A

GCS=14or other signs of altered mental statust, or Yes

palpable skull fracture
. CT recommended
13-9%of population 4-
,_
4% risk of ciTBI

No

,.
Occipital or parietal or temporal scalIp. haematoma, or Yes Observation versus CTon the basisof
s
history of LOC s; orsevere mechanism of .. other clinical factors including:
injury¢, or not acting normally per parent 32·9% of population Physician experience
0·9% risk of ciTBI • Multiple versusisolated§ findings
Worsening symptoms or signs after
53-2%of popuI lati1on emergency department observation Age
No
<0·02% risk of ciTBI <3months
,. • Parental preference
CT not recommended,T

B
Yes
GCS=l4 or other signs of altered mental statust, or .
, CT recommended
signs of basilar skull fracture 14·0% of population
4·3% risk of ciTBI

No

"
History of LOC, or h.i[story of vomiting, or severe Yes Observation versus CTon the basisof
mechanism of injuryt, or severeheadache
.- other clinical factors including:
28-8% of population 0-
• Physician experience
8% risk of ciTBI
• Multiple versus isolated§findings
S7-2%of popu I Ilation
• Worsening symptoms or siigns after
No
<0·05% risk of ciTBI emergency department observation
,. Parental preference
CT not recommended,T

Figure 3: Suggested CT algorithm for children younger than 2years (A} and for those aged 2years and older
(B) with GCS scores of 14-15 after head trauma*
GCS=Glasgow Corna Scale. ciTBl =-dI inicallt y-- irnport ant traumatic brain injury. LOC=loss of consciousness. *Data are from the
combined derivation and validation populations. tOther signs of altered mental status: agitation, somnolence, repetitive
questioning, or slow response to verbal communication. isevere mechanism of injury: motor vehicle crash with patient ejection,
death of another passenger, or rollover; pedestrian or bicycl·11ist without
helmet struck by a motorised vehicle; falls of more than 0-9m (3 feet) (or more than 1·5m [5 feet] for panel B}; or
head struck by a high-impact object. SPatients with certain isolated findings (ie, with no other findings suggestive of traumatic
brain injury), such as isolated LOC,''" isolated headache, 41 isolated vomiting," and certain types of isolated scalp haematomas
in infants older than 3 months,'"' have arisk of ciTBI substantially lower than 1%.
,I Risk of ciTBI exceedingly low, generally lower than risk of CT-induced malignancies. Therefore, CT scans are not
indicated for most patients in this group.