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PECARN Pediatric Head Injury/Trauma Algorithm

Predicts need for brain imaging after pediatric head injury.

CréateurDr. Nathan Kuppermann, MD, MPH
Essayer
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Instructions

 The evaluation only applies to children with a Glascow Coma Scale of ≥ 14.

Introduction
In the pediatric population (age 18 years or younger), CT imaging of the head is thought to be associated with an increased risk of lethal malignancy over the life of the patient, with the risk decreasing with age. The estimated risk of lethal malignancy from a head CT in one year is 1 in 1000-1500. The risk decreases to 1 in 5000 once the patient is 10 years old. The Pediatric Emergency Care Applied Research Network (PECARN) conducted the largest study to derive and validate clinical prediction rules to identify children with very low risk of Clinically Important Traumatic Brain Injury (ciTBI) following blunt head trauma who do not need imaging. As a result, the PECARN Pediatric Head Injury Prediction Rule can assist providers in determining which pediatric patients they can safely discharge without obtaining a head CT. Of note, the PECARN study results suggest overall TBI in children is rare with low rates of TBI on head CT (5.2%) and even lower rates of ciTBI (0.9%).


Scoring

The PECARN Pediatric Head Injury Prediction Rule is a well-validated clinical decision aid. The criteria allow clinicians to safely rule out the presence of clinically important traumatic brain injuries among pediatric head injury patients without the need for CT imaging.

Recommendations

Criteria

PECARN Study Findings

CT not recommended 

(< 2 years old)

  • < 2 years

  • "No" to the following: GCS¹ ≤ 14 or other signs of AMS² or palpable skull fracture

  • "No" to the following: Occipital, parietal or temporal scalp hematoma; history of LOC³ ≥ 5 sec; not acting normally per parent or severe mechanism⁴ of injury

  • Represents 53.2% of population.

  • Risk of ciTBI⁷ (<0.02%) which is exceedingly low, generally lower than risk of CT-induced malignancies.

CT not recommended 

( ≥ 2 years old)

  • ≥ 2 years

  • "No" to the following: GCS ≤ 14 or other signs of AMS or signs of basilar skull fracture

  • "No" to the following: History of LOC or history of vomiting or severe headache or severe mechanism of injury

  • Represents 57.2% of population.

  • Risk of ciTBI (<0.05%) which is exceedingly low, generally lower than risk of CT-induced malignancies.

CT recommended 

(< 2 years old)

  • < 2 years

  • "Yes" to the following: GCS ≤ 14 or other signs of AMS or palpable skull fracture

  • Represents 13.9% of population.

  • Risk of ciTBI (4.4%) 

CT recommended 

(≥ 2 years old)

  • ≥ 2 years

  • "Yes" to the following: GCS ≤ 14 or other signs of AMS or signs of basilar skull fracture

  • Represents 14% of population.

  • Risk of ciTBI (4.3%)

Observation versus CT on the basis of other clinical factors⁵ (< 2 years old)

  • < 2 years

  • "Yes" to the following: GCS ≤ 14 or other signs of AMS or palpable skull fracture

  • "Yes" to the following: Occipital, parietal or temporal scalp hematoma; history of LOC ≥ 5 sec; not acting normally per parent or severe mechanism of injury

  • Represents 32.9% of population.

  • Risk of ciTBI (0.9%)

  • Patients with certain isolated findings (i.e. with no other findings suggestive of traumatic brain injury) have a risk of ciTBI substantially lower than 1%

Observation versus CT on the basis of other clinical factors (≥2 years old)

  • ≥ 2 years

  • "Yes" to the following: GCS ≤ 14 or other signs of AMS or signs of basilar skull fracture

  • "Yes" to the following: History of LOC or history of vomiting or severe headache or severe mechanism of injury

  • Represents 28.8% of population.

  • Risk of ciTBI (0.8%)

  • Patients with certain isolated findings (i.e. with no other findings suggestive of traumatic brain injury) have a risk of ciTBI substantially lower than 1%

 ¹Glascow Coma Scale (GCS)

²Other signs of altered mental status (AMS): Agitation, somnolence, repetitive questioning, or slow response to verbal communication.

