Head Injury Pathway: Under 16 Years

1. Initial ED Assessment

For any child under 16 presenting with head injury:

•  Perform ABCDE assessment
•  Record: 
  • GCS / paediatric GCS
  •  Mechanism of injury 
  •  Vomiting episodes 
  •  Seizure activity 
  •  Drowsiness 
  •  Focal neurology 
  •  Signs of skull fracture 
  •  Safeguarding concerns / possible non-accidental injury 
  •  Anticoagulant or antiplatelet use 
•  Assess for associated cervical spine injury if indicated 

2. Immediate CT Head Within 1 Hour

Arrange CT head within 1 hour if any one of the following is present:

• Suspicion of non-accidental injury
• Post-traumatic seizure with no history of epilepsy
• GCS <14 on initial ED assessment 
  •  or GCS <15 if under 1 year
• GCS <15 at 2 hours after injury
• Suspected open or depressed skull fracture
• Tense fontanelle
• Any sign of basal skull fracture
  •  haemotympanum 
  •  panda eyes 
  •  CSF leak from nose or ear 
  •  Battle’s sign 
• Focal neurological deficit
• For children under 1 year: bruise, swelling, or laceration >5 cm on the head

Also ensure a provisional written radiology report is available within 1 hour of the scan. 

3. Intermediate-Risk Group: Observe for at Least 4 Hours

If none of the immediate CT criteria above are present, check for the following secondary risk factors:

• Loss of consciousness >5 minutes (witnessed) 
• Any bleeding or clotting disorder
  •  including liver failure, haemophilia 
  •  anticoagulants or antiplatelets 
• Abnormal drowsiness
• 3 or more discrete episodes of vomiting
• Dangerous mechanism of injury
  •  high-speed road traffic collision as pedestrian, cyclist, or occupant 
  •  fall from >3 metres
  •  high-speed projectile or object injury 
• Amnesia >5 minutes
  •  antegrade or retrograde 
  •  note: often not assessable in preverbal children or many children under 5 

What to do:

•  If only 1 factor is present: 
  • Observe for at least 4 hours after the head injury
• During observation, if any of the following develop:
  • GCS <15
  • further vomiting
  • further episodes of abnormal drowsiness
• → CT head within 1 hour
•  If more than 1 factor is present: 
  • Consider CT head within 8 hours of injury
  •  or within 1 hour if the child presents more than 8 hours after injury

Again, the scan should have a provisional written radiology report within 1 hour. 

4. Anticoagulants / Antiplatelets

Ask specifically whether the child is taking:

• Warfarin
• DOACs
• Antiplatelets
  • excluding aspirin monotherapy

This places the child within a bleeding/clotting disorder risk group and may move them into the observation or CT pathway, depending on the full clinical picture. 

5. When CT Is Not Needed

If the child has:

• No immediate CT criteria
• No more than one minor/intermediate risk factor
•  Remains clinically well 
•  No deterioration during the observation period 

Then:

• CT head is not needed
•  Use clinical judgement to decide: 
  •  discharge 
  •  longer ED observation 
  •  paediatric review 
  •  safeguarding escalation if needed 

Practical Flow Version

Under-16 Head Injury ED Flowchart

Step 1 – Does the child meet any high-risk criteria?

If yes → CT head within 1 hour

High-risk criteria:

•  NAI suspected 
•  Post-traumatic seizure 
•  GCS <14 
  •  or <15 if under 1 year 
•  GCS <15 at 2 hours 
•  Open/depressed skull fracture 
•  Tense fontanelle 
•  Basal skull fracture signs 
•  Focal neurology 
•  Under 1 year with scalp bruise/swelling/laceration >5 cm 

Step 2 – If no high-risk criteria, are there intermediate-risk factors?

Intermediate-risk factors:

•  LOC >5 min 
•  Bleeding/clotting disorder or anticoagulants/antiplatelets 
•  Abnormal drowsiness 
•  ≥3 vomits 
•  Dangerous mechanism 
•  Amnesia >5 min 

If 1 factor

→ Observe for at least 4 hours

During observation, if:

•  GCS drops below 15 
•  further vomiting occurs 
•  further abnormal drowsiness develops 

→ CT head within 1 hour

If more than 1 factor

→ Consider CT head within 8 hours of injury
→ or within 1 hour if presenting after 8 hours

Step 3 – If no risk factors

→ No CT required
→ discharge or continue observation based on clinical judgement

Suggested ED Poster Wording

 Under 16 Head Injury CT Pathway

CT within 1 hour if any major risk factor
Observe 4 hours if one intermediate factor
Consider CT within 8 hours if more than one intermediate factor
CT not required if no risk factors and clinically well 

If you would like, I can turn this into a one-page hospital poster layout or a boxed flowchart for printing and lamination in the ED.