Discharge Instructions - Pediatric Head Injury (PECARN Recommendations)

As discussed in the Emergency Department prior to discharge, based on the mechanism of injury and your child’s exam and applying the PECARN Pediatric Head Injury Prediction Rule, it was felt your child had a very low risk of clinically important traumatic brain injury (ciTBI).

The PECARN rule is based on the largest study to date aiming to develop a clinical decision rule to identify children with head injury who are at very low risk for having an injury to the brain that would require more significant treatment.  This is important because computed tomography (or CT) scans expose patients to radiation, which can increase the long-term risk of cancer.  This concern over exposure to radiation is especially important in young children.  The PECARN study involved over 40,000 children under the age of 18, and has been validated in subsequent 2 studies.

As discussed prior to discharge, when this rule was applied to your child they were noted to have a risk of clinically important traumatic brain injury (ciTBI) of [<0.02/0.9/##]%. Given this [very low risk] risk, PECARN recommended [not getting a CT at this time and observing the child for development of signs concerning for ciTBI/obtaining CT, which was ultimately without evidence of ciTBI].

Return to the Emergency Department immediately should your child develop confusion, appear more drowsy, lethargic, or difficult to arouse, vomiting (especially repetitive episodes or unprovoked episodes, as in those not occurring in the setting of feeding), difficulty walking in children who are old enough, or any new or concerning symptoms.

It is important to allow your child to rest.  It is not uncommon for children with minor head injuries to want to nap or sleep early than usual.  It is not necessary to try to keep your child awake.  It is reasonable to keep your children from particularly strenuous activities for 24-48 hours.  If your child participated in physical education (PE) classes or sports you should notify the school and/or coach, and your child should not return to these activities for at least 24 hours from the time of injury.  Your child should not return to PE class or sports until they are without symptoms with normal activity.  If your child is still experiencing headaches after 3 days, you should have them evaluated by their primary care provider.

https://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm
https://www.aliem.com/pecarn-pediatric-head-trauma-official-visual-decision-aid/

Discussion - PECARN

Discussed PECARN pediatric head trauma algorithm with the patient’s [mother/father/parents] to identify children with head injury at very low risk for clinically significant head injury.  Discussed that by applying this clinical decision rule, the patient has a risk of clinically important traumatic brain injury (ciTBI) of [<0.02/0.9/##]%.  Discussed risks and benefits of observation and CT studies with recommendation for [observation/CT of the head] at this time based on [very low/increased] risk of ciTBI.

Patient’s [mother/father/parents] demonstrated understanding of risks, benefits, and alternatives, and agreement with plan for [observation/CT] at this time.

https://www.mdcalc.com/pecarn-rule-low-risk-febrile-infants-29-60-days-old

MDM - Pediatric Head Injury

[##-year/month-old male/female] with head injury with history and exam consistent with [low/moderate] risk for clinically important traumatic brain injury (ciTBI) [additional/concussion].

Initial considerations in this patient included ciTBI including intracranial hemorrhages and contusions, moderate-to-severe TBI with elevated intracranial pressure (ICP), skull fracture including basilar skull fracture, and cervical spine and maxillofacial trauma among others.

Patient presented after [describe mechanism of injury] with reported head injury.  Fall was reported as [witnessed/unwitnessed] with [no] reported loss of consciousness (LOC) [describe].  Patient noted to have a normal neurologic exam in the ED [additional].  PECARN rule applied with a [###]% risk of clinically important TBI as noted above.  We discussed recommendations for [CT/observation] based on the patient’s PECARN score with the patient’s [mother/father/parents] who demonstrated understanding and agreement with plan.  Patient observed in the ED [for ## hours/up to ## hours from the time of injury] with no evidence of signs or symptoms suggestive of clinically important TBI.

Prior to discharge, we discussed return precautions, specifically for evidence of worsening TBI, observation period and symptomatic treatment, and follow up with primary care doctor within [2-3 days/1 week] for further evaluation, and the patient's [mother/father/parents] demonstrated understanding and agreement with this plan.

https://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm