Two very concerned parents bring their two-year old son into the Emergency Department after they heard a thud.
 

 
“I was watching him sitting on the couch while I was folding clothes. I turned around to put the laundry basket away, and the next thing I know, I hear a loud crash, and little Timmy is face-down on the hardwood floor crying,” said the father sheepishly.
 

 
“I rushed into the room when I heard the noise to find my husband rushing over to pick up Timmy, but I didn’t see the fall either,” added the mother. “Of course, by the time we get here, he isn’t crying any more. But will he be okay?”
 
From across the room, Timmy eyes you nervously, clinging to his mother. He seems to be moving all four extremities as he squirms trying to put more distance between himself and you.
 
Vitals:
T 38C temporally HR 145 RR 26 BP 84/42 O2 Sat 99% on RA
 
Physical Exam

 
CV: RRR, no m/g/r
Lungs: CTAB
Abd: soft, NTND, normo-acitve bowel wounds
MSK: no tenderness to distal extremities nor over clavicles, chest wall, or bony aspects of back
 
What elements of the exam do you want to focus on? For what are you specifically looking?
 
The HEENT exam and the Neurologic exam!
 
HEENT:

    No palpable skull fracture
    No battle signs
    No septal hematoma
    No hemotypanum
    No intra-oral trauma including injuries to the frenulum nor loose teeth

Neuro:

    Moving all four extremities including reaching out to grab your badge
    Per the parents acting at his baseline currently
    Eyes open spontaneously
    Appropriately interactive with his parents, shaking his head no when asked if he likes the doctor
    After some coaxing, Timmy states that he is, “This many” holding up two fingers to the question of how old he is.
 
 
Are there any decision support rules that can help guide your management of little Timmy?
 
The management of this patient should be guided by the PECARN algorithm. This validated, age-based decision-support algorithm is applied iteratively to pediatric patients after suffering head trauma who meet inclusion criteria.
 
Does PECARN definitively tell you who to image?
 
Yes and no: If a child less than two years of age with GCS of 14, has AMS per the patients, or has a palpable skull fracture, a CT head is recommended. Similarly, in pediatric patients ages two and up with GCS of 14, AMS, or signs of basilar skull fracture, imaging is recommended. In general, PECARN is used to support the decision NOT to image.
 
 
 
How long should you watch the child if you aren't going to image them?
 
Usually 4-6 hours
 
 
What changes would prompt you to re-evaluate the need for imaging?
 
Change in mental status
Vomiting
Worsening headache
Development of a scalp hematoma?
 

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