Minor blunt head trauma in children (≥2 years): Clinical features and evaluation

INTRODUCTION — This topic will discuss the clinical features and evaluation of minor blunt head trauma in children two years of age and older.

The clinical features and evaluation of minor blunt head trauma in infants, the management of minor head trauma in children, and diagnosis of and treatment of concussion in children and adolescents are discussed separately:

●(See "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation".)

●(See "Minor head trauma in infants and children: Management".)

●(See "Concussion in children and adolescents: Management".)

RATIONALE — Minor blunt head trauma occurs commonly in children and is typically not associated with brain injury or long-term sequelae. However, a small number of children with apparently minor blunt head trauma may have a clinically important traumatic brain injury (ciTBI) that requires extended observation or acute intervention such as intensive supportive care or neurosurgery. Neuroimaging with computed tomography (CT) is highly sensitive for identifying brain injury that requires intervention; however, it exposes patients to radiation. By performing a complete history and physical and utilizing a clinical decision rule, the clinician can identify children at higher risk for traumatic brain injury (TBI) while minimizing overuse of CT. (See "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'Clinically important traumatic brain injury versus traumatic brain injury'.)

DEFINITIONS

Minor blunt head trauma — For the purposes of this discussion, we define minor head trauma in previously healthy children two years of age and older as follows:

●Glasgow Coma Scale (GCS) score of 14 or 15 at the initial examination

●No abnormal or focal findings on neurologic examination

●No physical evidence of skull fracture (eg, no palpable skull defect and no signs of basilar skull fracture such as hemotympanum, cerebrospinal fluid (CSF) oto- or rhinorrhea, or periocular or posterior auricular hematomas)

However, the clinician should regard these patients as having apparently minor head trauma because approximately 5 percent have traumatic brain injury (TBI) on neuroimaging, and 1 percent have clinically important traumatic brain injury (ciTBI). (See 'Epidemiology' below.)

Clinically important traumatic brain injury versus traumatic brain injury — For this topic, we use the definition of ciTBI established in large observational studies of children with minor blunt head trauma, which consists of any one of the following [1-4]:

●Presence of an intracranial injury (eg, epidural hematoma, subdural hematoma, or cerebral contusion) on CT associated with one or more of the following:

•Neurosurgical intervention (either surgery or invasive intracranial pressure monitoring)

•Endotracheal intubation for the management of head injury

•Hospitalization directly related to the head injury for two nights or longer

•Death

or

●Depressed skull fracture warranting operative elevation (ie, depressed past the inner table of the skull)

or

●Clinical findings of a basilar skull fracture (periorbital ecchymosis, Battle sign, hemotympanum (picture 1), CSF otorrhea, or CSF rhinorrhea)

These same studies also defined TBI (as opposed to ciTBI) as any intracranial injury on CT that does not require acute intervention or prolonged hospitalization as described above [1-4]. Short-term follow-up (four weeks post-injury) indicates that the risk of morbidity or mortality in children with TBI is very low. However, because there are no long-term studies of infants and children with TBI on CT who do not meet criteria for ciTBI, the long-term implications of these findings are unknown.

Mild traumatic brain injury — The World Health Organization and the Centers for Disease Control and Prevention define mild TBI as an acute TBI that is associated with one or more of the following signs or symptoms [5,6]:

●Confusion or disorientation

●Post-traumatic amnesia for <24 hours

●Loss of consciousness (LOC) for ≤30 minutes

●Transient neurologic abnormalities such as seizures and focal neurologic signs or symptoms

and

●GCS score 13 to 15 (table 1) at 30 minutes or longer after their injury

This definition covers a broad range of patients with a highly variable risk for ciTBI. For example, the rate of ciTBI in patients with a GCS score of 13 is as high as 17 percent [2,7,8], and in one study, patients with a GCS score of 14, compared with a GCS score of 15, had a much higher frequency of ciTBI (8 versus 0.7 percent) and need for neurosurgical intervention (1.3 versus 0.1 percent) [8].

