Minor head trauma in the pediatric emergency department: decision making nodes

BACKGROUND: Minor head trauma is one of the leading causes of accessing pediatric emergency departments; however, only a limited number of patients develops clinically relevant brain injuries. OBJECTIVES: The aim of this review is to provide physicians a clinical pathway for managing pediatric minor head trauma. METHODS: A Pubmed/Medline search was conducted through the following entries: "minor head trauma", "mild head trauma", "minor head injury", "mild head injury" or "acute head trauma". All the studies including pediatric samples between 2000 and 2015 were considered for a critical review. A few articles written before 2000 were analyzed for their relevance. RESULTS: The Pediatric Emergency Care Applied Research Network (PECARN) algorithm identified children with a very low risk for clinically relevant brain injuries (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, no severe headache, no evident clinical worsening over time and no multiple symptoms) and offered the only validated clinical prediction rule to select candidates for CT scans. Other proposed clinical prediction rules (including NEXUS II, CHALICE and CATCH), that were not validated, have a lower sensitivity than PECARN algorithm. Skull X-ray, cerebral magnetic resonance and cranial ultrasonography could provide useful information in selected cases. CONCLUSIONS: The critical use of PECARN rule represents the best validated clinical tool for the early identification of children with a clinically relevant brain injury. Its application should be integrated with physician experience and judgement, parental compliance and clinical observation.