Blunt head trauma in the pediatric patient is a common presentation to emergency departments. Clinical decision rules such as the PECARN rule (Lancet. 2009, PubMed ID: 19758692), CATCH rule (CMAJ 2010, PubMed ID: 20142371) and CHALICE rule (Arch Dis Child 2006, PubMed ID: 17056862) have identified predictor variables for traumatic brain injury on CT (TBI CT)  and clinically important traumatic brain injury (ciTBI). These rules have been validated  and are used to guide the decision for CT scanning in the pediatric patient, weighing the risks and benefits of radiation exposure in this sensitive population. However, The PECARN and CATCH decision rules and were derived in patients presenting within 24 hours of injury. The CHALICE rule did not exclude patient presenting after 24 hours from injury but did not analyze them separately. Predictors of TBI CT and ciTBI have not been identified in those presenting more than 24 hours after injury.

Clinical Question

In children less than 18 years old presenting to the ED more than 24 hours after head injury, do history and physical exam factors predict those with traumatic brain injury on CT scan and clinically important TBI when compared to patients presenting within 24 hours of head injury?


Observational: Prospective cohort


Inclusion: Children < 18 years with head injury of any severity

Exclusion: GCS <14, re-presentations to the ED for the same injury

Setting: 10 pediatric EDs (Australia, New Zealand: PREDICT research network)


Rule parameters from the PECARN, CATCH and CHALICE pediatric head trauma decision rules were assessed.

It is unclear if the parameter “acting normally as per parents” was assessed and suspected nonaccidental trauma was not included in PECARN


  • CT at MD discretion
  • Clinical follow-up for discharged patients
  • Hospital course for admitted patients

Traumatic Brain Injury on CT (TBI CT)

Intracranial hemorrhage or contusion, cerebral edema, traumatic infarction, diffuse axonal injury, shearing injury, sigmoid sinus thrombosis, signs of brain herniation, midline shift, diastasis of the skull, pneumocephalus, and depressed skull fracture.

Clinically Important Traumatic Brain Injury (ciTBI)

  • Death
  • Intubation for TBI >24 hours
  • TBI-related hospital admission for ³ 2 nights
  • Neurosurgery: ICP monitoring, craniotomy, hematoma evacuation, elevation of depressed skull fracture, dura repair, tissue debridement, and lobectomy)


  • Comparison: Prevalence of TBI CT and ciTBI (< 24 hrs vs > 24 hrs)
  • Predictors of TBI CT and ciTBI > 24 hrs
  • Test characteristics of statistically significant predictors


Primary Results


  • TBI CT: 37 patients (3.8%, 95% CI 2.6-5.0%
  • ciTBI: 8 (0.8%, 95% CI 0.4-1.6%)
  • Neurosurgical intervention: 2 patients (0.2%, 95% CI 0.0-0.5%)


  • TBI CT:
    • Non-frontal scalp hematoma: Odds Ratio 19.0, 95% CI (8.2, 43.9)
  • ciTBI:
    • Non-frontal scalp hematoma: Odds Ratio: 11.7, 95% CI (2.4, 58.6)
    • Suspected depressed skull fracture: Odds Ratio: 19.7, 95% CI (2.1, 182.1)


  • Multicenter: 10 Pediatric EDs in the PREDICT Network (Australia, New Zealand)
  • Similar definitions of TBI CT and ciTBI as in PECARN allows for comparison
  • ciTBI rate similar in PREDICT (< 24 hours): 0.8% (0.3, 1.4%), PREDICT (> 24 hours): 0.8%, 95% CI (0.7, 0.9%) and PECARN ciTBI rate of 9%, 95% CI (0.8, 1.0%).


  • Limited number of TBI CT and ciTBI precluded a regression analysis and analysis of age specific cohorts as in the PECARN Rule (< 2 years, ³ 2 years)
  • Lower study CT rates in the study may limit generalizability

Author's Conclusions

“Delayed presentation greater than 24 hours after head injury in children, although infrequent, may be significantly associated with traumatic brain injury. Factors associated with traumatic brain injury include suspicion for depressed skull fracture and non-frontal scalp hematoma. Treating clinicians should evaluate and manage delayed presentations outside of the current head injury clinical decision rule parameters because these rules have not been validated for this subset of patients.”

Our Conclusions

This is the first prospective study to attempt to characterize pediatric patients with delayed presentations to the emergency department following head trauma. Its generalizability is limited by the small number of patients with TBI CT and ciTBI which precluded the use of regression analysis and did not allow for the cohort to be divided into less than two years and greater than 2 years are PECARN decision rules.

Potential Impact To Current Practice

The impact of the identified predictors of TBI CT and ciTBI on neuroimaging decisions is unclear.  Those patients with a suspected depressed skull fracture would very likely have a head CT regardless of the study’s results. The predictive ability of a non-frontal scalp hematoma in patients older than 2 years is unclear. Only 1 of the 5 patients over 2 years of age with ciTBI had an isolated non-frontal scalp hematoma.

Read More

PEMCAR – Delayed Presentation of Pediatric Head Trauma – Annals EM 2019