Concussion — From a clinical standpoint, concussion can be defined as trauma-induced brain dysfunction without demonstrable structural injury on standard neuroimaging. As such, concussion is a type of mild TBI. (See "Concussion in children and adolescents: Clinical manifestations and diagnosis", section on 'Definitions' and "Acute mild traumatic brain injury (concussion) in adults", section on 'Definitions'.)

The clinical manifestations, diagnosis, and management of concussion in children and adolescents are discussed in greater detail separately. (See "Concussion in children and adolescents: Clinical manifestations and diagnosis" and "Concussion in children and adolescents: Management" and "Acute mild traumatic brain injury (concussion) in adults".)

PATHOPHYSIOLOGY — Most children with minor blunt head trauma do not sustain traumatic brain injury (TBI). However, either concussion or clinically important traumatic brain injury (ciTBI) can occur after minor blunt head trauma even in children who have minimal symptoms:

●Concussion is associated with a rapid rotational acceleration of the brain. (See "Concussion in children and adolescents: Clinical manifestations and diagnosis", section on 'Pathophysiology'.)

●Subdural hematoma may arise from rotational acceleration-deceleration of the head. (See "Intracranial subdural hematoma in children: Epidemiology, anatomy, and pathophysiology", section on 'Pathophysiology'.)

●Epidural hematomas typically arise from a direct blow to the temporal region. This force often results in a linear fracture that disrupts middle meningeal arterial branches or dural venous sinuses. However, epidural hematomas may also occur without an associated fracture in a significant number of children. (See "Intracranial epidural hematoma in children", section on 'Anatomy'.)

EPIDEMIOLOGY — Head trauma occurs commonly in children with approximate annual rates of 1100 emergency department visits, 31 hospitalizations, and 3.4 deaths per 100,000 population in the United States [9,10]. Among children two years of age and older with minor blunt head trauma and a normal neurologic examination, 3 to 7 percent may have a traumatic brain injury (TBI) noted on CT [2,11-15]. Approximately 1 percent have clinically important traumatic brain injury (ciTBI), and 0.1 to 0.6 percent require surgical intervention [1-3,13,16-18]. Falls are the most common mechanism of injury for children sustaining minor blunt head trauma, followed by motor vehicle crashes, pedestrian and bicycle accidents, projectiles, assaults, and sports-related trauma [2,19]. These mechanisms cause isolated head trauma in the majority of patients [2].

Many clinicians regard children with ventricular shunts or bleeding disorders as having a higher risk for ciTBI after minor head trauma. However, it is not clear that ciTBI after minor head trauma actually occurs more frequently than in normal children. As an example, in planned secondary analyses of a large, multicenter, observational study of children with minor head injury, approximately 1 percent of children with either ventricular shunts (98 children) or bleeding disorders (230 children) had a ciTBI compared with 0.9 percent of the approximately 40,000 normal children [20-22]. However, with the low numbers of patients with either risk factor in these studies, the true frequency of ciTBI following minor head trauma could be as high as 4 percent in children with bleeding disorders or 5 percent in children with ventricular shunts. Furthermore, the rate of ciTBI seen in children with bleeding disorders occurred despite significantly fewer severe mechanisms of injury when compared with normal children [21,22]. Thus, until further evidence is available, a more cautious approach to imaging in these patients may still be warranted.

CLINICAL FEATURES

Common findings — Observational studies have identified altered mental status, loss of consciousness (LOC), vomiting, and headache as common features associated with minor head trauma in children evaluated in emergency departments [23].

Altered mental status — Altered mental status, defined in one large cohort study as Glasgow Coma Scale (GCS) score <15, agitation, lethargy, slow response, or repetitive questioning, has been described in about 13 percent of children with minor head trauma and is strongly associated with clinically important traumatic brain injury (ciTBI) [2].

