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PECARN Pediatric Head Injury Rule

Identifies children at very low risk for clinically important traumatic brain injury

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Why use it

Reduces unnecessary CT scans in children (radiation exposure). Identifies very low-risk patients (< 0.05% ciTBI risk) who can be observed. Largest validated pediatric TBI clinical prediction rule (> 42,000 patients).

About

The PECARN (Pediatric Emergency Care Applied Research Network) Head Injury algorithm identifies children with minor head trauma who are at very low risk for clinically important traumatic brain injury (ciTBI) and therefore do NOT need CT imaging. It uses age-stratified criteria (< 2 years and ≥ 2 years) to guide CT decisions.

When to use

  • Children presenting with minor head trauma (GCS ≥ 14)
  • Decision on CT head imaging after pediatric head injury

Formula

Age < 2 years — high risk if ANY present: • GCS < 15 • Altered mental status • Palpable skull fracture Age < 2 years — intermediate risk: • Non-frontal scalp hematoma • Loss of consciousness ≥ 5 seconds • Severe mechanism of injury • Not acting normally per parent Age ≥ 2 years — high risk if ANY present: • GCS < 15 • Altered mental status • Signs of basilar skull fracture Age ≥ 2 years — intermediate risk: • LOC • Vomiting • Severe mechanism • Severe headache

Pearls & pitfalls

  • PECARN is for GCS ≥ 14 only. GCS < 14 should get CT regardless.
  • Two separate algorithms: one for age < 2 years, another for ≥ 2 years.
  • ciTBI defined as: death, neurosurgery, intubation > 24h, or hospital admission ≥ 2 nights for TBI.
  • A "very low risk" categorization has sensitivity > 99% for ciTBI.
  • Observation for 4-6 hours is a valid alternative to CT in intermediate-risk patients.
  • Scalp hematoma in children < 2 years (especially occipital, temporal, or parietal) is concerning.

Next steps

All criteria negative: Very low risk (< 0.05% ciTBI). CT NOT recommended — observation is sufficient. Any criterion positive: Risk not negligible. Consider CT based on severity, clinical judgment, and parental preference.

Evidence

Kuppermann et al. (Lancet, 2009). Prospective multicenter study of 42,412 children < 18 years with head trauma. Validated with > 99% sensitivity and > 99% NPV for ciTBI in very low-risk groups.

References

  1. Kuppermann N et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170. — link