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).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| acetaminophen | 10-15 mg/kg PO/IV q4-6h PRN (max 75 mg/kg/day or 4 g/day adult-equivalent) | PO/IV | q4-6h PRN | First-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) |
| ibuprofen | 5-10 mg/kg PO q6h PRN (max 40 mg/kg/day; max 800 mg/dose) | PO | q6h PRN | Adjunctive 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) |
| ondansetron | 0.15 mg/kg IV (max 4 mg per dose) q8h PRN | IV | q8h PRN | First-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 doses | IV | PRN for raised ICP signs | BTF 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 |
| mannitol | 0.5-1 g/kg IV over 15-30 min (max 1 g/kg per dose) | IV | PRN for raised ICP signs | BTF 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 |
| ketamine | RSI induction 1-2 mg/kg IV (procedural sedation 1-2 mg/kg IV by pediatric sedation team) | IV | single dose for RSI; procedural | Preferred 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 |
| rocuronium | RSI 1.2 mg/kg IV | IV | single dose for RSI | Preferred RSI paralytic in pediatric TBI — rapid onset + intermediate duration; sugammadex reversal available if needed; standard pediatric RSI per AAP / PALS |
| fentanyl | RSI 1-2 mcg/kg IV; analgesic 1 mcg/kg IV PRN q1-2h post-RSI | IV | single dose for RSI; PRN post-RSI | Adjunctive opioid analgesic for RSI + post-intubation analgesia in severe pediatric TBI; rapid onset, short duration, hemodynamic stability |
| midazolam | 0.05-0.1 mg/kg IV (max 2 mg single dose) for anxiolysis adjunct OR 0.1-0.2 mg/kg/h IV infusion for sedation | IV | PRN procedural; continuous for sedation post-RSI | Adjunct anxiolysis for procedural sedation; continuous sedation post-RSI in severe pediatric TBI per institutional ICU protocol |
| lorazepam | 0.1 mg/kg IV (max 4 mg per dose) | IV | q5 min × 2 max | First-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's | 20 mL/kg IV bolus over 30-60 min, repeat × 1-2 PRN with reassessment for fluid overload | IV | bolus PRN with reassessment | Maintain 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)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
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.
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)