Who the rule applies to
PECARN is for minor blunt head trauma within the past 24 hours in a child with a Glasgow Coma Scale (GCS) score of 14 or 15. It does not apply in several situations, each of which needs a different approach.
- GCS 13 or lower, penetrating injury, a focal neurologic deficit or a seizure since the injury: treat as moderate to severe head injury with CT now and neurosurgery
- Bleeding disorder, anticoagulant use, a VP shunt or a brain tumor: low threshold for CT, and treat the bleeding risk first
- An injury story that does not fit, or suspected abuse: image and evaluate for abuse
Children under 2 years
High-risk findings in children under 2 are GCS 14, other signs of altered mental status (agitation, sleepiness, repetitive questions, slow responses) and a palpable skull fracture. Any one of these means a CT is recommended; the risk of a clinically important brain injury is about 4.4%.
If there is no high-risk finding, look for intermediate-risk findings: a scalp hematoma that is occipital, parietal or temporal, loss of consciousness for 5 seconds or longer, a severe mechanism, or a child who is not acting normally according to the parent.
Children 2 years and older
High-risk findings at 2 years and older are GCS 14, other signs of altered mental status, and signs of a basilar skull fracture: hemotympanum, raccoon eyes, Battle sign, or CSF leaking from the nose or ear. Any one means a CT is recommended; the risk is about 4.3%.
Intermediate-risk findings in this age group are any loss of consciousness, vomiting, a severe mechanism, or a severe headache.
What counts as a severe mechanism
A severe mechanism is a car crash with ejection, rollover or death of another passenger; a pedestrian or unhelmeted cyclist hit by a motor vehicle; the head struck by a high-impact object; or a fall of more than 3 ft (0.9 m) under age 2, or more than 5 ft (1.5 m) at age 2 or older.
CT, observation or no CT
The decision follows from the findings present.
| Findings | Recommendation | Risk of clinically important brain injury |
|---|---|---|
| Any high-risk finding, under 2 | CT head | About 4.4% |
| Any high-risk finding, 2 or older | CT head | About 4.3% |
| One isolated intermediate finding | Observe until 4 to 6 h after the injury, rather than CT | About 0.9% |
| Several intermediate findings, worsening symptoms, or age under 3 months | Favor CT, or extended observation with a low threshold for CT | Higher than an isolated finding |
| No findings, under 2 | No CT needed | Below 0.02% |
| No findings, 2 or older | No CT needed | Below 0.05% |
- During observation, repeat neurologic checks and get a CT if symptoms worsen or new findings appear
- Make the observation-versus-CT choice together with the family
- When a CT is done, use a non-contrast CT head, and involve neurosurgery for bleeding or a depressed fracture
Symptom relief and discharge advice
Ondansetron 0.15 mg/kg once (maximum 4 mg) can be given for vomiting at 6 months or older, and acetaminophen 15 mg/kg every 6 hours (maximum 1 g) for pain. Ibuprofen 10 mg/kg every 6 to 8 hours (maximum 600 mg) is used once intracranial bleeding is excluded or the risk is very low.
Families should watch the child for 24 hours and return at once for a worsening headache, repeated vomiting, sleepiness that makes the child hard to wake, confusion, a seizure or weakness. After a concussion, 24 to 48 hours of relative rest is followed by a gradual return to school and activity, with no contact sport until symptom-free and cleared. Follow up with primary care in 2 to 3 days if symptoms persist.
Use the free tool
PECARN CT decision for GCS 14–15, plus severe injury and bleeding-disorder branches.
Open Head Trauma →Common questions
Does every child with a head injury need a CT?
No. Under PECARN, a child with GCS 15 and none of the high-risk or intermediate-risk findings is at very low risk (below 0.02% under age 2, below 0.05% at 2 or older) and does not need a CT.
How long should a child be observed instead of having a CT?
With one isolated intermediate-risk finding, the tool suggests observation with repeated neurologic checks until 4 to 6 hours after the injury, and a CT if symptoms worsen.
Can PECARN be used for a child on anticoagulants or with a shunt?
No. Bleeding disorders, anticoagulants, VP shunts and brain tumors are excluded. These children need a low threshold for CT and management of the bleeding risk.
Does vomiting alone mean a CT is needed?
In children 2 and older, vomiting is an intermediate-risk finding. As a single isolated finding, observation is usually chosen over CT.
Sources
Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009;374:1160-1170.; Lumba-Brown A, et al. CDC guideline on pediatric mild traumatic brain injury. JAMA Pediatr 2018.; Kochanek PM, et al. Guidelines for the management of pediatric severe traumatic brain injury, 3rd ed. Pediatr Crit Care Med 2019.
For education only, not medical advice. Always confirm against current guidelines and your local protocols. Pedemy is independent and not affiliated with or endorsed by the organizations cited.