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Patient handout

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

PRODUCTION

1. Your condition

This handout is for pediatric head injury / mild tbi / concussion (pecarn-stratified). Your care team identified this based on: 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).

Other reasons your team may use this plan: 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 gcs < 15 at presentation — pecarn high-risk feature in both age bands; ct recommended (kuppermann 2009 pmid 19758692); 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).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

MedicationStarting doseHowWhenWhat it does
acetaminophen10-15 mg/kg PO/IV q4-6h PRN (max 75 mg/kg/day or 4 g/day adult-equivalent)PO/IVq4-6h PRNFirst-line PO/IV analgesic-antipyretic in pediatric head injury; safe with no effect on platelets or coagulation; preferred over NSAIDs first 24 h until structural injury excluded (AAP/CDC mTBI 2018 PMID 30193284)
ibuprofen5-10 mg/kg PO q6h PRN (max 40 mg/kg/day; max 800 mg/dose)POq6h PRNAdjunctive PO analgesic for persistent post-injury headache AFTER structural injury excluded on CT (typically > 24 h post-injury); AVOID in first 24 h or if surgical management likely (platelet effect)
ondansetron0.15 mg/kg IV (max 4 mg per dose) q8h PRNIVq8h PRNFirst-line pediatric antiemetic; minimal sedation (preferred so as not to obscure neuro exam); preferred over prochlorperazine / promethazine in peds
hypertonic saline 3%3-5 mL/kg IV over 15-30 min (max 250 mL); central line preferred for repeat dosesIVPRN for raised ICP signsBTF pediatric guidelines (Kochanek 2019) — preferred hyperosmolar therapy for raised ICP / herniation signs in severe pediatric TBI; preferred over mannitol in many centers due to predictable response + no diuresis
mannitol0.5-1 g/kg IV over 15-30 min (max 1 g/kg per dose)IVPRN for raised ICP signsBTF pediatric guidelines — alternative hyperosmolar therapy; produces osmotic diuresis (replenish volume); risk of rebound increase in ICP with serum osmolarity > 320; less commonly used in peds than hypertonic saline
ketamineRSI induction 1-2 mg/kg IV (procedural sedation 1-2 mg/kg IV by pediatric sedation team)IVsingle dose for RSI; proceduralPreferred RSI induction agent in severe pediatric TBI — minimal hemodynamic impact + preserved airway reflexes; recent evidence supports use even in TBI (no longer contraindicated per older concerns about ICP elevation); standard pediatric procedural sedation per AAP guidance
rocuroniumRSI 1.2 mg/kg IVIVsingle dose for RSIPreferred RSI paralytic in pediatric TBI — rapid onset + intermediate duration; sugammadex reversal available if needed; standard pediatric RSI per AAP / PALS
fentanylRSI 1-2 mcg/kg IV; analgesic 1 mcg/kg IV PRN q1-2h post-RSIIVsingle dose for RSI; PRN post-RSIAdjunctive opioid analgesic for RSI + post-intubation analgesia in severe pediatric TBI; rapid onset, short duration, hemodynamic stability
midazolam0.05-0.1 mg/kg IV (max 2 mg single dose) for anxiolysis adjunct OR 0.1-0.2 mg/kg/h IV infusion for sedationIVPRN procedural; continuous for sedation post-RSIAdjunct anxiolysis for procedural sedation; continuous sedation post-RSI in severe pediatric TBI per institutional ICU protocol
lorazepam0.1 mg/kg IV (max 4 mg per dose)IVq5 min × 2 maxFirst-line benzodiazepine for post-traumatic seizure abortion per AES/NCS 2016 Glauser pediatric SE algorithm (routes to peds.status_epilepticus.v1)
normal saline / lactated Ringer's20 mL/kg IV bolus over 30-60 min, repeat × 1-2 PRN with reassessment for fluid overloadIVbolus PRN with reassessmentMaintain age-appropriate MAP target; AVOID hypotension in severe TBI (secondary injury); pediatric-specific slower bolus rate vs adult

Plan: Pediatric head injury ICP management + analgesia + antiemetic + RSI (BTF pediatric guidelines Kochanek 2019 + AAP/CDC mTBI 2018 PMID 30193284 + AAP pediatric sedation guidance)

3. When to call your provider

Contact your care team if any of the following happen:

  • New focal neurologic deficit at follow-up → return to ED + emergent imaging + neurosurgery
  • New seizure post-discharge → return to ED + CT + neurology; routes to peds.status_epilepticus.v1 if SE
  • Worsening or new headache + vomiting + lethargy → return to ED + repeat imaging
  • Persistent PCS symptoms beyond 4 weeks → multidisciplinary rehab referral + neurology direct
  • Sports concussion family insisting on premature return-to-play → educate per Berlin 2017 strong recommendation; document family education + medical clearance gating before stage 5
  • AHT escalating concerns during outpatient management → multidisciplinary care team + child protective services
  • Suicidality post-concussion in adolescent → routes to psych.suicidality.ed.core.v1 + mental-health urgent referral

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

  • Severe pediatric TBI (GCS ≤ 8) — life-threatening; immediate airway management + intubation + CT + neurosurgery + ICP management per BTF pediatric guidelines (Kochanek 2019); AVOID hypotension + hypoxia (secondary injury); PICU; routes to neuro.ich if structural hemorrhage(life-threatening)
  • PECARN < 2 yo high-risk feature (any one) — CT recommended per Kuppermann *Lancet* 2009 PMID 19758692; features: GCS < 15, altered mental status, palpable skull fracture, scalp hematoma (non-frontal — parietal/temporal/occipital), LOC ≥ 5 sec, severe mechanism, not acting normally per parent; rule sensitivity > 99% for ciTBI; ciTBI prevalence ~ 0.9% in < 2 yo presenting cohort
  • PECARN ≥ 2 yo high-risk feature (any one) — CT recommended per Kuppermann *Lancet* 2009 PMID 19758692; features: GCS < 15, altered mental status, signs of basilar skull fracture (battle sign, raccoon eyes, hemotympanum, CSF rhinorrhea/otorrhea), LOC (any duration), vomiting, severe mechanism, severe headache; rule sensitivity > 99% for ciTBI; ciTBI prevalence ~ 0.5% in ≥ 2 yo presenting cohort
  • Suspected abusive head trauma (AHT) in infant — intracranial injury + atypical mechanism / inconsistent history / unexplained skeletal injuries / concerning social factors; LIFE-THREATENING multi-system + multidisciplinary evaluation; mandated reporting + child protective services per Christian AAP 2009(life-threatening)
  • Post-traumatic seizure — immediate impact (< 24 h, typically benign) OR delayed (> 24 h, more concerning for structural injury); CT + pediatric neurology consult; if seizure ≥ 5 min OR ≥ 2 without recovery → status epilepticus, routes to peds.status_epilepticus.v1
  • Persistent vomiting (≥ 3 episodes) post-head-injury — PECARN ≥ 2 yo high-risk feature (vomiting is single-feature high-risk per PECARN); persistent multiple episodes despite mild presentation features → CT consideration; rule out raised ICP
  • Signs of basilar skull fracture (≥ 2 yo) — battle sign (mastoid bruising), raccoon eyes (periorbital bruising), hemotympanum, CSF rhinorrhea/otorrhea — PECARN ≥ 2 yo high-risk feature; LR+ ~ 15-25 for ciTBI; CT + neurosurgery consult; antibiotic prophylaxis controversial (most guidelines advise against routine prophylaxis); monitor for CSF leak
  • Imaging-negative CT but concerning clinical progression (worsening GCS, new symptoms, persistent vomiting, new focal deficit) — repeat CT or MRI; admit for observation; expand differential to delayed hemorrhage, diffuse axonal injury, subtle contusion (AAP/CDC mTBI 2018 PMID 30193284)

5. Follow-up

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.

6. Sources

Guideline: PECARN Kuppermann *Lancet* 2009 PMID 19758692 (clinical decision rule for CT in children with minor blunt head trauma; > 99% sensitivity for ciTBI; age-stratified < 2 yo and ≥ 2 yo rules) + AAP/CDC mTBI Lumba-Brown *JAMA Pediatr* 2018 PMID 30193284 (pediatric mTBI management framework; replaces CDC 2003) + Berlin Consensus on Concussion in Sport 2017 (McCrory CISG 5th) + Amsterdam 2022 update (CISG 6th International Conference; SCAT-6) + CHALICE Dunning *Arch Dis Child* 2006 (alternative UK pediatric rule) + CATCH Osmond *CMAJ* 2010 (alternative Canadian pediatric rule) + AAP Clinical Report Sport-Related Concussion 2018 (Halstead) + Christian AAP AHT 2009 (multidisciplinary AHT evaluation framework) + BTF pediatric severe TBI guidelines (Kochanek 2019) + AAP pediatric sedation guidance + AES/NCS 2016 Glauser (post-traumatic seizure abortion)

  1. pubmed.ncbi.nlm.nih.gov/19758692
  2. pubmed.ncbi.nlm.nih.gov/30193284
  3. pubmed.ncbi.nlm.nih.gov/26900382