Minor Head Trauma (< 18 years)



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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?




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