Loss of consciousness — LOC following minor head trauma is frequently reported in children ≥2 years of age [2,24]. LOC may be associated with ciTBI depending upon its duration and the presence of other clinical predictors [2,3,24]:

●Isolated LOC – For this discussion, isolated LOC refers to LOC without any of the age-related Pediatric Emergency Care Applied Research Network (PECARN) clinical predictors for ciTBI such as severe mechanism of injury, altered mental status, vomiting, headache, or signs of basilar skull fracture (table 2). In such patients, the risk of ciTBI is low. For example, in one large multicenter, prospective cohort study of 5850 children with LOC after mild head trauma, 0.5 percent of 2780 children with isolated LOC had ciTBI [24]. Longer duration of LOC was not associated with an increased risk although the sample size was small.

●LOC and at least one additional predictor – The presence of one additional PECARN clinical predictor in patients with LOC markedly increases the likelihood of ciTBI. In the same study describe above, ciTBI occurred in 4 percent of 3070 children with LOC and other PECARN clinical predictors [24]. Longer duration of LOC was also associated with ciTBI, occurring in 1 percent of 907 children with LOC for <5 seconds and up to 4 percent of 200 children with LOC >5 minutes.

Vomiting — At least one episode of vomiting is reported in approximately 13 percent of children following minor head trauma [2]. Most of these patients do not have ciTBI [1,2,25,26]. However, ciTBI is more likely in children who have vomiting and other findings associated with ciTBI (eg, severe mechanism of injury, LOC, or altered mental status) [25,26]. As an example, of 5557 children evaluated for vomiting after minor head trauma at multiple centers, ciTBI occurred in 0.2 percent (95% CI 0-0.9 percent) of 815 children with isolated vomiting (ie, vomiting alone without other findings of ciTBI) and in 2.5 percent (95% CI 2.1-3 percent) of 4577 children with vomiting and other findings of ciTBI [25]. Although the incidence of ciTBI among those with isolated vomiting was low, it was higher than patients without vomiting or other high-risk symptoms (0.2 versus 0.04 percent).

Whether the number of vomiting episodes and the timing of these episodes can help identify patients with ciTBI is unclear. Vomiting two or more times after head trauma was associated with an approximately 37 percent increase in traumatic brain injury (TBI) in one multicenter observational study [1]. However, vomiting more than once or later onset of vomiting after head injury did not identify children with ciTBI in another multicenter cohort [25].

Headache — Headache is a frequent complaint, occurring in up to 46 percent of verbal children with minor blunt head trauma [27]. In children who are unable to describe their headache, irritability may also be an indication of discomfort [2,3].

Most children with headache after minor blunt head trauma do not have ciTBI. However, when severe or present with other symptoms, headache does increase the risk of ciTBi. As an example, in a planned secondary analysis of a large multicenter cohort of children with minor head trauma, among the 2462 patients with an isolated headache by an "extensive definition" (headache of any degree and excluding patients with other PECARN predictors as well as seizure, amnesia, neurologic deficits, or any traumatic scalp findings), no patient (0 percent, 95% CI 0-0.1) had ciTBI versus 162 of 10,105 patients (1.6 percent, 95% CI 1.3-1.9) with headache and other symptoms [27]. Of patients with isolated severe headache by PECARN criteria (table 2), 3 of 209 (1.4 percent, 95% CI 0.3-4.1) had ciTBI, and 4 of 128 (3.1 percent, 95% CI 0.9-7.8) had TBI on CT. Severe headache and the addition of other single PECARN predictors did not significantly change the risk of ciTBi or TBI on CT; however, the number of patients with these features was low.

Scalp hematoma — Most children with isolated scalp hematomas, no findings of skull fracture, and no other clinical symptoms have a low risk of ciTBI. Scalp hematomas are an important clinical risk factor in infants. (See "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'Scalp hematoma'.)

