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peds.head-injury-mtbi.v1

Pediatric head injury / mild TBI / concussion (PECARN-stratified)

pediatricsacutepediatricacuteinpatient
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NEW Phase C dossier — authored 2026-05-15 for shard-5-obped-id wave 9. Covers pediatric head injury, especially mild TBI (mTBI) / concussion (PECARN-stratified; sports concussion + AHT aware) — one of the highest-volume pediatric ED presentations (~ 500,000 ED visits/year in US for pediatric head injury per CDC). Anchored on PECARN clinical decision rule for CT in children with minor blunt head trauma (Kuppermann N et al *Lancet* 2009 PMID 19758692) — > 99% sensitivity for clinically-important TBI (ciTBI); age-stratified rules (< 2 yo and ≥ 2 yo). Reconciled with AAP/CDC mTBI guideline 2018 (Lumba-Brown PMID 30193284) for mTBI management framework + Berlin Concussion in Sport Consensus 2017 + Amsterdam 2022 update for sports concussion subtype (SCAT-6, graded RTL/RTP). Manifest field intentionally blanked (manifest: "") per shard-5 precedent on peds.appendicitis.v1 + peds.status_epilepticus.v1 + peds.dka.v1 + peds.febrile-infant.core.v1 + peds.nec.v1 + peds.intussusception.v1 + id.influenza.core.v1 + id.neonatal-sepsis.early-late.v1 + id.sepsis.peds.v1 — seed manifest authoring at prisma/seed/manifests/peds.head-injury-mtbi.v1.{ts,atoms.ts} is out-of-shard scope and deferred to a future shard once the manifest + atoms cycle ships. Audit may report broken_pointers cleared but next-tier "missing manifest pointer" until manifest lands. Refined Phase-C-wave-9 pattern: 3-file new-dossier batch (TS + brief + research bundle) WITHOUT touching _registry.ts — registration will be picked up in a wave-roll-up commit (parallel-agent staging conflict avoidance per shard refined pattern). Distinct from neuro.tbi.core.v1 (adult parent TBI dossier; Canadian CT Head Rule + New Orleans Criteria; this peds dossier carries PECARN + age-stratified high-risk features + AHT workup + sports concussion + pediatric-specific RTP gating distinct from adult); neuro.ich (traumatic ICH neurosurgical management; coordinates with peds team for severe TBI); peds.status_epilepticus.v1 (post-traumatic SE staged algorithm; routes here if seizure ≥ 5 min OR ≥ 2 without recovery); id.bacterial-meningitis.peds.v1 (post-basilar-skull-fracture infection risk + CSF leak monitoring); psych.suicidality.ed.core.v1 (post-concussion mood / SI screen in adolescent); peds.abusive-head-trauma.v1 (not yet authored; sibling for non-accidental head trauma with multidisciplinary management — Christian AAP 2009 framework rendered here). Sibling differentiation explicitly encoded for neuro.tbi.core.v1 + neuro.ich + peds.status_epilepticus.v1. Phenotype matrix (7-axis: age × severity GCS × mechanism × symptoms LOC/amnesia/vomiting/seizure × PECARN tier × injury type concussion/structural/penetrating × persistent symptoms — collapsed by clinical meaning to 10 anchor combinations) encoded indirectly via regimen_axes (pediatric_head_injury_icp_analgesia_rsi) + severity_triggers (10 phenotype-specific triggers) + setting playbooks (ed = primary venue with PECARN + CT + SCAT-6 + AHT workup if applicable / inpatient = moderate TBI close neuro observation or AHT multidisciplinary workup / icu = severe TBI GCS ≤ 8 + ICP management + neurosurgery / outpatient = peds neurology + sports medicine + concussion clinic + PCS evaluation at 4 wk + multidisciplinary rehab + school accommodations). First-class