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peds.head-injury-mtbi.v1PRODUCTION
peds.head-injury-mtbi.v1

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

pediatricsacutepediatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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).

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Age band + GCS + mechanism tagged; severity tier + PECARN rule applied; AHT or sports concussion flagged if applicable

Patient inputs (37)

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

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-based dosing for all fluids + analgesia + sedation + ICP-management drugs (hypertonic saline, mannitol); RSI drug dosing in severe TBI

Fever may indicate concurrent infection or hyperthermia in severe TBI; targeted temperature management considerations in severe TBI

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

PECARN < 2 yo high-risk if ≥ 5 sec; PECARN ≥ 2 yo high-risk if any duration; informs ciTBI risk + CT decision

PECARN component (informs AMS / GCS); duration > 24 h moves out of mTBI definition into moderate TBI (Lumba-Brown 2018 PMID 30193284)

PECARN high-risk feature in both age bands — agitation, somnolence, repetitive questioning, slow response to verbal communication (Kuppermann 2009 PMID 19758692)

PECARN ≥ 2 yo high-risk if any vomiting; persistent (≥ 3 episodes) → CT consideration even if isolated; rule out raised ICP

PECARN ≥ 2 yo high-risk feature — severe (worst-ever / unrelenting) headache → CT

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

PECARN < 2 yo high-risk if non-frontal (parietal / temporal / occipital); LR+ ~ 3-5 for ciTBI; size + boggy quality + age 3-12 mo intermediate

PECARN < 2 yo high-risk feature; very high LR+ ~ 15-25 for ciTBI; CT + neurosurgery consult

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

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

PECARN < 2 yo high-risk feature — parental report of behavior change is meaningful; lower threshold for CT in pre-verbal infants

AHT red flag — atypical mechanism / changing history / unexplained findings; lower threshold for AHT workup if infant + intracranial injury (Christian AAP 2009)

Bradycardia + hypertension = Cushing triad sign of raised ICP; tachycardia + hypotension may indicate concurrent hemorrhage or shock

AVOID HYPOTENSION in severe TBI (secondary injury); maintain age-appropriate MAP target; hypertension may indicate Cushing response to raised ICP

AVOID HYPOXIA in severe TBI (secondary injury); maintain SpO2 > 90% (target > 95% per BTF pediatric guidelines)

Respiratory pattern abnormalities (Cheyne-Stokes, ataxic breathing) indicate brainstem compromise; intubation if GCS ≤ 8 or inability to protect airway

High-risk feature; structural injury concern; CT + neurosurgery consult; cranial nerve palsy, hemiparesis, anisocoria, gaze palsy

Hypertension + bradycardia + irregular respiration → impending herniation; immediate hyperosmolar therapy + emergent neurosurgery + intubation

Pre-surgical type-and-screen if neurosurgery anticipated for severe TBI / structural injury

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 (CT or MRI) for severe TBI or high-mechanism injury; immobilize until cleared

Radiographic skeletal survey for occult fractures in suspected AHT (ribs, metaphyses, classical metaphyseal lesions); per AAP AHT protocol (Christian 2009)

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)

Pregnancy test mandatory in post-menarchal adolescent female with significant head injury / planned imaging; informs OB / MFM consult if applicable

AHT red flag — multiple unexplained injuries; skeletal survey indicated; LR+ ~ 8-15 for AHT in infant with intracranial injury (Christian AAP 2009)

Sports-related mechanism informs RTL/RTP planning; sport, position, helmet use, biomechanical force (Berlin 2017 + Amsterdam 2022)

Multiple prior concussions raises PCS + second-impact syndrome risk; informs RTP gradation + family counseling (AAP sports concussion 2018)

Rare in pediatrics but warfarin / DOAC / aspirin / other antiplatelet → significantly increases ICH risk; CT threshold lowered; reverse agent if indicated

Baseline if surgical / severe TBI; informs anemia + thrombocytopenia risk for bleeding diathesis or AHT workup

PT/INR/PTT baseline if severe TBI or AHT workup; reverse anticoagulant if applicable

Baseline electrolytes + sodium target for hyperosmolar therapy planning; AKI from rhabdo if multi-trauma

Mandatory before significant ionizing radiation imaging; informs OB / MFM consult if pregnant

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningsevere_head_injury_gcs_8_or_below
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsuspected_abusive_head_trauma
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepecarn_high_risk_under_2yo
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepecarn_high_risk_over_2yo
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereseizure_post_head_injury
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverevomiting_persistent_post_head_injury
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebasilar_skull_fracture_signs
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereimaging_negative_but_concerning_clinical_progression
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepost_concussion_syndrome_at_4_weeks
    Post-concussion syndrome (PCS) at 4 weeks post-mTBI — persistent symptoms (headache, dizziness, fatigue, cognitive complaints, mood symptoms); incidence ~ 10-30%; neurology referral + multidisciplinary rehab + cognitive rest + symptom-guided graded return (AAP/CDC mTBI 2018 PMID 30193284)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildsports_concussion_return_to_play_protocol
    Sports-related concussion (mTBI subtype) — IMMEDIATE removal from play + SCAT-6 sideline + serial assessment + cognitive + physical rest 24-48 h + graded RTL/RTP protocol (6 stages, min 24 h per stage, min 7 days total) + NO same-day return to play (Berlin 2017 + Amsterdam 2022 + AAP sports concussion 2018); medical clearance gating before stage 5
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Pediatric head injury ICP management + analgesia + antiemetic + RSI (BTF pediatric guidelines Kochanek 2019 + AAP/CDC mTBI 2018 PMID 30193284 + AAP pediatric sedation guidance)
axis: pediatric_head_injury_icp_analgesia_rsi
Selected axis "Pediatric head injury ICP management + analgesia + antiemetic + RSI (BTF pediatric guidelines Kochanek 2019 + AAP/CDC mTBI 2018 PMID 30193284 + AAP pediatric sedation guidance)" by default fallback (first axis)
  • acetaminophen
    first line
    analgesic_antipyretic
    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
    triggers: post_head_injury_headache_or_pain
    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)
    rxcui 161
  • ibuprofen
    add on
    NSAID
    5-10 mg/kg PO q6h PRN (max 40 mg/kg/day; max 800 mg/dose) • PO • q6h PRN
    triggers: structural_injury_excluded_after_24h_persistent_headache
    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)
    rxcui 5640
  • ondansetron
    first line
    serotonin_5HT3_antagonist_antiemetic
    0.15 mg/kg IV (max 4 mg per dose) q8h PRN • IV • q8h PRN
    triggers: post_head_injury_nausea_or_vomiting
    First-line pediatric antiemetic; minimal sedation (preferred so as not to obscure neuro exam); preferred over prochlorperazine / promethazine in peds
    rxcui 26225
  • hypertonic saline 3%
    first line
    hyperosmolar_therapy
    3-5 mL/kg IV over 15-30 min (max 250 mL); central line preferred for repeat doses • IV • PRN for raised ICP signs
    triggers: herniation_signs, sustained_icp_above_20, cushing_triad
    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
    rxcui 730781
  • mannitol
    first line
    hyperosmolar_therapy
    0.5-1 g/kg IV over 15-30 min (max 1 g/kg per dose) • IV • PRN for raised ICP signs
    triggers: herniation_signs, sustained_icp_above_20, cushing_triad, alternative_to_hypertonic_saline
    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
    rxcui 6628
  • ketamine
    first line
    dissociative_anesthetic_RSI
    RSI induction 1-2 mg/kg IV (procedural sedation 1-2 mg/kg IV by pediatric sedation team) • IV • single dose for RSI; procedural
    triggers: rsi_for_severe_tbi, procedural_sedation_for_imaging_in_young_child
    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
    rxcui 6130
  • rocuronium
    first line
    non_depolarizing_NMBD
    RSI 1.2 mg/kg IV • IV • single dose for RSI
    triggers: rsi_for_severe_tbi
    Preferred RSI paralytic in pediatric TBI — rapid onset + intermediate duration; sugammadex reversal available if needed; standard pediatric RSI per AAP / PALS
    rxcui 68139
  • fentanyl
    add on
    opioid_analgesic_anesthetic
    RSI 1-2 mcg/kg IV; analgesic 1 mcg/kg IV PRN q1-2h post-RSI • IV • single dose for RSI; PRN post-RSI
    triggers: rsi_for_severe_tbi, severe_pain_after_intubation
    Adjunctive opioid analgesic for RSI + post-intubation analgesia in severe pediatric TBI; rapid onset, short duration, hemodynamic stability
    rxcui 4337
  • midazolam
    add on
    benzodiazepine_sedation
    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
    triggers: adjunct_anxiolysis_for_procedural_sedation, sedation_post_rsi_for_severe_tbi
    Adjunct anxiolysis for procedural sedation; continuous sedation post-RSI in severe pediatric TBI per institutional ICU protocol
    rxcui 6960
  • lorazepam
    first line
    benzodiazepine
    0.1 mg/kg IV (max 4 mg per dose) • IV • q5 min × 2 max
    triggers: post_traumatic_seizure_active
    First-line benzodiazepine for post-traumatic seizure abortion per AES/NCS 2016 Glauser pediatric SE algorithm (routes to peds.status_epilepticus.v1)
    rxcui 6470
  • normal saline / lactated Ringer's
    first line
    crystalloid_isotonic
    20 mL/kg IV bolus over 30-60 min, repeat × 1-2 PRN with reassessment for fluid overload • IV • bolus PRN with reassessment
    triggers: hypovolemia_or_concurrent_shock
    Maintain age-appropriate MAP target; AVOID hypotension in severe TBI (secondary injury); pediatric-specific slower bolus rate vs adult
    rxcui 9863

