Emergency Department Clinical Pathway for the Evaluation/Treatment
of Children with Acute Head Trauma
Child with Acute Head Trauma
< 24 hours after Injury
No suspicion of abuse
< 24 hours after Injury
No suspicion of abuse
Triage
(Critical/Acute/Urgent)
(Critical/Acute/Urgent)
Critical
Proceed to Resuscitation Room
Proceed to Resuscitation Room
- FLOC/RN Team Assessment
- History and Physical
- Child > 5 yrs with concern for Concussion:
- Consider Non-accidental Trauma
- Children < 2 yrs
Decision Rule for Very Low Risk of Intracranial Injury
Children < 2 Years Old
- Normal Mental Status Children < 2 yrs
- No hematoma or isolated frontal hematoma
- No LOC or LOC for less than 5 seconds
- Non-severe Injury Mechanism Children < 2 yrs
- No palpable skull fracture
- Acting normally according to the parents
Children ≥ 2 Years Old
- Normal Mental Status Children ≥ 2 yrs
- No LOC
- No vomiting
- Non-severe Injury Mechanism Children ≥ 2 yrs
- No signs of basilar skull fracture
- No severe (intense) headache
All Very-Low Risk Criteria Present
All Very-Low Risk Criteria Not Present
Observe 2-4 hrs from time of injury
Review head trauma instructions
vs.
Discharge home
Review head trauma instructions
If observing
Reassess and/or Review Imaging
Observation and/or
CT Negative and PE Reassuring
CT Negative and PE Reassuring
CT Positive for Injury
Isolated linear,
non-depressed
skull fracture
non-depressed
skull fracture
Intracranial
injury present
injury present
Discharge Home
Review Head Trauma Instructions
Review Head Trauma Instructions
Yes
- Normal
- GCS, mental status
- Neurologic Exam
- Tolerating PO
No
Consult
Neurosurgery, Trauma
Neurosurgery, Trauma
Admit to PICU, Neurosurgery
or
Inpatient Trauma Service
or
Inpatient Trauma Service
- Criteria for Admission to Inpatient Trauma Service
- Isolated, non-epidural hemorrhage < 5 mm in diameter
- GCS = 15, normal mental status
- Non-focal neurologic examination
- No other trauma requiring ICU care
- No history of coagulopathy
- ED and Trauma Attending agree
Posted: December 2010
Revised: March 2023
Authors: F. Nadel, MD; D. Corwin, MD; M. Mittal, MD; C. Jacobstein, MD; J. Lavelle, MD; P. Scribano, DO, MSCE
Revised: March 2023
Authors: F. Nadel, MD; D. Corwin, MD; M. Mittal, MD; C. Jacobstein, MD; J. Lavelle, MD; P. Scribano, DO, MSCE
Evidence
- Clinical and Device-based Metrics of Gait and Balance in Diagnosing Youth Concussion
- Reliability of the Visio-vestibular Examination for Concussion Among Providers in a Pediatric Emergency Department
- Characteristics and Outcomes for Delayed Diagnosis of Concussion in Pediatric Patients Presenting to the Emergency Department
- Trends in Emergent Head Computed Tomography Utilization for Minor Head Trauma After Implementation of a Clinical Pathway
- Use of the Vestibular and Oculomotor Examination for Concussion in a Pediatric Emergency Department
- A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions
- Identification of Children at Very Low Risk of Clinically-important Brain Injuries After Head Trauma
Educational Media
- Primary Care Perspectives: Podcast for Pediatricians
Episode 125: Emergency Room or Not? - PEM Podcast Episode 19: Concussion