TS phenotype field is schema-blocked. Severity triggers (10): severe_head_injury_gcs_8_or_below (life_threatening — airway/intubation + CT + neurosurgery + ICP management per BTF pediatric Kochanek 2019; routes to neuro.ich if hemorrhage), pecarn_high_risk_under_2yo (severe — CT indicated per PECARN 2009 PMID 19758692; AHT workup considered if atypical), pecarn_high_risk_over_2yo (severe — CT indicated per PECARN 2009 PMID 19758692; basilar skull fracture signs LR+ 15-25), suspected_abusive_head_trauma (life_threatening — multidisciplinary CAP + skeletal survey + ophtho + CT + cervical spine + social work + child protective services + retinal exam + mandated reporting per Christian AAP 2009), post_concussion_syndrome_at_4_weeks (moderate — neurology referral + multidisciplinary rehab + cognitive rest + symptom-guided graded return per AAP/CDC mTBI 2018), sports_concussion_return_to_play_protocol (mild — SCAT-6 + graded RTL/RTP + NO same-day return per Berlin 2017 + Amsterdam 2022 + AAP sports concussion 2018; medical clearance before stage 5), seizure_post_head_injury (severe — CT + neurology + routes to peds.status_epilepticus.v1 if SE), vomiting_persistent_post_head_injury (severe — multiple episodes despite mild PECARN risk → CT consideration; rule out raised ICP), basilar_skull_fracture_signs (severe — battle sign / raccoon eyes / hemotympanum / CSF rhinorrhea/otorrhea → CT + neurosurgery; antibiotic prophylaxis controversial per Cochrane), imaging_negative_but_concerning_clinical_progression (severe — repeat CT or MRI; admit for observation; expand differential to delayed hemorrhage / DAI / subtle contusion). Bayesian linkage (per §5.5.2): pre-test priors documented in _research-bundles/peds.head-injury-mtbi.v1.md — PECARN derivation cohort ciTBI prevalence ~ 0.9% < 2 yo and ~ 0.5% ≥ 2 yo; PCS at 4 weeks ~ 10-30%; AHT prevalence in infants with ICH ~ 20-30% in some series; sports concussion ~ 1.1-1.9 million/year US under-18 athletes. Key LRs: any PECARN high-risk feature LR+ ~ 4-8 for ciTBI; GCS < 15 LR+ ~ 8-12; palpable skull fracture in < 2 yo LR+ ~ 15-25; basilar skull fracture signs in ≥ 2 yo LR+ ~ 15-25; severe mechanism alone LR+ ~ 2-3; no PECARN features LR− ~ 0.01-0.02 (excellent rule-out; NPV > 99.95%); retinal hemorrhage + intracranial injury in infant LR+ ~ 10-20 for AHT; persistent vomiting LR+ ~ 3-5; same-day RTP after sports concussion = catastrophic risk factor for second-impact syndrome. Conditional dependencies: age × high-risk feature set coupling (< 2 yo vs ≥ 2 yo distinct features); mechanism × age × ciTBI risk coupling; GCS × CT positivity × neurosurgery coupling; sports concussion × RTP × second-impact syndrome coupling; persistent symptom × PCS × multidisciplinary referral coupling. Decision thresholds: T_test_CT at any PECARN high-risk feature; T_treat_observation at intermediate-risk PECARN; T_treat_neurosurgery at any structural injury on CT; T_treat_ICP_management at GCS ≤ 8 or signs of raised ICP; T_test_AHT_workup at infant + intracranial injury + atypical mechanism; T_remove_from_play at any sports concussion (immediate); T_refer_neurology at PCS ≥ 4 weeks; T_test_MRI at imaging-negative CT but persistent concern. Cross-dossier routing: peds.status_epilepticus.v1 (post-traumatic seizure / SE), neuro.ich (traumatic intracranial hemorrhage), id.bacterial-meningitis.peds.v1 (post-basilar-skull-fracture infection), psych.suicidality.ed.core.v1 (post-concussion mood / SI), neuro.tbi.core.v1 (adult parent for transition