Emergency Medicine Hub / Pediatrics & Obstetrics • 3 min read • 2 sections

Pediatric Head Trauma & PECARN Decision Rules

Comprehensive emergency evaluation and protocolized decision-making for blunt pediatric head trauma: application of the validated PECARN (Pediatric Emergency Care Applied Research Network) neuroimaging rules stratified by age (< 2 years vs. 2–18 years), definition of Clinically Important Traumatic Brain Injury (ciTBI), high-risk criteria requiring immediate non-contrast head CT, intermediate-risk observation protocols, scalp hematoma location significance (parietal/temporal vs. frontal), and avoiding radiation exposure in low-risk children.

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PECARN Age Stratification

Algorithm is strictly divided into TWO distinct groups: 1) Children < 2 years of age, and 2) Children >= 2 to 18 years of age

< 2 yr High Risk (CT Stat)

GCS < 15, altered mental status (agitation, lethargy, slow response), OR palpable skull fracture -> CT Head IMMEDIATELY (ciTBI risk 4.4%)

< 2 yr Intermediate Risk

Non-frontal scalp hematoma (parietal/temporal), LOC >= 5 sec, severe mechanism, not acting normally per parents -> Observe 4–6h vs CT (ciTBI 0.9%)

>= 2 yr High Risk (CT Stat)

GCS < 15, altered mental status, OR signs of basilar skull fracture (hemotympanum, Battle's sign, raccoon eyes, CSF leak) -> CT Head STAT (ciTBI 4.3%)

>= 2 yr Intermediate Risk

Any LOC, vomiting, severe headache, severe mechanism (rollover, ejection, pedestrian struck, fall > 5 ft) -> Observe vs CT (ciTBI 0.9%)

Low Risk (Zero Criteria)

Children meeting ZERO criteria in their age group have a ciTBI risk < 0.05% (< 1 in 2,000) -> NO HEAD CT INDICATED

Bottom-Line Clinical Pearl

Blunt head trauma is the leading cause of death and disability in children. Routine head CT exposes developing pediatric brain tissue to lethal radiation-induced malignancy risk (1 in 1,000 to 1 in 5,000 lifetime fatal cancer risk). The PECARN head trauma rule is validated across > 42,000 children with a 99.9% sensitivity to identify Clinically Important Traumatic Brain Injury (ciTBI: death, neurosurgery, intubation > 24h, or hospital admission >= 2 nights with TBI on CT). Under PECARN, children < 2 years with GCS = 15, normal mental status, and no palpable skull fracture or non-frontal hematoma have a < 0.02% risk of ciTBI and require NO head CT.

1. PECARN Head Trauma Rule: Age < 2 Years

Pre-verbal infants ($< 2\text{ years}$) cannot communicate symptoms (headache, dizziness) and have thin, pliable cranial bones that can sustain substantial intracranial hemorrhage without overlying skull fractures. PECARN stratifies them into three risk categories:

Risk Tier (< 2 Years)	Clinical Criteria Components	ciTBI Risk & Recommended Action
High Risk	1. GCS $< 15$ or other signs of altered mental status (agitation, lethargy, slow verbal response)<br>2. Palpable skull fracture	ciTBI Risk: 4.4%<br>Immediate non-contrast Head CT recommended.
Intermediate Risk	1. Non-frontal scalp hematoma (parietal, temporal, or occipital)<br>2. Loss of consciousness $\ge 5\text{ seconds}$<br>3. Severe mechanism of injury (fall $> 3\text{ feet}$, motor vehicle collision with rollover/ejection, struck by vehicle, struck by high-impact object)<br>4. Not acting normally according to parent	ciTBI Risk: 0.9%<br>Observation (4 to 6 hours) in the ED vs. Head CT based on physician experience, multiple vs. isolated findings, worsening symptoms, or parental preference.
Low Risk	Zero criteria present	ciTBI Risk: < 0.02% (< 1 in 5,000)<br>NO Head CT recommended; discharge home with head injury return precautions.

2. PECARN Head Trauma Rule: Age 2 to 18 Years

Risk Tier (2–18 Years)	Clinical Criteria Components	ciTBI Risk & Recommended Action
High Risk	1. GCS $< 15$ or altered mental status<br>2. Signs of basilar skull fracture (hemotympanum, retroauricular ecchymosis [Battle's sign], periorbital ecchymosis [raccoon eyes], CSF rhinorrhea or otorrhea)	ciTBI Risk: 4.3%<br>Immediate non-contrast Head CT recommended.
Intermediate Risk	1. Any history of loss of consciousness<br>2. History of vomiting<br>3. Severe or worsening headache<br>4. Severe mechanism of injury (fall $> 5\text{ feet}$, high-speed MVC, bicycle without helmet struck by car)	ciTBI Risk: 0.9%<br>Observation (4 to 6 hours) vs. Head CT; observation allows symptoms to resolve and eliminates up to 50% of unnecessary CT scans without missing injuries.
Low Risk	Zero criteria present	ciTBI Risk: < 0.05% (< 1 in 2,000)<br>NO Head CT recommended; discharge home with head injury return instructions.

Clinical Caution

SIGNIFICANCE OF SCALP HEMATOMA LOCATION IN INFANTS: Scalp hematomas in infants < 2 years carry vastly different risks based on location. An isolated frontal ('forehead') hematoma carries an extremely low risk of underlying fracture or brain injury. Conversely, non-frontal hematomas (parietal, temporal, and occipital) have a dramatically higher association with underlying linear skull fractures and acute epidural hematomas. Large (> 3 cm) or 'boggy' temporal/parietal hematomas strongly favor head CT imaging.

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