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Pediatric patient with minor blunt head trauma not classified as low risk according to the pecarn prediction rules

HCPCS code

Name of the Procedure:

Pediatric Head Injury Evaluation and Management

  • Common Names: Pediatric Head Trauma Evaluation, Pediatric Head Injury Management
  • Medical Term: Blunt Head Trauma Evaluation


A thorough examination and management approach for pediatric patients experiencing minor blunt head trauma. This evaluation ensures that the injury is properly assessed and treated to prevent further complications.


  • Conditions Addressed: Minor blunt head trauma in pediatric patients not classified as low risk according to the PECARN prediction rules.
  • Goals: To accurately diagnose the extent of the head injury and provide appropriate care. This includes monitoring for signs of more serious injury, preventing complications, and ensuring the child's safety and well-being.


  • Symptoms like headache, nausea, vomiting, confusion, or abnormal behavior following head trauma.
  • History of a moderate to severe impact to the head.
  • Risk factors such as fall from significant height, motor vehicle collisions, or being struck by a heavy object.


  • Pre-procedure instructions generally include keeping the child calm and still.
  • Parents may be advised to avoid giving food or drink if sedation or further imaging is anticipated.
  • Initial assessment via physical examination and possibly imaging tests like a CT scan or MRI if indicated.

Procedure Description

  1. Initial Evaluation: Conduct a thorough history and physical examination, checking vital signs and neurological status.
  2. Imaging Studies: If the condition warrants, perform imaging studies like CT scans to assess for fractures or internal brain injury.
  3. Monitoring: Continuous monitoring of the child's neurological status to detect any changes.
  4. Treatment: Administer medications if needed (e.g., for pain or to reduce swelling). Surgical intervention may be necessary in rare cases of severe injury.
  5. Observation: Provide observation in the hospital setting to ensure there are no delayed complications.

Tools and Equipment:

  • Neurological assessment tools (e.g., reflex hammer, penlight).
  • Imaging technology (CT scanner, MRI machine).
  • Monitoring equipment (pulse oximeter, blood pressure monitor).

Anesthesia/Sedation: May be required for imaging studies or surgical interventions.


The evaluation itself typically takes 1-2 hours, but ongoing monitoring could last 24-48 hours or longer depending on the child's condition.


This procedure is usually performed in a hospital emergency department or a specialized pediatric trauma center.


  • Emergency physicians or pediatricians
  • Nurses
  • Radiologists
  • Neurologists or neurosurgeons (if more severe injury is suspected)
  • Anesthesiologists (if sedation is required)

Risks and Complications

  • Common Risks: Discomfort during examination or minor side effects from medications.
  • Rare Complications: In rare cases, complications might include bleeding, infection, or adverse reactions to medications.


  • Accurate diagnosis and prompt treatment, reducing the risk of long-term damage.
  • Peace of mind for parents knowing that the injury has been properly assessed and managed.
  • Prevention of complications related to undiagnosed head injuries.


  • Post-Procedure Care: Regular monitoring of the child's condition, adherence to prescribed medications, and follow-up visits with the healthcare provider.
  • Recovery Time: Most children recover fully within a few days to a week. Rest and avoiding strenuous activities are generally recommended.
  • Restrictions: Limiting activities that could lead to another head injury.


  • Watchful Waiting: In cases where the injury is deemed very minor, close observation by parents with follow-up by a healthcare provider may be considered.
  • Other Imaging Techniques: Instead of a CT scan, an MRI may be used in certain cases to reduce radiation exposure.

    Pros and cons vary based on the child's specific condition and the likelihood of more severe injury not being detected.

Patient Experience

  • During the Procedure: The child may feel anxious or scared. Pain or discomfort can be managed with appropriate medications.
  • After the Procedure: Some children may experience tiredness or minor pain. Comfort measures include rest, a calm environment, and reassurance from caregivers.

Pain management will be individualized, often involving over-the-counter pain relievers and ensuring the child gets plenty of rest.

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