outpatient playbook — drug actions (5)

  1. 1. PO analgesia transition + taper
    acetaminophen 10-15 mg/kg PO q4-6h PRN ± ibuprofen 5-10 mg/kg PO q6h PRN (after 24 h structural injury excluded) • PO • PRN
    trigger: Post-injury mild discomfort outpatient
    Standard pediatric multimodal analgesia; opioid-sparing approach
  2. 2. continue levetiracetam if started for severe TBI seizure prophylaxis × 7 d
    30-60 mg/kg/day PO divided BID • PO • BID
    trigger: Severe TBI seizure prophylaxis course
    BTF pediatric guidelines — 7-day course; tapered after seizure-free period; pediatric neurology directs
  3. 3. continue AED if developed post-traumatic epilepsy
    per pediatric neurology regimen • PO • per agent
    trigger: Post-traumatic epilepsy diagnosed
    Pediatric neurology directs long-term AED management
  4. 4. continue routine vaccines per ACIP
    per ACIP age-based schedule • IM or PO • per ACIP
    trigger: Routine well-child care
    AAP standard schedule; head injury history does not modify vaccination schedule
  5. 5. mental-health pharmacotherapy if mood symptoms persist (pediatric psychiatry directs)
    per pediatric psychiatry • PO • per agent
    trigger: PCS-associated depression / anxiety / SI in adolescent (routes to psych.suicidality.ed.core.v1 if acute SI)
    Multidisciplinary PCS management includes mental-health as needed (AAP/CDC mTBI 2018)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: 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 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Pediatric head injury / mild TBI / concussion (PECARN-stratified)** (peds.head-injury-mtbi.v1).
Phenotype framing: 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).
Scope: 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).

No severity triggers fired against current inputs.

Plan

Regimen axis: **Pediatric head injury ICP management + analgesia + antiemetic + RSI (BTF pediatric guidelines Kochanek 2019 + AAP/CDC mTBI 2018 PMID 30193284 + AAP pediatric sedation guidance)**.
1. 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 (analgesic_antipyretic, first line) — 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)
2. ibuprofen 5-10 mg/kg PO q6h PRN (max 40 mg/kg/day; max 800 mg/dose) PO q6h PRN (NSAID, add on) — 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)
3. ondansetron 0.15 mg/kg IV (max 4 mg per dose) q8h PRN IV q8h PRN (serotonin_5HT3_antagonist_antiemetic, first line) — First-line pediatric antiemetic; minimal sedation (preferred so as not to obscure neuro exam); preferred over prochlorperazine / promethazine in peds
4. 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 (hyperosmolar_therapy, first line) — 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
5. mannitol 0.5-1 g/kg IV over 15-30 min (max 1 g/kg per dose) IV PRN for raised ICP signs (hyperosmolar_therapy, first line) — 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
6. 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 (dissociative_anesthetic_RSI, first line) — 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
7. rocuronium RSI 1.2 mg/kg IV IV single dose for RSI (non_depolarizing_NMBD, first line) — Preferred RSI paralytic in pediatric TBI — rapid onset + intermediate duration; sugammadex reversal available if needed; standard pediatric RSI per AAP / PALS
8. 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 (opioid_analgesic_anesthetic, add on) — Adjunctive opioid analgesic for RSI + post-intubation analgesia in severe pediatric TBI; rapid onset, short duration, hemodynamic stability
9. 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 (benzodiazepine_sedation, add on) — Adjunct anxiolysis for procedural sedation; continuous sedation post-RSI in severe pediatric TBI per institutional ICU protocol
10. lorazepam 0.1 mg/kg IV (max 4 mg per dose) IV q5 min × 2 max (benzodiazepine, first line) — First-line benzodiazepine for post-traumatic seizure abortion per AES/NCS 2016 Glauser pediatric SE algorithm (routes to peds.status_epilepticus.v1)
11. 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 (crystalloid_isotonic, first line) — Maintain age-appropriate MAP target; AVOID hypotension in severe TBI (secondary injury); pediatric-specific slower bolus rate vs adult