cases ≥ 16-18 y). ROS/DDx LR seed data NOT touched (cross-cutting; not in shard scope). Settings (4): ed (primary venue — PECARN stratification + age-band-appropriate workup + CT decision + concussion precautions + AHT evaluation if indicated + neurosurgery consult if structural injury), inpatient (observation period for intermediate-risk PECARN or imaging-equivocal cases + moderate TBI close neuro observation + AHT multidisciplinary workup), icu (severe TBI GCS ≤ 8 + intubated + ICP management + neurosurgery + AHT severe cases), outpatient (peds neurology / sports medicine / concussion clinic at 1-2 wk + PCS evaluation at 4 wk + graded RTL/RTP for sports concussion + school accommodations + mental-health if mood symptoms + multidisciplinary rehab if PCS). Drug guidance grounded in BTF pediatric severe TBI guidelines (Kochanek 2019) + AAP/CDC mTBI 2018 PMID 30193284 + AAP pediatric sedation guidance + AES/NCS 2016 Glauser for post-traumatic seizure abortion (carryover from peds.status_epilepticus.v1) + Berlin 2017 + Amsterdam 2022 for sports concussion management + Christian AAP 2009 for AHT multidisciplinary workup. RxCUIs referenced (RxNav-verified live 2026-05-25): acetaminophen (161), ibuprofen (5640), ondansetron (26225), hypertonic saline 3% (730781 = sodium chloride 30 MG/ML injection), mannitol (6628), ketamine (6130), rocuronium (68139), fentanyl (4337), midazolam (6960), lorazepam (6470), sodium chloride / normal saline (9863) — three codes corrected on 2026-05-25 (656659 was bosentan→730781 hypertonic saline 3%; 6726 invalid→6628 mannitol; 56500 invalid→68139 rocuronium). Open gaps: (1) Phenotype matrix not first-class TS field — schema-blocked. (2) Bayesian LR seed data not encoded — lives in narrative + research bundle only this pass; ROS/DDx seed edit cross-cutting. (3) Prehospital not a DossierSetting value — schema-blocked. (4) calc.pecarn_head_injury_under_2yo (PECARN < 2 yo decision rule) not yet registered in clinical-tools-registry.ts — pending registry addition (high-value first-class addition). (5) calc.pecarn_head_injury_over_2yo (PECARN ≥ 2 yo decision rule) not yet registered — pending registry addition. (6) calc.gcs_pediatric (age-appropriate pediatric GCS) not yet registered — pending registry addition. (7) calc.scat6_concussion_assessment (Berlin / Amsterdam SCAT-6) not yet registered — pending registry addition. (8) workup.pediatric_head_injury not yet registered — pending registry addition. (9) protocol.return_to_play_graded (Berlin 2017 + Amsterdam 2022 6-stage RTP protocol) not yet registered — pending registry addition. (10) protocol.pediatric_aht_workup (Christian AAP 2009 multidisciplinary AHT workup) not yet registered — pending registry addition. (11) Manifest file not authored this pass — shard precedent for manifest: "" with seed deferred. (12) Co-located test file (peds.head-injury-mtbi.v1.test.ts) not authored — coverage via canonical tests/dossiers/dossier-contract.test.ts only. (13) _registry.ts NOT modified this commit — refined Phase-C-wave-9 pattern; registration will be picked up in a wave-roll-up commit. (14) Berlin 2017 + Amsterdam 2022 + CHALICE Dunning 2006 + CATCH Osmond 2010 + AAP sports concussion 2018 + Christian AAP AHT 2009 + BTF pediatric Kochanek 2019 PMIDs deferred to next research:pubmed loop. Status declared PLANNED with manifest: "" matching audit-resolved actual_status — audit gate honored. Per shard precedent, this is acceptable for new Phase C dossiers awaiting manifest authoring in a future shard.