Seizures — Post-traumatic seizures occur in about 1 percent of children with blunt head trauma and indicate a high risk for ciTBI [28]. For example, in one observational study of 332 children (median age 5.6 years) with post-traumatic seizures and a GCS score of 15 who underwent head CT, TBI was found in 6 percent, and 3 percent had ciTBI (hospitalization for two or more nights in 10 patients and neurosurgery in one) [28].

Skull fractures — Skull fractures occur in approximately 2 percent of children two years of age and older with minor blunt head trauma [2,29]. Most skull fractures in this population are linear. Among children with linear skull fractures, 15 to 30 percent have associated intracranial injuries, and the potential for ciTBI appears high [13,14,30]. Among children with basilar skull fractures in one large cohort study, approximately 7 percent had ciTBI [2].

Most children with skull fractures will also have overlying scalp hematomas. However, most children with scalp hematomas, outside of infancy, do not have a skull fracture. Other findings of skull fracture include a palpable skull defect, cerebrospinal fluid (CSF) rhinorrhea or otorrhea, posterior auricular hematoma (Battle sign), hemotympanum (picture 1), and periorbital hematomas ("raccoon eyes") (picture 2).

The evaluation and management of skull fractures in children are discussed in greater detail separately. (See "Skull fractures in children: Clinical manifestations, diagnosis, and management".)

Other findings — Transient cortical defects, such as cortical blindness and acute confusional states, have been reported rarely in association with minor head trauma [31-33]. These deficits are thought to be secondary to vascular hyperreactivity and may be trauma-induced, migraine-equivalent phenomena. Although rare, there are also case reports of ischemic or thrombotic stroke following mild head trauma in children [34,35].

EVALUATION — The priority for the evaluation of children with apparently minor head trauma is to identify those patients with traumatic brain injury (TBI) who may require immediate intervention (eg, an expanding epidural hematoma), admission for monitoring (eg, small stable epidural hematomas or cerebral contusions), or close follow-up (eg, skull fracture without intracranial injury) while limiting unnecessary neuroimaging.

Clinical findings can help stratify a patient's risk of clinically important traumatic brain injury (ciTBI) as high, intermediate, or low, with implications for the need for neuroimaging. Focused evaluation to support these clinical decisions can be facilitated by clinical practice guidelines and implementation of computerized decision support based upon validated clinical prediction rules such as the Pediatric Emergency Care Applied Research Network (PECARN) TBI rules (table 2) [2,7]. (See 'Approach' below.)

History — The history should include time of the event, mechanism of injury, presence of loss of consciousness (LOC), vomiting, seizure, mental status, and course since the traumatic event. Historical features that suggest an increased risk of ciTBI include the following [2,15,18,36-40] (see 'Clinical features' above):

●Seizure

●LOC

●Confusion or other change in mental status

●Severe or worsening headache, especially if associated with other clinical risk factors

●Vomiting, especially if associated with other clinical risk factors

●High-risk mechanism, such as a fall from >5 feet, significant motor vehicle collision (eg, patient ejection, death of another passenger, or rollover), bicyclist without a helmet or pedestrian struck by a motor vehicle, or head struck by a high-impact object

●Pre-existing conditions that place the child at risk for intracranial hemorrhage, such as arteriovenous malformation or a bleeding disorder (see 'Epidemiology' above)

Physical examination — The clinician should perform a thorough head and neurological examination (including mental status). Vital signs and evidence of associated extracranial injury, such as neck, abdominal or extremity tenderness, also warrant careful evaluation.