Setting playbook (outpatient) — Post-discharge pediatric neurology / sports medicine / concussion clinic follow-up; graded RTL/RTP protocol for sports concussion (Berlin 2017 + Amsterdam 2022); PCS evaluation at 4 weeks with multidisciplinary rehab (PT / vestibular / cognitive / mental-health); school accommodations (504 plan / IEP); family education on long-term recovery + return precautions; AHT case management + foster / kinship coordination
12. PO analgesia transition + taper acetaminophen 10-15 mg/kg PO q4-6h PRN ± ibuprofen 5-10 mg/kg PO q6h PRN (after 24 h structural injury excluded) PO PRN — Post-injury mild discomfort outpatient (Standard pediatric multimodal analgesia; opioid-sparing approach)
13. continue levetiracetam if started for severe TBI seizure prophylaxis × 7 d 30-60 mg/kg/day PO divided BID PO BID — Severe TBI seizure prophylaxis course (BTF pediatric guidelines — 7-day course; tapered after seizure-free period; pediatric neurology directs)
14. continue AED if developed post-traumatic epilepsy per pediatric neurology regimen PO per agent — Post-traumatic epilepsy diagnosed (Pediatric neurology directs long-term AED management)
15. continue routine vaccines per ACIP per ACIP age-based schedule IM or PO per ACIP — Routine well-child care (AAP standard schedule; head injury history does not modify vaccination schedule)
16. mental-health pharmacotherapy if mood symptoms persist (pediatric psychiatry directs) per pediatric psychiatry PO per agent — PCS-associated depression / anxiety / SI in adolescent (routes to psych.suicidality.ed.core.v1 if acute SI) (Multidisciplinary PCS management includes mental-health as needed (AAP/CDC mTBI 2018))

Non-pharmacologic actions:
- Family education reinforcement on concussion precautions + return precautions
- Pediatric neurology / sports medicine / concussion clinic at 1-2 weeks post-discharge
- Graded RTL/RTP protocol with sport-specific application + medical clearance gating
- School accommodations (504 plan / IEP) coordination — gradual return-to-learn with sensory accommodations as needed
- PCS multidisciplinary rehab at 4 weeks if persistent symptoms — PT / vestibular / OT / cognitive rehab / mental health
- AHT case management + child protective services + foster / kinship placement coordination if applicable
- Family caregiver psychosocial check at follow-up
- Coach education + family-clinician-coach shared decision-making for sports RTP
- Patient + family resources — Brain Injury Association of America, Concussion Legacy Foundation, USA Hockey concussion guidance, etc.