Entry points (10)

  • symptom
    Child or adolescent with head injury + LOC OR amnesia OR alteration in mental status — classic mTBI presentation requiring PECARN stratification (Kuppermann 2009 PMID 19758692; AAP/CDC mTBI 2018)
    pediatric_head_injury_with_loc_or_amnesia
  • symptom
    Pediatric head injury with severe mechanism (MVC with ejection / death of another passenger / rollover; pedestrian or unhelmeted bicyclist struck; fall > 0.9 m if < 2 yo or > 1.5 m if ≥ 2 yo; head struck by high-impact object) — PECARN high-risk mechanism feature (Kuppermann 2009 PMID 19758692)
    pediatric_head_injury_with_severe_mechanism
  • symptom
    Pediatric head injury with GCS < 15 at presentation — PECARN high-risk feature in both age bands; CT recommended (Kuppermann 2009 PMID 19758692)
    pediatric_head_injury_gcs_below_15
  • symptom
    Pediatric head injury with palpable skull fracture (< 2 yo) OR signs of basilar skull fracture (≥ 2 yo: battle sign, raccoon eyes, hemotympanum, CSF rhinorrhea/otorrhea) — PECARN high-risk feature; CT + neurosurgery consult (Kuppermann 2009 PMID 19758692)
    pediatric_head_injury_with_palpable_skull_fracture
  • symptom
    Pediatric head injury with post-traumatic seizure (immediate impact OR delayed) — high-risk feature; CT + neurology; routes to peds.status_epilepticus.v1 if seizure ≥ 5 min OR ≥ 2 seizures without recovery (AAP/CDC mTBI 2018)
    pediatric_head_injury_with_seizure
  • symptom
    Pediatric head injury with persistent vomiting (≥ 3 episodes) — PECARN ≥ 2 yo high-risk feature; CT consideration; rule out raised ICP (Kuppermann 2009 PMID 19758692)
    pediatric_head_injury_with_persistent_vomiting
  • symptom
    Sports-related concussion in pediatric athlete — IMMEDIATE removal from play ("when in doubt, sit them out"); sideline SCAT-6 assessment; no same-day return to play (Berlin 2017 + Amsterdam 2022 + AAP sports concussion 2018)
    pediatric_sports_concussion_remove_from_play
  • symptom
    Infant with intracranial injury + atypical / inconsistent mechanism + changing history + unexplained skeletal fractures + concerning social factors — SUSPECTED ABUSIVE HEAD TRAUMA; multidisciplinary CAP + skeletal survey + ophtho + CT + child protective services + retinal exam (Christian AAP 2009)
    infant_with_intracranial_injury_atypical_mechanism
  • symptom
    Persistent post-concussion symptoms (headache, dizziness, fatigue, cognitive complaints, mood symptoms) at 4 weeks post-mTBI — PCS; neurology referral + multidisciplinary rehab (AAP/CDC mTBI 2018 PMID 30193284)
    pediatric_persistent_post_concussion_symptoms_at_4_weeks
  • history
    PECARN clinical decision rule applied at triage — age-band-appropriate (< 2 yo or ≥ 2 yo) high-risk features assessed; CT vs observation vs discharge decision documented (Kuppermann 2009 PMID 19758692)
    pecarn_stratification_calculated_at_triage

Required inputs (37)

  • age_in_yearsrequired
    demographic • used at CONTEXT
    Age band drives PECARN rule applied (< 2 yo vs ≥ 2 yo); < 2 yo cohort has skull immaturity + fontanelle + limited verbal capacity considerations; also drives developmental concussion-symptom presentation
  • weight_kgrequired
    demographic • used at CONTEXT
    Weight-based dosing for all fluids + analgesia + sedation + ICP-management drugs (hypertonic saline, mannitol); RSI drug dosing in severe TBI
  • sex_at_birth_and_gender_identity
    demographic • used at CONTEXT
    Pregnancy test mandatory in post-menarchal adolescent female with significant head injury / planned imaging; informs OB / MFM consult if applicable
  • temperature_pediatricrequired
    vital • used at CONTEXT
    Fever may indicate concurrent infection or hyperthermia in severe TBI; targeted temperature management considerations in severe TBI
  • hr_pediatricrequired
    vital • used at RED_FLAGS
    Bradycardia + hypertension = Cushing triad sign of raised ICP; tachycardia + hypotension may indicate concurrent hemorrhage or shock
  • sbp_pediatricrequired
    vital • used at RED_FLAGS
    AVOID HYPOTENSION in severe TBI (secondary injury); maintain age-appropriate MAP target; hypertension may indicate Cushing response to raised ICP