The presence of the following specific findings on physical examination in a child with an otherwise nonfocal neurologic examination raises concern for ciTBI [3,15,18,36-38]:

●Abnormal mental status (persistent Glasgow Coma Scale [GCS] score ≤14) (table 1)

●Palpable skull defect (depression or irregularity) indicating a likely skull fracture

●Signs of basilar skull fracture (periorbital ecchymosis, Battle sign (picture 3), hemotympanum (picture 1), cerebrospinal fluid [CSF] otorrhea, or CSF rhinorrhea)

Neuroimaging

Approach — The goal of evaluating minor head trauma in pediatric patients is to identify those children with ciTBI (by neuroimaging) while limiting unnecessary radiographic imaging and the radiation exposure of CT. Most children with minor head trauma do not need CT to exclude ciTBI. The decision to obtain a head CT must balance the importance of identifying a significant but rare ciTBI with the estimated risks of late-onset malignancy associated with radiation exposure from CT. Although only a very small number of patients with ciTBI require neurosurgery, the risk of missing such an injury is immediate and may have serious consequences for the patient. The risk of radiation-related malignancy is real; however, it wound not occur for years [41,42]. Although preliminary evidence suggests that magnetic resonance imaging (MRI) rather than CT may be feasible, it is not widely available in many settings.

Evaluation for high-risk findings and the use of a clinical decision rule can provide a balanced approach that stratifies patients by risk for ciTBI (table 3) [2,7] (see 'Clinical decision rules' below):

●High risk: Perform neuroimaging

●Intermediate risk: Observe; neuroimaging in selected patients

●Low risk: No neuroimaging

This approach does not apply to children for whom there is clinical concern for abusive head trauma. All such patients warrant neuroimaging. Similarly, children with evidence of increased intracranial pressure and/or focal neurologic findings after apparently minor blunt head trauma should undergo emergency neuroimaging.

Clinical decision rules — Clinical decision rules are valuable aids that inform the clinician's approach to neuroimaging. However, they are not intended to fully replace clinical judgment and are intended to assist rather than completely direct the clinician's approach to neuroimaging for children with minor head trauma.

For children two years of age and older with minor blunt head trauma and no suspicion for child abuse, we suggest that management decisions, especially the performance of neuroimaging and observation, be guided by the use of the PECARN low-risk clinical decision rules (table 2) rather than other rules because they were derived in the largest cohort and have the best discrimination for ciTBI [2,43-48].

In prospective validation, the sensitivity for detection of ciTBI in children ≥2 years was 97 percent (95% CI 89-100 percent) with a negative predictive value of 99.95 percent (95% CI 99.81-100 percent) in a population with approximately 1 percent prevalence of ciTBI in both the derivation and validation cohorts [2]. In addition to deriving and validating the clinical rules to identify children at low risk for ciTBI, these results support grouping of children with minor head trauma into three risk categories to inform CT decision-making and provide guidance for children who are not at low risk (table 3).

Subsequently, the PECARN rule has shown high accuracy in both prospective and retrospective validation studies in a variety of settings [43-47,49]. For example, in a prospective, multicenter study from Australia and New Zealand among over 11,100 children >2 years, the risk estimates for ciTBI were consistent with the original PECARN study for this age group: high risk 5.7 percent (95% CI 4.4-7.2 percent), intermediate risk 0.7 percent (95% CI 0.5-1 percent), and low risk 0 percent (95% CI 0-0.1 percent) [50]. Successful implementation of the PECARN rules have been described using a variety of methods including clinician education, clinical pathways, and clinical decision support embedded in the electronic health record [41,51,52]. The PECARN and other clinical decision rules are discussed in greater detail separately. (See "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'Clinical decision rules'.)

Clinical judgment — Evidence suggests that clinical decisions rules improve the detection of ciTBI in children with minor blunt head trauma compared with clinical judgment alone. In settings where clinician judgment is already documented to be highly accurate (eg, pediatric emergency medicine attendings practicing in high-volume tertiary care pediatric facilities), implementation of the PECARN decision rules may have limited impact on improving detection of ciTBI. (See "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'Clinical judgment'.)

