Head Trauma: Intervention Bundle

More than 30% of children evaluated in the ED for head trauma undergo CT imaging.[8] CT is widely available, fast, and remains the standard tool for identifying acute traumatic brain injury (TBI), including skull fractures and intracranial hemorrhage. However, only a small percentage of children actually have an injury on imaging, and an even smaller fraction requires clinically important interventions such as neurosurgery or intubation.^[9,10]

To guide decision-making, clinicians use risk stratification tools such as the commonly used PECARN Pediatric Head Trauma Algorithm to help identify children at risk for clinically important TBI (ciTBI).^[9,10] ciTBI refers to clinically actionable outcomes of head injury, which are defined as the need for neurosurgery, intubation, prolonged hospitalizat,ion or mortality from TBI. The PECARN algorithm supports 3 care pathways: immediate CT imaging for children who meet high-risk criteria, a period of observation (typically 4-6 hours from the time of injury) in lieu of CT for those at moderate risk, and discharge home without imaging for children classified as very low risk. Identifying which children are truly at risk allows ED teams to avoid unnecessary imaging while ensuring high-risk children are promptly diagnosed and treated.

Balancing Risks: Radiation Exposure versus Missed Injury:

While CT is essential in many cases, it exposes children to ionizing radiation, which carries a small but measurable lifetime risk of future cancer, a risk that accumulates with each scan.^[11] Therefore, clinicians must carefully balance the risk of missing a clinically important injury with the risk of exposing a child to unnecessary radiation.

Opportunities for Improvement in ED Care:

Nationally, children with head trauma are still imaged frequently, even when the risk is very low. Contributing factors include variability in clinical practice, limited access to pediatric-specific CT protocols, the availability of standardized practices in the care of children with head trauma, and inconsistent communication between transferring and receiving facilities.

Head trauma in children spans a wide range of clinical severity. Recognizing these categories helps guide assessment, imaging decisions, and early management:

Mild Head Trauma (Glasgow Coma Scale (GCS) score of 14-15):

Most children with head injury fall into this category. They may have symptoms such as headache, vomiting, brief confusion, dizziness, or changes in behavior, but typically maintain normal or near-normal mental status. The majority have no injury on imaging, and many can be safely managed with observation and discharge instructions.

Moderate TBI (GCS 9-13):

These children show more noticeable neurologic impairment and are at higher risk for intracranial injury or clinical deterioration. They usually require closer observation, a lower threshold for imaging, and possible transfer depending on available resources and their clinical course.

Severe TBI (GCS ≤8):

These injuries are life-threatening and require immediate stabilization, airway support, neurosurgical evaluation, and rapid imaging. Children in this category have a high risk of ciTBI and may need transfer to a trauma center.

A concussion is a form of mild head trauma in which the child experiences a transient alteration in brain function without the structural abnormalities seen on CT. Key points for ED teams include:

• Concussion symptoms may be subtle in young children (e.g., irritability, vomiting, poor feeding, lethargy), and common symptoms in older children include headache, dizziness, nausea, light/noise sensitivity, difficulty concentrating, and sleep disruption. Loss of consciousness is not required for a concussion diagnosis.
• Imaging is not indicated for concussion unless the child meets PECARN or other criteria that raise concern for ciTBI.
• Discharge instructions should emphasize: Return precautions for worsening symptoms, 24-48 hours of avoidance of screentime, gradual return to school and activities, avoidance of sports until cleared by a healthcare professional, and follow-up with a primary care provider or concussion specialist.

Because mild head trauma and concussion are so common, consistent assessment, clear documentation, and caregiver education are important

For teams that select to work on an intervention specific to head trauma for their quality improvement project, they will select one or more quality measures to work on. The following measures are included within the National Pediatric Readiness Quality Initiative (NPRQI), where you will enter select data. Please see here to learn more about the quality measure development.

The quality measures related to head trauma are:

• Percentage of pediatric patients with a full set of vital signs obtained.
• Percentage of pediatric patients with a Glasgow Coma Scale reassessment.
• Percentage of pediatric patients with a head CT that met one or more of the PECARN criteria.
• Percentage of pediatric patients who received hypotonic saline.

Gathering data when implementing changes to your system is important. Data collection allows you to measure how your implementation is going and if your changes are moving towards your process measure goal. Data and measurement can help you give insight on how the changes are being accepted or not accepted into your system.