AVOID / contraindication checks:
- AVOID hypotension in severe TBI — secondary injury (BTF pediatric guidelines Kochanek 2019)
- AVOID hypoxia in severe TBI — maintain SpO2 > 95% (BTF pediatric guidelines)
- AVOID hyperventilation in severe TBI — maintain normocapnia PCO2 35 40 mmHg (BTF pediatric guidelines)
- Hyperosmolar therapy only for herniation signs or sustained ICP > 20 (BTF pediatric guidelines)
- Hypertonic saline 3% requires central line preferred for repeat doses; serum sodium monitoring; target 145 155 (BTF pediatric guidelines)
- Mannitol risk of rebound increase in ICP with serum osmolarity > 320; replenish volume after diuresis (BTF pediatric guidelines)
- Ketamine preferred RSI agent in severe pediatric TBI — minimal hemodynamic impact + preserved airway reflexes (recent evidence; older ICP concerns refuted)
- AVOID NSAIDs first 24 h after head injury until structural injury excluded — platelet effect risks bleeding (AAP/CDC mTBI 2018)
- No routine antibiotic prophylaxis for basilar skull fracture (most guidelines advise against; Cochrane Review)
- No routine anti seizure prophylaxis for pediatric TBI (evidence weak in peds; consider for severe TBI per BTF)
- Remove from play IMMEDIATELY after sports concussion ("when in doubt, sit them out") (Berlin 2017 strong recommendation)
- NO same day return to play after sports concussion (Berlin 2017 strong recommendation)
- Graded RTP protocol minimum 24 h per stage, minimum 7 days total (Berlin 2017)
- Medical clearance prior to stage 5 (full contact practice) (Berlin 2017)
- Mandated reporting for suspected AHT (Christian AAP 2009 + state specific child welfare law)
- Multidisciplinary AHT evaluation — CAP + ophtho + skeletal survey + CT + social work + child protective services (Christian AAP 2009)
- Cervical spine immobilization until clinically cleared in severe TBI or high mechanism injury (BTF pediatric guidelines)
- Fluid bolus 20 mL/kg with reassessment for fluid overload (AAP pediatric resuscitation principles)

Monitoring

Regimen monitoring:
- serial pediatric GCS q15 min during ED; q1h post-admission for severe; q4h for moderate; q1h × 4 h for ED observation in mTBI
- continuous ECG + SpO2 + capnography during severe TBI workup
- arterial line if vasoactive or hyperosmolar therapy
- pupillary response + cranial nerve exam q15-60 min based on severity
- serum sodium + osmolarity if hypertonic saline or mannitol
- PECARN feature documentation at triage + reassessed after imaging
- concussion symptom diary for outpatient mTBI follow-up
- serial SCAT-6 in sports concussion follow-up
- family-bedside-instruction documentation on return precautions for worsening signs
- cervical-spine clearance documented before mobilization in high-mechanism injury

Setting (outpatient) monitoring:
- Pediatric neurology / sports medicine / concussion clinic follow-up at 1-2 weeks
- PCS evaluation at 4 weeks
- Serial SCAT-6 in sports concussion follow-up
- Symptom diary + recovery tracking
- School accommodations effectiveness monitoring
- Vaccination catch-up review at every well-child visit

Follow-up plan: 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.
- Close-out criterion: Follow-up scheduled + return precautions delivered + RTP/RTL protocol initiated + AHT case-management arranged

Monitoring phase: 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.

Disposition

Current setting: outpatient — Post-discharge pediatric neurology / sports medicine / concussion clinic follow-up; graded RTL/RTP protocol for sports concussion (Berlin 2017 + Amsterdam 2022); PCS evaluation at 4 weeks with multidisciplinary rehab (PT / vestibular / cognitive / mental-health); school accommodations (504 plan / IEP); family education on long-term recovery + return precautions; AHT case management + foster / kinship coordination

Disposition criteria:
- Sustained recovery — return to baseline + no recurrent episodes + completed RTP/RTL protocol + family demonstrating return-precaution knowledge + ongoing well-child care; AHT case-management arrangements settled + child welfare stable if applicable

Escalation triggers (move to higher acuity):
- 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

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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] 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
- [SEVERE] 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

Citations

- 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) [PMID:19758692](https://pubmed.ncbi.nlm.nih.gov/19758692/)
- Cited evidence (PMID 30193284) [PMID:30193284](https://pubmed.ncbi.nlm.nih.gov/30193284/)
- Cited evidence (PMID 26900382) [PMID:26900382](https://pubmed.ncbi.nlm.nih.gov/26900382/)
- Cited evidence (PMID 22335736) [PMID:22335736](https://pubmed.ncbi.nlm.nih.gov/22335736/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 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) — PMID:19758692
  • Cited evidence (PMID 30193284) — PMID:30193284
  • Cited evidence (PMID 26900382) — PMID:26900382
  • Cited evidence (PMID 22335736) — PMID:22335736