Patient populations

High risk — Children ≥2 years of age with one or more of the following signs and symptoms appear to be at the highest risk for ciTBI and should have CT of the head performed [2,3,15,36]:

●History of a post-traumatic seizure

●Persistent altered mental status (eg, GCS ≤14, agitation, lethargy, repetitive questioning, or slow response to verbal questioning)

●Physical examination findings of skull fracture, including signs of basilar skull fracture

Based upon observational studies, these findings correlate with a ≥3 to 4 percent probability of ciTBI (table 3) [1-3,7].

Intermediate risk — We suggest that intermediate-risk children undergo close observation for four to six hours after the injury with neuroimaging obtained in individuals who do not improve or who develop worsening signs or symptoms during this period. Some intermediate-risk patients may undergo immediate CT based on the presence of multiple findings, severity of symptoms, clinical course, physician experience, and shared decision-making.

Intermediate-risk findings for ciTBI include any one of the following (table 3):

•Vomiting (see 'Vomiting' above)

•Headache

•History of LOC

•Injury caused by high-risk mechanism

The clinician should have a lower threshold for imaging for severe, persistent, worsening, or multiple clinical findings [2,15,42]. A decision aid can increase caregiver knowledge and encourage their involvement in the decision regarding neuroimaging in these patients [53].

Observation appears to be a safe and effective approach for selected children who are at an intermediate risk of ciTBI based upon the PECARN decision rules because it decreases the utilization of head CT without missing ciTBI [54-56]:

●In a planned secondary analysis of a multicenter, prospective, observational study of over 18,000 children with minor blunt head trauma (about 75 percent two years of age and older) presenting to emergency departments in New Zealand and Australia, planned observation was associated with lower CT use than patients who had imaging decisions made immediately after initial evaluation (unadjusted CT rate 4 versus 10 percent, respectively; adjusted odds ratio [OR] 0.2) [56]. Most patients undergoing planned observation were at intermediate risk of ciTBI by PECARN criteria. Among intermediate-risk patients, there was no difference in ciTBI between patients observed (0.5 percent) and those with no planned observation (0.6 percent). Two intermediate-risk patients who underwent planned observation had ciTBI requiring neurosurgery. Among high-risk patients, ciTBI was noted in 1.2 percent of the observed group compared with 9.4 percent of patients with no planned observation (rate difference -8.3, 95% CI -10.2 to -6.3). Since decision to observe was the treating clinician's choice, and both intermediate- and high-risk groups are heterogeneous, it is possible that the observed patients may have been less symptomatic.

●In a single-center, prospective, observational study of 1318 children evaluated for minor head trauma at a single pediatric emergency department, the CT rate for children undergoing observation was 5 percent (median observation time 2.5 hours) [55]. Overall, 20 percent of children received a head CT. The adjusted time-dependent decrease in overall CT rate was 69 percent. Most observed patients were intermediate risk by the PECARN decision rules and two years of age or older. All eight children with ciTBI had an immediate head CT, although clinical follow-up was confined to electronic medical record review.

●In a multicenter, prospective, observational study of 5433 children (median age five years), children who were observed after minor blunt head trauma had a lower CT rate than individuals who were not (31 versus 35 percent, respectively) [54]. The observed patients had a similar rate of ciTBI (0.8 versus 0.9 percent). In this study, most observed children were older than two years of age.

Low risk — For children ≥2 years of age at low risk for ciTBI, we recommend no neuroimaging. These patients should have a normal neurologic examination, no physical findings suggesting a skull fracture, no concern for child abuse, and no pre-existing condition that might increase the risk of intracranial hemorrhage (eg, bleeding disorder) [57].

Low-risk patients should meet all of the following criteria (table 2) [2]:

●No LOC (see 'Loss of consciousness' above)

●No vomiting (see 'Vomiting' above)

●No severe headache

●No high-risk mechanism of injury (severe mechanisms: fall >1.5 m [5 feet]; head struck by high-impact object; motor vehicle collision with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without a helmet struck by a motorized vehicle)

●Normal mental status

●No signs of basilar skull fracture

In one large observational study, the risk for ciTBI was <0.05 percent when none of these findings were present [2].

