Resources and Memory //

Patient has suffered from minor blunt head trauma that occurred on the following data and time: [***]. The patient has a GCS of [***] The PECARN criteria were applied (www.mdcalc.com) for age < 2[***] / age > 2. AGE < 2 In this patient < 2 years of age: GCS < 14 [***]No Palpable skull fracture [***]No Altered mental status (agitation, somnolence, repetitive questioning, slow response [***]No If yes to any of the above, this suggests potential for significant traumatic brain injury and CT Head is indicated. If no to all of the above, secondary PECARN criteria were reviewed: Occipital/parietal/temporal scalp hematoma [***]No LOC > 5 seconds [***]No Parental reporting of abnormal behavior [***]No Concerning mechanism of injury (fall > 3 feet, MVA with ejection, rollover or fatality, pedestrian vs vehicle without a helmet, high impact object) [***] No If yes to any of the above, shared decision making occurred with the parent(s). I discussed the options of observation versus CT Head, and the 0.9% risk of clinically significant traumatic brain injury. Parents and I decided [***]. Upon discharge, parent(s) were educated on head injury precautions and advised for close follow up with their primary care doctor. AGE >2 In this patient > 2 years old Evidence of GCS<14 [***]No Signs of basilar skull fracture [***]No Altered mental status (agitation, somnolence, repetitive questioning, slow response) [***]No If yes to any of the above, this suggests potential for significant traumatic brain injury and CT Head is indicated. If no to all of the above, secondary PECARN criteria were reviewed: Evidence of vomiting [***]No LOC of any duration [***]No Severe headache [***]No Concerning mechanism of injury (fall > 5 feet, MVA with ejection, rollover or fatality, pedestrian vs vehicle without a helmet, high impact object) [***]No If yes to any of the above, shared decision making occurred with the parent(s). I discussed the options of observation versus CT Head, and the 0.9% risk of clinically significant traumatic brain injury. Parents and I decided [***]. Upon discharge, parent(s) were educated on head injury precautions and advised for close follow up with their primary care doctor. [***] Exclusion statement – Patient has a known history of Ventricular shunt, brain tumor, coagulopathy, including thrombocytopenia



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