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    Do Less

    A 4 y female arrives to ED accompanied by mother after witnessed mechanical fall off out of stroller (approximately 3.5 feet high) with head hitting linoleum floor.  Mom states that the child cried immediately afterwards and never experienced LOC.  Denies n/v.  Now acting normally.  Physical exam is remarkable only for a small, left parietal scalp hematoma, but no laceration.  Neurologic exam is WNL.  With the provided information what should be your next step?  Discharge home? Observe the patient? CT head?

    Typically we observe for a period of 4-6 hours post injury in this scenario to evaluate for deterioration and if all is normal patients may be discharged and follow up with their PMD.  According to the PECARN study there is an exceedingly low risk for this patient to have a clinically important traumatic brain injury (defined as death from TBI, need for neurosurgery, intubation for >24 hours, or hospital admission 2 days or more) and the risk is generally lower than the risk of radiation induced malignancies.  PECARN was a large (>42,000 patients) multicentered prospective cohort study of patients younger than 18 years old.  The investigators defined rules to avoid CT based on age of the patient (less than 2 years old and 2 years and older).  In children younger than 2 years old the sensitivity and negative predictive values were both 100%.  In children 2 years and older the rules had 96.8% sensitivity and 99.5% negative predictive value.  It is important to note that if patients fulfill these criteria they do not require scans, but these criteria should not be used to trigger a scan in the event that a patient does not fulfill the criteria.

    The algorithm for the 2 age groups are provided below (also mdcalc.com is a great resource for calculating risk).

    Pecarn-algorithm

     

    To view the PECARN study visit this site:

    http://www.sciencedirect.com/science/article/pii/S0140673609615580

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