Recommended study — Cranial CT can rapidly identify TBIs (enabling appropriate management) and is readily available at most hospitals. MRI of the brain can identify ciTBI and has been shown to be feasible for the evaluation of children with minor head trauma in some settings [58]. However, MRI is not as available as CT in many settings, may lead to delays in diagnosis, and may require use of sedation. Because they provide no information regarding the presence of intracranial injury, plain radiographs of the skull have no role in children with minor blunt head trauma.

Other markers of brain injury — S100B protein is a calcium-binding protein located in glial cells that is released into the blood stream after trauma. Based upon a meta-analysis of eight studies that evaluated 601 pediatric patients with minor head trauma who also underwent CT of the head, S100B measurement had a high sensitivity (100 percent, 95% CI 98-100 percent) and negative predictive value (100 percent, prevalence of TBI on CT 22 percent) for intracranial lesions on CT [59]. However, S100B protein testing is not widely available, and further study is needed to establish reference ranges in children.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Increased intracranial pressure and moderate-to-severe traumatic brain injury" and "Society guideline links: Minor head trauma and concussion".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Head injury in children and teens (The Basics)")

●Beyond the Basics topic (see "Patient education: Head injury in children and adolescents (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Rationale – Minor blunt head trauma occurs commonly in children and is typically not associated with brain injury or long-term sequelae. However, a small number of children with apparently minor injuries may have a clinically important traumatic brain injury (ciTBI) that requires extended observation or acute intervention such as intensive supportive care or neurosurgery. (See 'Rationale' above and 'Definitions' above.)

●Epidemiology – Among children two years of age and older with minor blunt head trauma and a normal neurologic examination, approximately 3 to 7 percent have a traumatic brain injury (TBI) noted on CT, approximately 1 percent have ciTBI, and 0.1 to 0.6 percent require neurosurgical intervention. (See 'Epidemiology' above.)

●Evaluation – The clinician should perform a thorough history and physical examination in children with minor blunt head trauma with specific attention to clinical findings that should raise concern for ciTBI. (See 'Evaluation' above.)

•PECARN clinical decision rules – Children older than two years of age with minor blunt head trauma can be stratified as high, intermediate, or low risk for ciTBI based on clinical features. We suggest that evaluation decisions, especially the performance of neuroimaging and observation, be guided by the use of the Pediatric Emergency Care Applied Research Network (PECARN) low-risk clinical decision rules rather than other rules or clinical judgment alone. The table summarizes the criteria for high, intermediate, and low risk and the corresponding imaging decision (table 3). (See 'Clinical decision rules' above and 'Clinical judgment' above.)

•Approach to neuroimaging – The approach to neuroimaging two years of age and older with minor blunt head trauma based upon clinical findings is provided in the table (table 3). Patients at high risk for ciTBI should undergo prompt neuroimaging. Those at intermediate risk may undergo neuroimaging or observation based on the specific clinical scenario, with performance of imaging if persistent, worsening, or new symptoms occur during observation. Individuals at low risk for ciTBI should not undergo neuroimaging. (See 'Approach' above.)

This approach does not apply to children for whom there is clinical concern for abusive head trauma (see "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children"). All such patients warrant neuroimaging. Similarly, children with evidence of increased intracranial pressure and/or focal neurologic findings after apparently minor blunt head trauma should undergo emergency neuroimaging. (See 'Approach' above.)

•Recommended study – Both unenhanced CT of the head or MRI of the brain have the necessary sensitivity to identify ciTBI. Head CT can be rapidly obtained in most hospitals. Although MRI has no associated radiation, it is less available in most settings, which can result in delays in care and may require use of sedation due to longer scanning times. (See 'Recommended study' above.)

●Management – Specific management recommendations based on results of the evaluation are addressed separately. (See "Minor head trauma in infants and children: Management".)