Please see also Pediatric Glasgow Coma Scale (pGCS) from MDCalc:
NSTRUCTIONSUse for children 2 years and younger only. For older children, use the standard Glasgow Coma Scale (GCS)
Today, I review, link to, and excerpt from Emergency Medicine Cases’ Ep 153 Pediatric Minor Head Injury and Concussion.*
*Helman, A. Reid, S. Zemek, R. Pediatric Minor Head Injury and Concussion. Emergency Medicine Cases. March, 2021. https://emergencymedicinecases.com/pediatric-minor-head-injury-concussion. Accessed 9-19-2025
All that follows is from the above resource.
Ep 153 Pediatric Minor Head Injury and Concussion
We see about 750,000 pediatric patients annually with traumatic head injury in EDs across North America. That’s a lot of kids. While most of these kids will be fine regardless of what we do in the ED, even minor pediatric head injury may require neurosurgical intervention, investigating is not without serious risk, there may be long term consequences even with trivial bonks and the signs can be devilishly subtle. Recent literature suggests that pediatric patients take longer to recover from mild traumatic brain injury compared to adults and persistent post-concussive symptoms (PPCS) after 1 month occur in up to 30% of children after minor head injury. These children can and should be identified in the ED based on the PPCS clinical risk score. In this EM Cases main episode podcast “Pediatric Minor Head Injury and Concussion” Dr. Sarah Reid and Dr. Roger Zemek discuss how best to incorporate the PECARN and CRASH2 decision tools into your practice, the role of Fast MRI, how to identify children who are at risk for long term sequelae after a minor head injury and how to manage persistent concussion symptoms when a child returns to the ED after a minor head injury….
Emergency physicians should have a rock-solid approach to identify high-risk patient with minor head injury; to identify those at risk for long term sequelae, to use imaging responsibly, and to ensure ongoing appropriate care for the concussed child after they leave the ED.
Classification of pediatric head injury
The classification of pediatric head trauma is divided into minor, moderate and severe which are defined by GCS cut offs on first assessment in the ED.
GCS 14 to 15: Minor head trauma
GCS 9 to 13: Moderate head trauma
GCS ≤8: Severe head trauma
Pediatric Glasgow Coma Scale (pGCS) from MDCalc:
NSTRUCTIONSUse for children 2 years and younger only. For older children, use the standard Glasgow Coma Scale (GCS)
Minor head injury is defined as injury within the past 24 hours associated with one of the following:
- Witnessed loss of consciousness
- Definite amnesia
- Witnessed disorientation
- persistent vomiting (> 1 episode) or
- persistent irritability (< 2 years old)
- and a GCS score of 14–15
Fortunately, only 5% of children with minor head injury will have an intracranial abnormality and about 1% will have a clinically important outcome. It is important that we use our history and physical exam to identify the patients at high risk for a clinically important outcome.
Key features on history to identify children at risk for an intracranial lesion requiring imaging
Mechanism of injury
PECARN: severe mechanism (MVC with ejection, death another passenger, rollover, pedestrian or bicyclist w/o helmet struck by motorized vehicle, fall 0.9m or 3ft, head struck by high-impact object)
CATCH2: high risk mechanism (fall ≥3ft or 5 stairs, bicycle with no helmet), worsening headache, persistent irritability if under 2 years old)
Recurrent vomiting
Isolated vomiting in the absence of other high-risk factors is rarely associated with significant traumatic brain injury (TBI). Recurrent vomiting (≥ 4 episodes, at least 15min apart) is a significant risk factor for intracranial injury in children after minor head injury. The addition of ≥ 4 episodes of vomiting to CATCH2 increased sensitivity to 100% for neurosurgical intervention and 99.5% for any brain abnormality.
Age and persistent irritability
Not acting normally as per parent or persistent irritability is always a worrisome sign in a head-injured child under the age of 2 years. In a nonverbal child, assess whether the child can be settled by their caregiver.
CT should be more strongly considered for children with multiple findings, worsening symptoms or signs, and for infants younger than 3 months of age – owing to their limited ability to communicate and thinner skull.
Key features on history to identify children at risk for an intracranial lesion requiring imaging
Mechanism of injury
PECARN: severe mechanism (MVC with ejection, death another passenger, rollover, pedestrian or bicyclist w/o helmet struck by motorized vehicle, fall 0.9m or 3ft, head struck by high-impact object)
CATCH2: high risk mechanism (fall ≥3ft or 5 stairs, bicycle with no helmet), worsening headache, persistent irritability if under 2 years old)
Recurrent vomiting
Isolated vomiting in the absence of other high-risk factors is rarely associated with significant traumatic brain injury (TBI). Recurrent vomiting (≥ 4 episodes, at least 15min apart) is a significant risk factor for intracranial injury in children after minor head injury. The addition of ≥ 4 episodes of vomiting to CATCH2 increased sensitivity to 100% for neurosurgical intervention and 99.5% for any brain abnormality.
Age and persistent irritability
Not acting normally as per parent or persistent irritability is always a worrisome sign in a head-injured child under the age of 2 years. In a nonverbal child, assess whether the child can be settled by their caregiver.
CT should be more strongly considered for children with multiple findings, worsening symptoms or signs, and for infants younger than 3 months of age – owing to their limited ability to communicate and thinner skull.
Isolated features on history not associated with an intracranial lesion requiring imaging
Children who present with the following isolated clinical features with no high risk features on history or physical have an extremely low risk of clinically important TBI and can generally be safely discharged without imaging:
- Isolated headache
- Isolated loss of consciousness (LOC)
- Impact seizure (seizure immediately following head injury)
Key physical exam findings/maneuvers to identify children at risk of intracranial injury or post-concussion symptoms
Assess the child’s general appearance, GCS (see below), mental status and whether they are agitated, somnolent, displaying repetitive questioning or are slow to respond. Look for signs of basal skull fracture including hemotympanum, Battle’s sign, raccoon eyes, and CSF rhinorrhea. Palpate to look for a skull fracture and for non-frontal boggy scalp hematoma >2cm in size, which carries a higher risk for clinically important outcomes.
Pediatric GCS
Update 2022: A secondary analysis of the NEXUS validation study with 1,018 pediatric patients including 128 notable injuries on CT found that the sensitivity and specificity of provider physical examination to detect skull fracture was 18.5% and 96.6% respectively. The authors concluded that physical exams have a poor sensitivity for skull fractures in the pediatric population. Abstract