There are a variety of ways to assess how your implementation is going.  Some include:

• Conducting chart audits to assess adherence to vital signs, GCS, and PECARN algorithm documentation.
• Can be conducted in real-time or retrospectively; may be automatically set up in a report to capture pediatric patients with head trauma.
• Can be all charts or a representative sample of charts selected for surveillance using a random or systematic sampling approach (e.g., every 5th pediatric patient over 10 years old, or all pediatric patients evaluated over a given time period).
• Gathering feedback from staff on confidence and comfort with pediatric GCS, PECARN, and TBI best practices.
• Consider surveying staff experience and satisfaction with the implementation to better learn from your intervention strategies.
• Create a brief survey for families for any of the process measures above.

In order to include patients in your head trauma dashboard, please check “Head Trauma” for the clinical bundle question in your encounter form. The head trauma bundle should include all children with head injury, including minor injuries (e.g. a fall). Below is a list of mechanisms that could be included in your head trauma bundle.

• Fall to ground from standing, walking, or running, fall from a height, fall down stairs
• Walked or ran into a stationary object
• Sport-related head injury
• Head struck by an object (unintentional or as assault)
• Pedestrian or bicycle rider struck by a vehicle
• Bicycle collision or fall
• Occupant in motor vehicle crash
• Other wheeled transport crash
• Other mechanisms that result in head injury

Below you will find suggested possible interventions, also called change strategies, for the process measure. These are suggestions on different steps that may assist your team in accomplishing the aim you are focusing on. Interventions or change strategies are often grouped into “Guidelines/Protocols, Education, Electronic Medical Records Optimization, and Resources (inclusive of personnel and equipment)”.

As the local expert, you may have other ideas regarding how to best implement change in your hospital or ED. You should always feel free to reach out to your team leader and/or brainstorm these ideas with the other ED team leaders or participants working on similar aims in this collaborative.

Quality Measure: Percentage of pediatric patients with a full set of vital signs obtained

WRITTEN POLICY/PROCEDURE

Change Strategies

• Written procedure/guideline should include vital sign norms for children (i.e., American Heart Association Pediatric Advanced Life Support (PALS), Pediatric Early Warning Score (PEWS), Emergency Severity Index (ESI))
• Conduct a GCS assessment
• Select a site-specific threshold for abnormal vitals

NOTIFICATION PROTOCOL

Change Strategies

• Establish criteria for activating the notification protocol
• Establish a protocol for addressing abnormal vital signs
• Key areas of focus: Which members of the care team should be contacted, Method of contact, Frequency of reassessments
• Establish a communication method to make the care team aware of abnormal vital signs
• Implement a visual alert system for high-risk patients
• Develop a recommended course of action when vital signs are out of range (e.g., initiate evidence-based guidelines, pathways, or protocols).
• Adopt a validated triage tool
• Implement standing physician orders in triage

EMR OPTIMIZATION

Change Strategies

• EMR alerts the care team when a vital sign is out of range.
• Integrate a clinical decision support tool that evaluates a combination of factors.

EDUCATION

Change Strategies

• Develop a training/educational program for the care team
• Identify training delivery modality (e.g., online, in-person staff meetings, peer-to-peer)
• Tabletop exercises
• Simulation

KNOWLEDGE REINFORCEMENT FOR CARE TEAM

Change Strategies

• Tabletop exercise to recognize patients with abnormal vital signs
• Posters in the triage area with normal vital ranges
• Posters with a scoring tool for abnormal vital signs
• Pocket cards/badge cards for the care team with normal vital ranges
• Direct feedback to the care team following chart audits.

Quality Measure: Percentage of pediatric patients with a Glasgow Coma Scale reassessment

WRITTEN POLICY/PROCEDURE

Change Strategies

• Adopt the validated GCS scale
• Conduct GCS assessment at triage or with initial vitals
• Establish a triage protocol for addressing head trauma
• Identify the timeframe/frequency of GCS re-assessment

NOTIFICATION PROTOCOL

Change Strategies

• Establish criteria for activating the notification protocol
• Consider using a designation on the ED tracking board
• Establish a communication method to make the care team aware of the need for GCS reassessment
• Key areas of focus: Which members of the care team should be contacted, Method of contact, Frequency of reassessments
• Develop a recommended course of action when head trauma occurs, such as a written guideline pathway or protocol.
• Implement standing physician orders in triage if allowable
• Improving communication during transfer (sending and receiving facilities) to ensure timely sharing of imaging findings, neurologic changes, and treatment provided.
  

