Acute Head Trauma Clinical Pathway — Emergency Department

Goals and Metrics

Provider Resources

Related Pathways

Child with Acute Head Trauma
< 24 hrs after Injury
No suspicion of abuse

Modified Glasgow Coma Scale
for Infants and Children

ED Triage

Critical
Proceed to Resuscitation Room

ED Team Assessment

GCS, mental status, neuro checks, pain
CR Monitor
Assess need for c-spine immobilization
Consider analgesia, anti-emetics
NPO, IVF as indicated
History and Physical
Child > 5 yrs with concern for Concussion:
- Perform Visio-Vestibular Exam

Consider Non-Accidental Trauma
Children < 2 yrs
- SW Consult
- ED Physical Abuse Pathway
  - Screen for Occult Injury
  - Skeletal Survey Recommendations

Decision Rule for Very Low Risk of Intracranial Injury

Children < 2 Years Old

Normal Mental Status Children < 2 yrs
Acting normally according to the parents
No palpable skull fracture
No hematoma or isolated frontal hematoma
No LOC or LOC for less than 5 seconds
Non-Severe Injury Mechanism Children < 2 yrs

Children ≥ 2 Years Old

Normal Mental Status Children ≥ 2 yrs
No signs of basilar skull fracture
No LOC
No vomiting
No severe (intense) headache
Non-Severe Injury Mechanism Children ≥ 2 yrs

All Very-Low Risk Criteria Present

All Very-Low Risk Criteria Not Present

Review Imaging Guidance

Observe 2-4 hrs from time of injury
or
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

Posted: December 2010
Last Revised: May 2025, Revisions

Authors:
- F. Nadel, MD;
- D. Corwin, MD;
- M. Mittal, MD;
- C. Jacobstein, MD;
- J. Lavelle, MD;
- P. Scribano, DO;
- S. Chen, MD

Editors: Clinical Pathways Team

Evidence

Educational Media

Primary Care Perspectives: Podcast for Pediatricians
Episode 125: Emergency Room
or Not?
PEM Podcast Episode 19: Concussion

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway, please contact us.

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.