Note: This only applies to children with GCS scores of 14 or greater.
Advice
- In patients with suspected or radiologically-confirmed TBI, first assess ABC’s and consider neurosurgical/ICU consultation or local policies in regards to fluid management, seizure prophylaxis, hypertonic saline/mannitol, disposition, etc.
- Observation for 4-6 hours for those who are not imaged to assess for changes in clinical status.
- Reassurance, Education, and Strict Return Precautions for those discharged without imaging.
- Follow-up with primary care provider or neurologist and Return to Play/School anticipatory guidance if concussion is suspected.
Management
PECARN Algorithm:
Use A if <2 years old and B if ≥2 years old.
Critical Actions
- ciTBI was a rare event (0.9%) and neurosurgical intervention was even more rare (0.1%).
- Over 50% of each age cohort did not meet any predictors, and CT imaging is not indicated for the vast majority of these patients as risk of ciTBI was exceedingly low.
- Risk of ciTBI was >4% with either of the 2 higher-risk predictors in each age cohort, and imaging is recommended.
- For the remaining 4 lower-risk predictors in each cohort the risk of ciTBI is approximately 0.9% per predictor, and CT imaging versus observation is indicated.
- Judgment may be based on clinical experience, single versus multiple findings, signs clinical deterioration during observation period, patient age, and parental preference.