with PMD follow up within 24 hours
Evaluate secondary factors:
- Loss of consciousness
- History of vomiting
- Severe headache
- Severe mechanism
Severe mechanism
- Motor vehicle crash with patient ejection, death of another passenger, or rollover
- Pedestrian or bicyclist without helmet struck by a motorized vehicle
- Falls onto head
- < 2 years: greater than 0.9 m (3 feet)
- > 2 years: greater than 1.5 m (5 feet)
- Head struck by a high-impact object
Discharge criteria
- Reassuring vital signs
- Tolerating PO
- Well-appearing
- No social/family concerns
- Reliable follow up in 24 hours
- Parents comfortable and understand discharge plan
- Provider comfortable with outpatient therapy
1 or more factors present?
- GCS 14
- Signs of altered mental status
- Signs of basiler skull fracture
- Focal neurologic findings
- Seizure after injury
- Persistent vomiting
Signs of altered mental status
- Agitation
- Somnolence
- Repetitive questioning
- Slow response to verbal communication
Common mechanisms
- Falls
- Motor vehicle crashes
- Pedestrian and bicycle accidents
- Projectiles
- Assaults
- Sports-related trauma
- Abuse
Inclusion Criteria
- Head trauma in the past 24 hours
Exclusion Criteria
- Known brain tumors or ventricular shunts (VP)
- Coagulopathy or bleeding disorder
- Toxic appearance
- Glasgow Coma Scale score < 14
- Trivial injury mechanisms (ground-level falls or walking / running into stationary objects)
- Pre-existing neurological disorders complicating clinical assessment
- Penetrating trauma
CT or MRI neuroimaging
MRI Brain WO Contrast
CT Head WO Contrast
Worsening signs/symptoms during 2 - 6 hour observation?