EHR OPTIMIZATION

Change Strategies

• EMR alerts the care team when a GCS score is XX
• EMR alert for GCS reassessment at a certain time interval, and/or with discharge vitals

EDUCATION

Change Strategies

• Develop a training/educational program for the care team. Learning objectives should include:
  • Education on GCS scoring, developmental considerations, and reassessment timing.
• Identify training delivery modality (e.g., online, in-person staff meetings, peer-to-peer, tabletop exercises, simulation) consistent with other successful training modalities in your ED

KNOWLEDGE REINFORCEMENT FOR THE CARE TEAM

Change Strategies

• Reminders during shift change huddles
• Posters in triage and exam rooms with child-appropriate GCS scales
• Pocket cards/badge cards for care team with xxx
• Direct feedback to the care team following chart audits

Quality Measure: Percentage of pediatric patients with a head CT that met one or more of the PECARN criteria

WRITTEN POLICY/PROCEDURE

Change Strategies

• Applying the PECARN Head CT decision rules to guide imaging decisions and reduce unnecessary radiation exposure.
  

EMR OPTIMIZATION

Change Strategies

• Incorporate the PECARN criteria as a decision support tool

EDUCATION

Change Strategies

• Develop a training/educational program for the care team. Learning objectives should include:
• Education on PECARN Criteria
  • Identify training delivery modality (e.g., online, in-person staff meetings, peer-to-peer, tabletop exercises, simulation) consistent with other successful training modalities in your ED
  • Education resources for parents - Ensuring parents/caregivers receive clear explanations of CT indications, risks, and alternatives.

KNOWLEDGE REINFORCEMENT FOR THE CARE TEAM

Change Strategies

• Reminders during shift change huddles
• Pocket cards/badge cards for care team with xxx
• Direct feedback to the care team following chart audits
• PECARN Criteria Poster/ Pediatric imaging poster for pediatric trauma in resuscitation bays and dictation areas

References​​

1. ​​​Faul M, Xu L, Wald MM, Coronado VG. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002–2006. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Published online 2010.
2. .Title : Report to Congress : the management of traumatic brain injury in childrenPersonal Author(s) : Haarbauer-Krupa, Juliet K.;Glang, Ann;Kurowski, Brad;Breiding, Matthew J.; Corporate Authors(s) : National Center for Injury Prevention and Control (U.S.). Division of Unintentional Injury Prevention.;Centers for Disease Control and Prevention (U.S.); Published Date : 2018 Pages in Document : 89 numbered pagesURL : https://stacks.cdc.gov/view/cdc/51852
3. .https://pmc.ncbi.nlm.nih.gov/articles/PMC5341344/
4. Holmes, J. F., Yen, K., Ugalde, I. T., Ishimine, P., Chaudhari, P. P., Atigapramoj, N., Badawy, M., McCarten-Gibbs, K. A., Nielsen, D., Sage, A. C., Tatro, G., Upperman, J. S., Adelson, P. D., Tancredi, D. J., & Kuppermann, N. (2024). PECARN prediction rules for CT imaging of children presenting to the emergency department with blunt abdominal or minor head trauma: a multicentre prospective validation study. The Lancet. Child & adolescent health, 8(5), 339–347. https://doi.org/10.1016/S2352-4642(24)00029-4
5. .Kuppermann, N., Holmes, J. F., Dayan, P. S., Hoyle, J. D., Jr, Atabaki, S. M., Holubkov, R., Nadel, F. M., Monroe, D., Stanley, R. M., Borgialli, D. A., Badawy, M. K., Schunk, J. E., Quayle, K. S., Mahajan, P., Lichenstein, R., Lillis, K. A., Tunik, M. G., Jacobs, E. S., Callahan, J. M., Gorelick, M. H., … Pediatric Emergency Care Applied Research Network (PECARN) (2009). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet (London, England), 374(9696), 1160–1170. https://doi.org/10.1016/S0140-6736(09)61558-0
6. Halstead, M. E., Walter, K. D., Moffatt, K., & COUNCIL ON SPORTS MEDICINE AND FITNESS (2018). Sport-Related Concussion in Children and Adolescents. Pediatrics, 142(6), e20183074. https://doi.org/10.1542/peds.2018-3074
7. Lyons, T. W., Mannix, R., Monuteaux, M. C., & Schutzman, S. A. (2024). Emergency Department Evaluation of Young Infants With Head Injury. Pediatrics, 153(6), e2023065037. https://doi.org/10.1542/peds.2023-065037
8. Burstein B, Upton JEM, Terra HF, Neuman MI. Use of CT for Head Trauma: 2007-2015. Pediatrics. 2018;142(4). doi:10.1542/peds.2018-0814.
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11. Smith-Bindman R, Chu PW, Azman Firdaus H, et al. Projected Lifetime Cancer Risks From Current Computed Tomography Imaging. JAMA Intern Med. 2025;185(6):710–719. doi:10.1001/jamainternmed.2025.0505.