Management of Minor Head Trauma in a 5-Year-Old with Normal CT Scan

Clinical Context

PECARN Decision Framework (for context / future reference)

EMERGENCY DEPARTMENT / INITIAL MANAGEMENT

1. Immediate Assessment

• GCS (should be 15 in a child with normal CT and no ongoing deficit)
• Neurological exam: pupils, focal deficits, cerebellar signs
• Scalp inspection: lacerations, hematoma size/location
• Rule out non-accidental injury (NAI): ensure mechanism matches developmental stage; look for bruising outside typical accident distribution

2. Observation Period in ED

• Minimum 4–6 hours of observation recommended after any head injury in a child
• Monitor: GCS every 30 min, pupillary response, vomiting, behavior
• If the child remains GCS 15, neurologically intact, tolerating fluids → eligible for discharge

3. Criteria to ADMIT (do NOT discharge if any present)

OPD PRESCRIPTION / DISCHARGE PLAN

Medications

Note: Do NOT prescribe opioids, sedatives, or antiemetics (metoclopramide) routinely — they mask neurological deterioration. Avoid aspirin in children.

Symptomatic Management

• Headache: Paracetamol ± Ibuprofen as above
• Nausea/vomiting (if present): Ondansetron 0.15 mg/kg oral (max 4 mg) — single dose only if needed; reassess if vomiting is persistent
• Sleep: Normal sleep is safe and should not be withheld; parents should do a brief check at 4–6 hours after the child falls asleep (not every 15 minutes — this is outdated advice)

DISCHARGE INSTRUCTIONS FOR PARENTS

Return to ED IMMEDIATELY if child develops:

• Difficulty waking or cannot be roused
• Repeated vomiting (3 or more times)
• Seizure (any convulsive activity)
• Worsening or severe headache not relieved by paracetamol
• Unusual behavior, confusion, or agitation
• Weakness, numbness, or difficulty walking
• Unequal pupils or blurred/double vision
• Clear fluid from nose or ear

Activity Restrictions (Return-to-Learn / Return-to-Play Protocol)

Do NOT rush return to contact sport. Each stage requires minimum 24 hours symptom-free before progressing.

OPD FOLLOW-UP SCHEDULE

POST-CONCUSSION SYNDROME (Watch For)

• Persistent headache
• Poor concentration or school performance drop
• Sleep disturbance, irritability, mood changes
• → Refer to pediatric neurology or concussion clinic

KEY TEACHING POINTS

1. Normal CT does NOT rule out concussion — CT is normal by definition in concussion; it only rules out structural injury (bleed, fracture)
2. Children (≥2 yrs) with normal CT and GCS 14–15 can be safely discharged with strict return precautions (Mulholland & Greenfield's Surgery 7e, p. 1439)
3. Cognitive and physical rest in the first 24–48 hours, then graduated return
4. NAI must always be considered — ensure mechanism is consistent with the child's developmental stage (Bailey & Love's Surgery 28e, p. 391)
5. Do NOT wake child every hour at night — this is outdated; a single check at 4–6 hrs post-sleep is sufficient

5-Year-Old, Head Trauma >48 Hours, Normal CT — OPD Visit

CLINICAL CONTEXT AT THIS VISIT

1. Confirming there are no red-flag neurological signs
2. Treating ongoing concussion symptoms (headache, nausea, dizziness, fatigue, irritability)
3. Screening for persistent post-concussion symptoms (1 in 3 children will have symptoms beyond 4 weeks)
4. Guiding a safe graduated return to school and play
5. Counselling parents clearly about concussion and post-concussion syndrome

OPD PRESCRIPTION

━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
  OPD PRESCRIPTION
  Age: 5 years | Weight: ~18–20 kg (approx)
  Diagnosis: Post-Concussion State (S09.90)
  Day post-injury: >48 hours | CT Head: Normal
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━

Rx — Symptomatic (give only for active symptoms, not on a fixed schedule)

Do NOT prescribe: Opioids, benzodiazepines, antihistamines for sedation, or NSAIDs beyond 5 days. Ibuprofen overuse warning: If headache is occurring daily, stop ibuprofen after day 5 — analgesic overuse (>10 days/month) can perpetuate post-concussion headache.

Advice written on prescription

• Physical rest: Light activity only. No running, jumping, contact play, PE class until symptom-free
• Cognitive rest: Limit screen time to <1 hr/day; no homework if causing headache
• School: May return in 3–5 days if symptom-free; start with half-days
• Review: Return OPD in 7–10 days, or sooner if symptoms worsen

HOW TO EXPLAIN CONCUSSION TO PARENTS

What to say (plain language script you can use in clinic):

"Your child's brain is like a bowl of jelly inside a hard shell. When the head gets a hard knock, the jelly inside shakes and wobbles — even if the shell (skull) is not cracked and even if the X-ray or scan looks perfectly normal. This shaking temporarily disrupts the chemical signals in the brain — we call this a concussion. It is not a structural injury. Nothing is torn or bleeding. But the brain cells are temporarily working in a disturbed way and need time and rest to recover — exactly like a sprained ankle needs rest before you walk on it again."

Key points to reinforce:

HOW TO EXPLAIN POST-CONCUSSION SYNDROME (PCS)

When to bring it up

• Symptoms already present for 2+ days
• ~1 in 3 children develop persistent symptoms beyond 4 weeks (Tintinalli's Emergency Medicine, Ch. 111)
• Early counselling prevents catastrophising and reduces anxiety-driven symptom amplification

Plain language explanation for parents:

"Most children fully recover within 2 to 4 weeks. However, in about 1 out of every 3 children, some symptoms like headaches, difficulty concentrating, tiredness, or mood changes continue for longer than a month. When that happens, we call it Post-Concussion Syndrome. It does NOT mean the brain is permanently damaged. It means the recovery is taking longer than usual. Think of it like a bad sprain that takes longer to heal in some people — the injury itself wasn't worse, the healing is just slower. We manage it the same way — with graded rest, gradual return, and targeted treatment for each symptom. With proper care, almost all children make a full recovery."

Symptoms of PCS to watch for (give this list to parents):

• Persistent or daily headache
• Dizziness, feeling off-balance
• Nausea, light-headedness
• Sensitivity to light or noise

• Poor concentration, "foggy" feeling
• Forgetting things easily
• Difficulty following instructions
• Drop in school performance

• Irritability, crying easily
• Anxiety, clinginess
• Low mood, withdrawn
• More emotional than usual

• Sleeping too much or too little
• Trouble falling asleep

Risk factors for prolonged recovery — warn parents if present:

• Previous concussions
• Pre-existing anxiety, ADHD, or learning difficulties
• Migraine history
• High symptom burden in first 24–48 hours
• Female gender (slightly higher risk)
• Returned to sport before symptoms fully cleared

FOLLOW-UP PLAN

⚠ SECOND IMPACT SYNDROME — WARN PARENTS

"Your child must NOT return to any contact sports or rough play until he/she is completely symptom-free. If the brain receives a second injury before it has healed, a rare but dangerous condition called Second Impact Syndrome can occur, causing severe brain swelling. It has a 50% mortality rate. We will only clear your child for full sport after a stepwise return programme is completed."