³Loss of Consciousness (LOC)

⁴Severe mechanism:

  • Motor vehicle crash (MVC) with patient ejection

  • MVC with death of another passenger or rollover

  • Pedestrian or bicyclist w/o helmet struck by motorized vehicle

  • Fall from > 3 ft (0.9 m)

  • Head struck by high-impact object

⁵Other clinical factors include:

  • Clinician experience

  • Multiple versus isolated findings⁶

  • Worsening symptoms or signs after emergency department observation

  • Age < 3 months

  • Parental preference

 

⁶Isolated findings:

  • Isolated Loss of Consciousness

  • Isolated headache

  • Isolated vomiting

  • Certain types of isolated scalp hematomas in infants > 3 months

 

⁷Definition of clinically important traumatic brain injury (ciTBI)

  (any of the following)

  • Death from traumatic brain injury (TBI)

  • Neurosurgical intervention for TBI

  • Intubation of more than 24 hours for TBI

  • Hospital Admission of 2 nights or more for the TBI in association with TBI on CT^

 

^Definition of TBI on CT (any of the following):

  • Intracranial hemorrhage or contusion

  • Cerebral edema

  • Traumatic infarction

  • Diffuse axonal injury

  • Shearing injury

  • Sigmoid sinus thrombosis

  • Midline shift of intracranial contents or signs of brain herniation

  • Diastasis of the skull

  • Pneumocephalus

  • Skull fracture depressed by at least the width of the table of the skull

 

Management Considerations:

  • Clinical judgement also plays a key role in work-up and disposition. For example, judgement may be based on:

    • If the event was witnessed or historical reliability

    • Patient age

    • Parental preference

    • Clinical deterioration

    • Patient co-morbidities

  • For those with suspected or radiologically-confirmed traumatic brain injury (TBI):

    • First assess ABC's and consider neurosurgical/ICU consultation 

    • Consult institutional protocols on, for example: 

      • Fluid management

      • Seizure prophylaxis

      • Hypertonic saline or mannitol

      • Admission or disposition

  • For those not imaged, observation for 4-6 hours to monitor changes in clinical status.

  • For those discharged

Toutes les questions et résultats possibles

InstructionsTitre non visible
Age

Select one option:

  • < 2 years
  • ≥ 2 years
GCS¹ ≤ 14 or other signs of AMS² or palpable skull fracture?

 

¹Glascow Coma Scale (GCS)

²Other signs of altered mental status (AMS): Agitation, somnolence, repetitive questioning, or slow response to verbal communication.

 

Select one option:

  • No
  • Yes
Occipital, parietal or temporal scalp hematoma; history of LOC¹ ≥ 5 sec; not acting normally per parent or severe mechanism² of injury?

 

¹Loss of Consciousness (LOC)

²Severe mechanism:

  • Motor vehicle crash (MVC) with patient ejection
  • MVC with death of another passenger or rollover
  • Pedestrian or bicyclist w/o helmet struck by motorized vehicle
  • Fall from > 3 ft (0.9 m)
  • Head struck by high-impact object

 

Select one option:

  • No
  • Yes
GCS¹ ≤ 14 or other signs of AMS² or signs of basilar skull fracture?

 

¹Glascow Coma Scale (GCS)

²Other signs of altered mental status (AMS): Agitation, somnolence, repetitive questioning, or slow response to verbal communication.

Select one option:

  • No
  • Yes
History of LOC¹ or history of vomiting or severe headache or severe mechanism² of injury?

 

¹Loss of Consciousness (LOC)

²Severe mechanism:

  • Motor vehicle crash (MVC) with patient ejection
  • MVC with death of another passenger or rollover
  • Pedestrian or bicyclist w/o helmet struck by motorized vehicle
  • Fall from > 5 ft (1.5 m)
  • Head struck by high-impact object

 

Select one option:

  • No
  • Yes
Résultats possibles
CT recommended (≥ 2 years old)

PECARN Findings:

  • Represents 14% of population.
  • Risk of ciTBI¹ (4.3%) 

 

Management Considerations:

  • Clinical judgement plays a key role in work-up and disposition. For example, judgement may be based on:
    • If the event was witnessed or historical reliability
    • Patient age
    • Parental preference
    • Clinical deterioration
    • Patient co-morbidities
  • For those with suspected or radiologically-confirmed TBI:
    • First assess ABC's and consider neurosurgical/ICU consultation 
    • Consult institutional protocols on, for example: 
      • Fluid management
      • Seizure prophylaxis
      • Hypertonic saline or mannitol
      • Admission or disposition
  • For those not imaged, observation for 4-6 hours to monitor changes in clinical status.
  • For those discharged

 

¹Definition of clinically important traumatic brain injury (ciTBI)

(any of the following)

  • Death from traumatic brain injury (TBI)
  • Neurosurgical intervention for TBI
  • Intubation of more than 24 hours for TBI
  • Hospital Admission of 2 nights or more for the TBI in association with TBI on CT²

 

²Definition of TBI on CT (any of the following):

  • Intracranial hemorrhage or contusion
  • Cerebral edema
  • Traumatic infarction
  • Diffuse axonal injury
  • Shearing injury
  • Sigmoid sinus thrombosis
  • Midline shift of intracranial contents or signs of brain herniation
  • Diastasis of the skull
  • Pneumocephalus
  • Skull fracture depressed by at least the width of the table of the skull
CT not recommended (< 2 years old)

PECARN Findings:

  • Represents 53.2% of population.
  • Risk of ciTBI¹ (<0.02%) which is exceedingly low, generally lower than risk of CT-induced malignancies.
  • Therefore, CT scans are not indicated for most patients in this group.

 

Management Considerations:

  • Clinical judgement plays a key role in work-up and disposition. Judgement may be based on:
    • If the event was witnessed or historical reliability
    • Patient age
    • Parental preference
    • Clinical deterioration
    • Patient co-morbidities
  • For those not imaged, observation for 4-6 hours to monitor changes in clinical status.
  • For those discharged

 

¹Definition of clinically important traumatic brain injury (ciTBI)

(any of the following)

  • Death from traumatic brain injury (TBI)
  • Neurosurgical intervention for TBI
  • Intubation of more than 24 hours for TBI
  • Hospital Admission of 2 nights or more for the TBI in association with TBI on CT²

 

²Definition of TBI on CT (any of the following):

  • Intracranial hemorrhage or contusion
  • Cerebral edema
  • Traumatic infarction
  • Diffuse axonal injury
  • Shearing injury
  • Sigmoid sinus thrombosis
  • Midline shift of intracranial contents or signs of brain herniation
  • Diastasis of the skull
  • Pneumocephalus
  • Skull fracture depressed by at least the width of the table of the skull
CT not recommended ( ≥ 2 years old)

PECARN Findings:

  • Represents 57.2% of population.
  • Risk of ciTBI¹ (<0.05%) which is exceedingly low, generally lower than risk of CT-induced malignancies.
  • Therefore, CT scans are not indicated for most patients in this group.

 

Management Considerations:

  • Clinical judgement plays a key role in work-up and disposition. Judgement may be based on:
    • If the event was witnessed or historical reliability
    • Patient age
    • Parental preference
    • Clinical deterioration
    • Patient co-morbidities
  • For those not imaged, observation for 4-6 hours to monitor changes in clinical status.
  • For those discharged

 

¹Definition of clinically important traumatic brain injury (ciTBI)

(any of the following)

  • Death from traumatic brain injury (TBI)
  • Neurosurgical intervention for TBI
  • Intubation of more than 24 hours for TBI
  • Hospital Admission of 2 nights or more for the TBI in association with TBI on CT²

 

²Definition of TBI on CT (any of the following):

  • Intracranial hemorrhage or contusion
  • Cerebral edema
  • Traumatic infarction
  • Diffuse axonal injury
  • Shearing injury
  • Sigmoid sinus thrombosis
  • Midline shift of intracranial contents or signs of brain herniation
  • Diastasis of the skull
  • Pneumocephalus
  • Skull fracture depressed by at least the width of the table of the skull
Observation versus CT on the basis of other clinical factors¹ (< 2 years old)

¹Other clinical factors include:

  • Clinician experience
  • Multiple versus isolated findings²
  • Worsening symptoms or signs after emergency department observation
  • Age < 3 months
  • Parental preference

 

²Isolated findings:

  • Isolated Loss of Consciousness
  • Isolated headache
  • Isolated vomiting
  • Certain types of isolated scalp hematomas in infants > 3 months

 

PECARN Findings:

  • Represents 32.9% of population.
  • Risk of ciTBI³ (0.9%)
  • Patients with certain isolated findings (i.e. with no other findings suggestive of traumatic brain injury) have a risk of ciTBI substantially lower than 1%

 

Management Considerations:

  • Clinical judgement also plays a key role in work-up and disposition. For example, judgement may be based on:
    • If the event was witnessed or historical reliability
    • Patient age
    • Parental preference
    • Clinical deterioration
    • Patient co-morbidities
  • For those with suspected or radiologically-confirmed traumatic brain injury (TBI):
    • First assess ABC's and consider neurosurgical/ICU consultation 
    • Consult institutional protocols on, for example: 
      • Fluid management
      • Seizure prophylaxis
      • Hypertonic saline or mannitol
      • Admission or disposition
  • For those not imaged, observation for 4-6 hours to monitor changes in clinical status.
  • For those discharged

 

³Definition of clinically important traumatic brain injury (ciTBI)

(any of the following)

  • Death from TBI
  • Neurosurgical intervention for TBI
  • Intubation of more than 24 hours for TBI
  • Hospital Admission of 2 nights or more for the TBI in association with TBI on CT⁴

 

⁴Definition of TBI on CT (any of the following):

  • Intracranial hemorrhage or contusion
  • Cerebral edema
  • Traumatic infarction
  • Diffuse axonal injury
  • Shearing injury
  • Sigmoid sinus thrombosis
  • Midline shift of intracranial contents or signs of brain herniation
  • Diastasis of the skull
  • Pneumocephalus
  • Skull fracture depressed by at least the width of the table of the skull
CT recommended (< 2 years old)

PECARN Findings:

  • Represents 13.9% of population.
  • Risk of ciTBI¹ (4.4%) 

 

Management Considerations:

  • Clinical judgement plays a key role in work-up and disposition. For example, judgement may be based on:
    • If the event was witnessed or historical reliability
    • Patient age
    • Parental preference
    • Clinical deterioration
    • Patient co-morbidities
  • For those with suspected or radiologically-confirmed TBI:
    • First assess ABC's and consider neurosurgical/ICU consultation 
    • Consult institutional protocols on, for example: 
      • Fluid management
      • Seizure prophylaxis
      • Hypertonic saline or mannitol
      • Admission or disposition
  • For those not imaged, observation for 4-6 hours to monitor changes in clinical status.
  • For those discharged

 

¹Definition of clinically important traumatic brain injury (ciTBI)

(any of the following)

  • Death from traumatic brain injury (TBI)
  • Neurosurgical intervention for TBI
  • Intubation of more than 24 hours for TBI
  • Hospital Admission of 2 nights or more for the TBI in association with TBI on CT²

 

²Definition of TBI on CT (any of the following):

  • Intracranial hemorrhage or contusion
  • Cerebral edema
  • Traumatic infarction
  • Diffuse axonal injury
  • Shearing injury
  • Sigmoid sinus thrombosis
  • Midline shift of intracranial contents or signs of brain herniation
  • Diastasis of the skull
  • Pneumocephalus
  • Skull fracture depressed by at least the width of the table of the skull
Resources

CDC Guidelines & Tools

CDC Heads Up Education Tools

AAFP Concussion Diagnosis, Awareness and Treatment Resources

Acute Concussion Evaluation (ACE): Physician/Clinician Office

School Letter: Return to school after a concussion

Observation versus CT on the basis of other clinical factors¹ (≥2 years old)

¹Other clinical factors include:

  • Clinician experience
  • Multiple versus isolated findings²
  • Worsening symptoms or signs after emergency department observation
  • Parental preference

 

²Isolated findings:

  • Isolated Loss of Consciousness
  • Isolated headache
  • Isolated vomiting
  • Certain types of isolated scalp hematomas in infants > 3 months

 

PECARN Findings:

  • Represents 28.8% of population.
  • Risk of ciTBI³ (0.8%)
  • Patients with certain isolated findings (i.e. with no other findings suggestive of traumatic brain injury) have a risk of ciTBI substantially lower than 1%

 

Management Considerations:

  • Clinical judgement also plays a key role in work-up and disposition. For example, judgement may be based on:
    • If the event was witnessed or historical reliability
    • Patient age
    • Parental preference
    • Clinical deterioration
    • Patient co-morbidities
  • For those with suspected or radiologically-confirmed traumatic brain injury (TBI):
    • First assess ABC's and consider neurosurgical/ICU consultation 
    • Consult institutional protocols on, for example: 
      • Fluid management
      • Seizure prophylaxis
      • Hypertonic saline or mannitol
      • Admission or disposition
  • For those not imaged, observation for 4-6 hours to monitor changes in clinical status.
  • For those discharged

 

³Definition of clinically important traumatic brain injury (ciTBI)

(any of the following)

  • Death from TBI
  • Neurosurgical intervention for TBI
  • Intubation of more than 24 hours for TBI
  • Hospital Admission of 2 nights or more for the TBI in association with TBI on CT⁴

 

⁴Definition of TBI on CT (any of the following):

  • Intracranial hemorrhage or contusion
  • Cerebral edema
  • Traumatic infarction
  • Diffuse axonal injury
  • Shearing injury
  • Sigmoid sinus thrombosis
  • Midline shift of intracranial contents or signs of brain herniation
  • Diastasis of the skull
  • Pneumocephalus
  • Skull fracture depressed by at least the width of the table of the skull

Citation

Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70. doi: 10.1016/S0140-6736(09)61558-0. Epub 2009 Sep 14. Erratum in: Lancet. 2014 Jan 25;383(9914):308. PMID: 19758692.

Bibliographie

  • Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70.

    Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL; Pediatric Emergency Care Applied Research Network (PECARN).

    https://pubmed.ncbi.nlm.nih.gov/19758692/

  • Pediatric Emergency Care Applied Research Network head injury clinical prediction rules are reliable in practice. Arch Dis Child. 2014 May;99(5):427-31.

    Schonfeld D, Bressan S, Da Dalt L, Henien MN, Winnett JA, Nigrovic LE.

    https://pubmed.ncbi.nlm.nih.gov/24431418/

  • Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol. 2001 Feb;176(2):289-96.

    Brenner D, Elliston C, Hall E, Berdon W.

    https://pubmed.ncbi.nlm.nih.gov/11159059/

  • Traumatic Brain Injury Study Group of the Pediatric Emergency Care Applied Research Network (PECARN). Association of traumatic brain injuries with vomiting in children with blunt head trauma. Ann Emerg Med. 2014 Jun;63(6):657-65.

    Dayan PS, Holmes JF, Atabaki S, Hoyle J Jr, Tunik MG, Lichenstein R, Alpern E, Miskin M, Kuppermann N;

    https://pubmed.ncbi.nlm.nih.gov/24559605/

  • Traumatic Brain Injury Study Group of the Pediatric Emergency Care Applied Research Network (PECARN). Risk of traumatic brain injuries in children younger than 24 months with isolated scalp hematomas. Ann Emerg Med. 2014 Aug;64(2):153-62.

    Dayan PS, Holmes JF, Schutzman S, Schunk J, Lichenstein R, Foerster LA, Hoyle J Jr, Atabaki S, Miskin M, Wisner D, Zuspan S, Kuppermann N;

    https://pubmed.ncbi.nlm.nih.gov/24635991/

  • Effectiveness of the head CT choice decision aid in parents of children with minor head trauma: study protocol for a multicenter randomized trial. Trials. 2014 Jun 25;15:253.

    Hess EP, Wyatt KD, Kharbanda AB, Louie JP, Dayan PS, Tzimenatos L, Wootton-Gorges SL, Homme JL, Pencille R N L, LeBlanc A, Westphal JJ, Shepel K, Shah ND, Branda M, Herrin J, Montori VM, Kuppermann N.

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4081461/

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