From: PREDICT GUIDELINE FOR CHILDREN WITH MILD TO MODERATE HEAD INJURIES (see www.predict.org.au) Version 1.

0 [150121]
Further details and footnotes are
Algorithm: Imaging & Observation Decision-Making for Children with Head Injuries important to interpretation of the
algorithm. Please see page 2.

Clinician assessment of child

presenting within 72 hours of head injury1,2 Does the child have these special conditions?
Possible abusive head trauma Neurodevelopmental disorders
Drug or alcohol intoxicated Ventricular shunt
< 6 months old Bleeding disorders
GCS ≤ 133 GCS 14-153 Please see page 2

Assess for risk factors for intracranial injury4 & initial observation
All children: Age < 2yrs: Age ≥ 2yrs:
GCS 14 or other signs of altered mental status5 Palpable skull fracture7 Signs of base of skull fracture10 ! If signs or symptoms deteriorate
Abnormal neurological examination Non-frontal scalp haematoma8 History of LOC9 during observation stop and
Severe mechanism of injury6 History of LOC9 ≥ 5 seconds History of vomiting11 request senior clinician review.
Post-traumatic seizure(s) Acting abnormally per parent Severe headache

Any risk factors: Recommended observation period is up to 4 hours post injury including 1 hour return to normal.12,13 No risk factors:
Clinician reassessment with deterioration, return to normal, or at 4 hours. No need for observation.

High risk Intermediate risk Low risk Very low risk

Alert senior clinician = imaging = consider imaging
Very close observation required Palpable skull fracture7 OR ≥ 2 Risk factors OR Not intermediate or high risk AND No risk factors
Signs of base of skull fracture10 OR Post-traumatic seizure(s) OR Improving signs and symptoms:
Worsening signs and symptoms OR Persistent severe headache or persistent GCS 15, acting normally, no current signs
Persistent GCS 14 OR vomiting > 4 hours post injury. of altered mental status, vomiting has
Persistent signs of altered mental status.5 stopped, severe headache resolved.

Head CT14 Senior clinician review to consider

need for observation vs head CT vs
Is the CT normal OR discharge.
Showing an isolated non-displaced skull
fracture AND
GCS 15?
Further observation
YES YES with serial reassessment12 NO
Senior clinician concerns?
Is there neurological deterioration OR
NO Patient has GCS 14 after 6 hours total
NO observation?
YES

Senior clinician review

If signs or symptoms stable:
consider (re)imaging or admission.
If signs or symptoms worsening:
(re)image and consult neurosurgery.

Consult neurosurgery and admit Discharge with advice if no other factors requiring admission13,15
 From: PREDICT GUIDELINE FOR CHILDREN WITH MILD TO MODERATE HEAD INJURIES (see www.predict.org.au) Version 1.0 [150121]