  • spo2required
    vital • used at RED_FLAGS
    AVOID HYPOXIA in severe TBI (secondary injury); maintain SpO2 > 90% (target > 95% per BTF pediatric guidelines)
  • rr_pediatricrequired
    vital • used at RED_FLAGS
    Respiratory pattern abnormalities (Cheyne-Stokes, ataxic breathing) indicate brainstem compromise; intubation if GCS ≤ 8 or inability to protect airway
  • gcs_pediatricrequired
    symptom • used at CONTEXT
    Cornerstone of severity stratification — mild 13-15 / moderate 9-12 / severe ≤ 8; age-appropriate pediatric GCS for pre-verbal infants; serial GCS critical for detecting deterioration
  • loss_of_consciousness_durationrequired
    symptom • used at CONTEXT
    PECARN < 2 yo high-risk if ≥ 5 sec; PECARN ≥ 2 yo high-risk if any duration; informs ciTBI risk + CT decision
  • amnesia_post_traumaticrequired
    symptom • used at CONTEXT
    PECARN component (informs AMS / GCS); duration > 24 h moves out of mTBI definition into moderate TBI (Lumba-Brown 2018 PMID 30193284)
  • altered_mental_status_signsrequired
    symptom • used at CONTEXT
    PECARN high-risk feature in both age bands — agitation, somnolence, repetitive questioning, slow response to verbal communication (Kuppermann 2009 PMID 19758692)
  • vomiting_episodes_count_post_injuryrequired
    symptom • used at CONTEXT
    PECARN ≥ 2 yo high-risk if any vomiting; persistent (≥ 3 episodes) → CT consideration even if isolated; rule out raised ICP
  • severe_headache_post_injuryrequired
    symptom • used at CONTEXT
    PECARN ≥ 2 yo high-risk feature — severe (worst-ever / unrelenting) headache → CT
  • post_traumatic_seizure_featuresrequired
    symptom • used at CONTEXT
    High-risk feature; immediate impact seizures (< 24 h) typically benign but mandate CT; delayed (> 24 h) more concerning for structural injury; routes to peds.status_epilepticus.v1 if SE
  • scalp_hematoma_location_and_agerequired
    symptom • used at CONTEXT
    PECARN < 2 yo high-risk if non-frontal (parietal / temporal / occipital); LR+ ~ 3-5 for ciTBI; size + boggy quality + age 3-12 mo intermediate
  • palpable_skull_fracturerequired
    symptom • used at CONTEXT
    PECARN < 2 yo high-risk feature; very high LR+ ~ 15-25 for ciTBI; CT + neurosurgery consult
  • basilar_skull_fracture_signsrequired
    symptom • used at CONTEXT
    PECARN ≥ 2 yo high-risk feature — battle sign (mastoid bruising), raccoon eyes (periorbital bruising), hemotympanum, CSF rhinorrhea/otorrhea; LR+ ~ 15-25 for ciTBI; CT + neurosurgery
  • focal_neurologic_deficitrequired
    symptom • used at RED_FLAGS
    High-risk feature; structural injury concern; CT + neurosurgery consult; cranial nerve palsy, hemiparesis, anisocoria, gaze palsy
  • cushing_triad_signs_of_raised_icprequired
    symptom • used at RED_FLAGS
    Hypertension + bradycardia + irregular respiration → impending herniation; immediate hyperosmolar therapy + emergent neurosurgery + intubation
  • mechanism_of_injury_detailrequired
    history • used at CONTEXT
    PECARN severe mechanism feature: MVC with ejection / death of another passenger / rollover; pedestrian or unhelmeted bicyclist struck; fall > 0.9 m (< 2 yo) or > 1.5 m (≥ 2 yo); head struck by high-impact object
  • not_acting_normally_per_parentrequired
    history • used at CONTEXT
    PECARN < 2 yo high-risk feature — parental report of behavior change is meaningful; lower threshold for CT in pre-verbal infants
  • inconsistent_or_changing_history_for_ahtrequired
    history • used at CONTEXT
    AHT red flag — atypical mechanism / changing history / unexplained findings; lower threshold for AHT workup if infant + intracranial injury (Christian AAP 2009)
  • unexplained_skeletal_injuries_or_bruising
    history • used at CONTEXT
    AHT red flag — multiple unexplained injuries; skeletal survey indicated; LR+ ~ 8-15 for AHT in infant with intracranial injury (Christian AAP 2009)
  • sports_concussion_event_details
    history • used at CONTEXT
    Sports-related mechanism informs RTL/RTP planning; sport, position, helmet use, biomechanical force (Berlin 2017 + Amsterdam 2022)
  • prior_concussion_history
    history • used at CONTEXT
    Multiple prior concussions raises PCS + second-impact syndrome risk; informs RTP gradation + family counseling (AAP sports concussion 2018)
  • anticoagulant_or_antiplatelet_use
    history • used at CONTEXT
    Rare in pediatrics but warfarin / DOAC / aspirin / other antiplatelet → significantly increases ICH risk; CT threshold lowered; reverse agent if indicated
  • cbc_with_diff_if_severe_or_aht
    lab • used at INITIAL_WORKUP
    Baseline if surgical / severe TBI; informs anemia + thrombocytopenia risk for bleeding diathesis or AHT workup
  • coagulation_studies_if_severe_or_aht
    lab • used at INITIAL_WORKUP
    PT/INR/PTT baseline if severe TBI or AHT workup; reverse anticoagulant if applicable
  • metabolic_panel_if_severe
    lab • used at INITIAL_WORKUP
    Baseline electrolytes + sodium target for hyperosmolar therapy planning; AKI from rhabdo if multi-trauma
  • urine_or_serum_bhcg_for_post_menarchal_female
    lab • used at INITIAL_WORKUP
    Mandatory before significant ionizing radiation imaging; informs OB / MFM consult if pregnant
  • type_and_screen_if_severe_tbi_surgical
    lab • used at BRANCHING_WORKUP
    Pre-surgical type-and-screen if neurosurgery anticipated for severe TBI / structural injury
  • ct_head_per_pecarn_decisionrequired
    imaging • used at BRANCHING_WORKUP
    Primary imaging for ciTBI evaluation per PECARN; high sensitivity for hemorrhage / fracture / contusion; radiation-aware ALARA principle balances against ciTBI risk; obtain non-contrast CT head
  • mri_brain_if_imaging_negative_but_concerning
    imaging • used at BRANCHING_WORKUP
    MRI for diffuse axonal injury / subtle contusion / suspected AHT (with sedation if needed); higher sensitivity than CT for some pathologies; no radiation
  • cervical_spine_imaging_if_severe_or_high_mechanism
    imaging • used at BRANCHING_WORKUP
    Cervical spine imaging (CT or MRI) for severe TBI or high-mechanism injury; immobilize until cleared
  • skeletal_survey_for_aht_workup
    imaging • used at BRANCHING_WORKUP
    Radiographic skeletal survey for occult fractures in suspected AHT (ribs, metaphyses, classical metaphyseal lesions); per AAP AHT protocol (Christian 2009)
  • ophthalmology_retinal_exam_for_aht
    imaging • used at BRANCHING_WORKUP
    Dilated retinal exam by ophthalmology in suspected AHT — bilateral, multilayered retinal hemorrhages extending to periphery are highly specific for AHT in infants (Christian AAP 2009)

12-phase flow (12)

  1. 1FRAME
    Frame the pediatric head injury presentation: age band (< 2 yo / 2-5 / 6-12 / 13-17) drives PECARN rule applied + concussion-symptom presentation interpretation; severity stratification by GCS (mild 13-15 / moderate 9-12 / severe ≤ 8); mechanism (fall / MVA / sports / assault / suspected AHT); special consideration for infant + atypical mechanism (AHT) and sports concussion (immediate remove from play).
    inputs: age_in_years, gcs_pediatric
    advance: Age band + GCS + mechanism tagged; severity tier + PECARN rule applied; AHT or sports concussion flagged if applicable
  2. 2ENTRY
    Recognise via classic presentation features (LOC, amnesia, altered mental status, vomiting, seizure, focal deficit, headache) OR severe mechanism / severe head injury (GCS ≤ 8) OR concerning population (infant + atypical mechanism for AHT; pediatric athlete for sports concussion). Apply PECARN clinical decision rule at triage (age-band appropriate).
    inputs: gcs_pediatric, loss_of_consciousness_duration, altered_mental_status_signs
    advance: Head injury severity recognized; PECARN feature set assessed; sports concussion / AHT / severe TBI subtype flagged
  3. 3CONTEXT
    Age + sex + weight + vitals + GCS + LOC duration + amnesia + AMS signs + vomiting count + severe headache + post-traumatic seizure features + scalp hematoma location + palpable skull fracture + basilar skull fracture signs + focal neurologic deficit + mechanism of injury detail + not acting normally per parent + AHT red flags (inconsistent history, unexplained injuries) + sports concussion event details + prior concussion history + anticoagulant use.
