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Acute Head Trauma Clinical Pathway — Emergency Department

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
ED Triage
(Critical/Acute/Urgent)
Critical
Proceed to Resuscitation Room
Decision Rule for Very Low Risk of Intracranial Injury
Children < 2 Years Old
Children ≥ 2 Years Old
All Very-Low Risk Criteria Present
All Very-Low Risk Criteria Not Present

Consider the following:

  • Observe 2-4 hours from time of injury
  • Head CT
Observe 2-4 hrs from time of injury
vs.
Discharge home
Review head trauma instructions
If observing
Reassess and/or Review Imaging
Observation and/or
CT Negative and PE Reassuring
CT Positive for Injury
Isolated linear,
non-depressed skull fracture
  • Depressed skull fracture
  • Fractures in multiple areas
  • Basilar skull fracture
Intracranial
injury present
  • Normal GCS, mental status, neuro exam
  • and
  • Tolerating PO
Neurosurgery and Trauma
consult/follow-up not required
  • Abnormal GCS, mental status or neuro exam
  • or
  • Unable to tolerate PO
Consult Neurosurgery and Trauma
Discharge
Review Head Trauma Instructions
Admit to Trauma Service
Surgical Unit vs. PICU
  • Criteria for Admission to Inpatient Surgical Unit
    • Epidural and subdural hematoma 5 mm in diameter
    • GCS = 15, normal mental status
    • No neurological symptoms/deficits
    • No other trauma requiring ICU care
    • No history of coagulopathy
  • Criteria for Admission to PICU
    • Epidural or subdural hematoma > 5 mm in diameter and neurological symptoms/deficits
    • Note: Epidural or subdural hematoma > 5 mm in diameter with no neurological symptoms or any other intracranial injuries, discuss disposition with Neurosurgery and Trauma

 

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