Further details to aid algorithm interpretation

1
Always consider possible cervical spine injuries and abusive head trauma in children presenting with head injuries.
2
Children with delayed initial presentation (24-72 hrs post head injury) and GCS 15 should be risk stratified the same way as children presenting within 24 hours. They do not need to be assessed with a further 4 hrs of observation.
3
Remember to use an age-appropriate Glasgow Coma Scale (GCS).
4
Risk factors adapted from Kuppermann N et al. Lancet 2009;374(9696):1160-70.
5
Other signs of altered mental status: agitation, drowsiness, repetitive questioning, slow response to verbal communication.
6
Severe mechanism of injury: motor vehicle accident with patient ejection or rollover, death of another passenger, pedestrian or cyclist without helmet struck by motor vehicle, falls of ≥ 1m (< 2 yrs), fall > 1.5m (≥ 2yrs), head struck by high impact object.
7
Palpable skull fracture: on palpation or possible on the basis of swelling or distortion of the scalp.
8
Non-frontal scalp haematoma: occipital, parietal, or temporal.
9
Loss of consciousness.
10
Signs of base of skull fracture: haemotympanum, ‘raccoon’ eyes, cerebrospinal fluid (CSF) otorrhoea or CSF rhinorrhoea, Battle’s signs.
11
Isolated vomiting, without any other risk factors, is an uncommon presentation of clinically important traumatic brain injury (ciTBI). Vomiting, regardless of the number or persistence of vomiting, in association with other risk factors, increases concern
for ciTBI.
12
Observation to occur in an optimal environment based on local resources. Frequency of observation to be ½ hourly for the first 2 hours, then 1-hourly until 4 hours post injury. After 4 hours, continue 2-hourly as long as the patient is in hospital.
Observation duration may be modified based on patient and family variables. These include time elapsed since injury/symptoms and ability of child/parent to follow advice on when to return to hospital.
13
Shared decision-making between families and clinicians should be considered.
14
Do not use plain X-rays, or ultrasound of the skull, prior to or in lieu of CT scan, to diagnose or risk stratify a head injury for possible intracranial injuries.
15
Other factors warranting hospital admission may include other injuries or clinician concerns e.g. persistent vomiting, drug or alcohol intoxication, social factors, underlying medical conditions, possible abusive head trauma.

Special Conditions

Possible abusive head trauma Bleeding disorders or anti-coagulant or anti-platelet therapy

Follow local screening tools for abusive head trauma (AHT). CT should be used as initial diagnostic Urgently seek advice from the treating haematology team around risk of bleeding and management of
tool to evaluate possible intracranial injury and other injuries relevant for the evaluation of AHT e.g. skull coagulopathy. Consider structured observation over immediate CT scan if there are no risk factors for
fractures. The extent of the assessment of a child with possible AHT should be co-ordinated with the intracranial injury. If there is a risk factor for intracranial injury a head CT should be performed. If there
involvement of an expert in the evaluation of non-accidental injury. is a deterioration in neurological status, perform urgent head CT scan.

Drug or alcohol intoxicated Coagulation factor deficiency

Treat as if the neurological findings are due to the head injury. Decision to CT scan or observe should be CT scan or decision to observe must not delay the urgent administration of replacement factor.
informed by risk factors for intracranial injury rather than the child being intoxicated.
Immune thrombocytopaenias (ITP)
< 6 months of age Check a platelet count in all patients and blood group in all symptomatic patients if not already
available. For ITP with platelet counts < 20 x 109 /L, consider empirical treatment after discussion
Consider at higher risk of intracranial injury with a lower threshold for observation or imaging. with the treating haematology team.
Discuss with a senior clinician.
On warfarin therapy or other newer anticoagulants (e.g. direct oral-anticoagulant)
Neurodevelopmental disorders or anti-platelet therapy
It is unclear whether these children have a different background risk for intracranial injury. As these Consider CT regardless of the presence or absence of risk factors for intracranial injury. Seek
children may be difficult to assess, consider structured observation or head CT scan and include senior clinician review to inform timing of the CT and discuss the patient with the team managing
the paediatric team that knows the child (parents, caregivers, and clinicians) in shared decision-making. the anticoagulation regarding early consideration of reversal agents. For children on anticoagulation
therapy, if available, check the appropriate anticoagulant measure (e.g. International normalised ratio).
Ventricular shunt (e.g. ventriculo-peritoneal shunt)
Consider structured observation over immediate CT scan if there are no risk factors of intracranial injury. Citation: Babl FE, Tavender E, Dalziel S. On behalf of the Guideline Working Group for the Paediatric
If there are local signs of shunt disconnection/shunt fracture (such as palpable disruption or swelling) or Research in Emergency Departments International Collaborative (PREDICT). Australian and New Zealand
signs of shunt malfunction, consider obtaining a shunt series based on consultation with a neurosurgical Guideline for Mild to Moderate Head injuries in Children – Algorithm (2021). PREDICT, Melbourne, Australia.
service.