    inputs: age_in_years, weight_kg, temperature_pediatric, hr_pediatric, gcs_pediatric, loss_of_consciousness_duration, amnesia_post_traumatic, altered_mental_status_signs, vomiting_episodes_count_post_injury, severe_headache_post_injury, post_traumatic_seizure_features, scalp_hematoma_location_and_age, palpable_skull_fracture, basilar_skull_fracture_signs, mechanism_of_injury_detail, not_acting_normally_per_parent, inconsistent_or_changing_history_for_aht
    advance: PECARN features documented; severity tier finalized; AHT / sports concussion / severe TBI subtype confirmed
  4. 4RED_FLAGS
    Severe TBI (GCS ≤ 8) → airway / intubation / CT / neurosurgery / ICP management / PICU; Cushing triad (hypertension + bradycardia + irregular respiration) → impending herniation, immediate hyperosmolar therapy + emergent neurosurgery; AVOID HYPOTENSION + HYPOXIA (secondary injury); focal neurologic deficit → structural injury concern; suspected AHT in infant → multidisciplinary workup + child protective services + mandated reporting; post-traumatic seizure → CT + neurology + routes to peds.status_epilepticus.v1 if SE; persistent vomiting (≥ 3 episodes) → CT consideration regardless of other features.
    inputs: sbp_pediatric, spo2, rr_pediatric, focal_neurologic_deficit, cushing_triad_signs_of_raised_icp
    advance: Life-threatening features evaluated; airway / ICP / circulation optimized; emergent consults triggered if needed
  5. 5INITIAL_WORKUP
    IV access + cervical spine immobilization if severe or high-mechanism; serial GCS q15 min during ED workup; head of bed 30° if severe TBI; vital signs continuous; analgesia (acetaminophen 10-15 mg/kg PO/IV q4-6h; AVOID NSAIDs first 24 h until structural injury excluded; opioids cautiously if needed); antiemetic (ondansetron 0.15 mg/kg IV PRN); avoid sedation that obscures neuro exam; PECARN stratification applied. CT head per PECARN decision for high-risk features.
    inputs: gcs_pediatric
    actions: panel.cbc
    advance: IV access + immobilization (if applicable) + analgesia + antiemetic given; PECARN bucket documented; CT obtained if high-risk
  6. 6BRANCHING_WORKUP
    Source-directed: CT head if PECARN high-risk feature (any one in age-band); MRI if imaging-negative CT but persistent clinical concern OR suspected diffuse axonal injury / subtle contusion / suspected AHT; cervical spine imaging if severe TBI or high-mechanism; AHT workup if indicated (skeletal survey + ophtho retinal exam + CT head + cervical spine + social work); pregnancy test if post-menarchal female; type-and-screen if neurosurgery anticipated.
    inputs: ct_head_per_pecarn_decision
    advance: Imaging completed; structural injury or normal; AHT workup initiated if indicated; pre-surgical workup ready if neurosurgery needed
  7. 7DIFFERENTIAL
    Concussion (mTBI without structural injury — most common); structural intracranial injury (subdural / epidural / subarachnoid / intraparenchymal hemorrhage; contusion); skull fracture (linear / depressed / basilar); diffuse axonal injury (MRI > CT sensitivity; characteristic punctate lesions at grey-white interfaces); abusive head trauma (infant with atypical mechanism / changing history / multiple injuries / retinal hemorrhages — Christian AAP 2009); post-traumatic seizure / status epilepticus (routes to peds.status_epilepticus.v1); cervical spine injury (concurrent in severe TBI); polytrauma (rule out other injuries — abdominal, chest, extremity).
    advance: Differential narrowed by imaging + clinical features; specific diagnosis or severity tier documented
  8. 8RISK_STRATIFICATION
    Tier 1 (life-threatening): severe TBI (GCS ≤ 8) + Cushing triad / herniation / structural injury requiring neurosurgery; suspected AHT in unstable infant with structural injury. Tier 2 (severe — admit + neurosurgery): moderate TBI (GCS 9-12) + any structural injury on CT + post-traumatic seizure requiring AED + basilar skull fracture signs + persistent vomiting with imaging-negative CT but high concern. Tier 3 (moderate — observation): PECARN intermediate-risk (isolated single feature without others); imaging-equivocal cases; ED observation × 4-6 h with serial GCS. Tier 4 (mild — discharge with precautions): PECARN low-risk + no features + reassuring exam + family understands return precautions. Tier 5 (sports concussion mTBI): immediate removal from play + SCAT-6 + graded RTL / RTP + no same-day return.
    inputs: age_in_years, gcs_pediatric, mechanism_of_injury_detail
    advance: Tier assigned + admit vs observation vs discharge vs RTP-protocol decision documented
  9. 9TREATMENT
    Severe TBI (GCS ≤ 8): airway / RSI / intubation (ketamine 1-2 mg/kg + rocuronium 1.2 mg/kg preferred; minimal hemodynamic impact; ketamine fine in TBI per recent evidence); maintain normocapnia (PCO2 35-40); SpO2 > 95%; SBP at age-appropriate target; head of bed 30°; cervical spine immobilization until cleared; serial GCS q15 min; hyperosmolar therapy for herniation signs or sustained ICP > 20: 3% hypertonic saline 3-5 mL/kg IV over 15-30 min OR mannitol 0.5-1 g/kg IV over 15-30 min; emergent neurosurgery consult for structural injury / decompression; PICU. Moderate TBI: admit + serial GCS + close neuro observation + CT + neurosurgery consult. mTBI / concussion: cognitive + physical rest 24-48 h (NOT aggressive complete rest; symptom-guided gradual return); acetaminophen for headache (AVOID NSAIDs first 24 h until structural injury excluded); ondansetron for nausea; education on concussion precautions. Sports concussion: SCAT-6 sideline + serial; graded RTL/RTP protocol (6 stages, min 24 h per stage, min 7 days total); NO same-day return; medical clearance before stage 5. AHT: multidisciplinary workup + child protective services + mandated reporting + foster placement during workup.
    inputs: weight_kg, gcs_pediatric
    advance: Treatment plan in place; airway / ICP / pain / nausea / RTP-protocol or AHT workup initiated
  10. 10DISPOSITION
    Severe TBI → PICU + neurosurgery + ICP management. Moderate TBI → inpatient ward + close neuro observation + neurosurgery consult. mTBI with PECARN intermediate-risk → ED observation × 4-6 h then discharge if reassuring OR inpatient ward 24-48 h observation. mTBI with PECARN low-risk → discharge home with concussion precautions + family education + follow-up in 1-2 weeks. Sports concussion → discharge home with sport-specific RTL/RTP protocol + sports medicine / concussion clinic follow-up. AHT → admit to ward + multidisciplinary workup + child protective services arrangement.
    inputs: sbp_pediatric, gcs_pediatric
    advance: Disposition + level of care + follow-up plan in place
  11. 11MONITORING
    Severe TBI: continuous ECG + SpO2 + capnography + arterial line + serial GCS q1h + neurology / neurosurgery / PICU; ICP monitor if GCS ≤ 8 + abnormal CT OR high-risk normal CT; serial CBC + electrolytes + sodium + ABG. Moderate TBI: vitals q2h + serial GCS q2h × first 24 h then per protocol; serial neuro exam. mTBI: vitals q4h during ED observation; serial GCS q1h × 4 h if observed; discharge instructions delivered with family teach-back. Concussion / mTBI outpatient: symptom diary; SCAT-6 serial in sports concussion; school accommodations as needed. AHT: continuous monitoring + ongoing workup + family interactions documented + social work + child protective services.
    inputs: gcs_pediatric
    advance: Monitoring orders documented; clinical progress trended; concerning changes prompt re-evaluation
  12. 12FOLLOWUP
    Severe TBI: pediatric neurosurgery + neurology + rehabilitation medicine + multidisciplinary post-TBI clinic; family support / mental health. Moderate TBI: pediatric neurology / neurosurgery follow-up at 1-2 weeks then per progress. mTBI / concussion: pediatrician / sports medicine / concussion clinic at 1-2 weeks; neurology referral if persistent symptoms ≥ 4 weeks (PCS); school accommodations (504 plan / IEP if cognitive symptoms persist); graded return to learn + activity. Sports concussion: sports medicine / concussion clinic; serial SCAT-6; graded RTL/RTP protocol; medical clearance before stage 5; family-clinician-coach shared decision-making. PCS at 4 weeks: neurology referral + multidisciplinary rehab (PT / vestibular if dizziness; OT / cognitive rehab if cognitive symptoms; mental-health if mood symptoms); most resolve within 3-6 months. AHT: multidisciplinary care team + child protective services follow-up + foster placement coordination + family / kinship social services + ongoing CAP follow-up.
    advance: Follow-up scheduled + return precautions delivered + RTP/RTL protocol initiated + AHT case-management arranged