• GCS < 13 on initial assessment
• GCS < 15 at 2 hours after injury on assessment in the emergency department
• Suspected open or depressed skull fracture
• Any sign of basal skull fracture
• Post-traumatic seizure
• Focal neurological deficit (note how this is poorly defined...)
• More than one episode of vomiting since the head injury

• anticoagulation
• LOC or amnesia AND
  • age>65
  • bleeding disorder
  • dangerous MOI
  • >30 mins retrograde amnesia prior to injury

• Suspicion of non-accidental injury
• Post-traumatic seizure, but no history of epilepsy
• On initial assessment GCS <14, or for children under 1 year GCS (paediatric) < 15
• At 2 hours after the injury GCS < 15
• Suspected open or depressed skull injury or tense fontanelle.
• Any sign of basal skull fracture (haemotympanum ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
• Focal neurological deficit
• For children under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head
• more than one of the following
  • Witnessed loss of consciousness > 5 minutes
  • Abnormal drowsiness
  • 3 or more discrete episodes of vomiting
  • Dangerous mechanism of injury (high-speed road traffic accident either as a pedestrian, cyclist or vehicle occupant, fall from height of > 3 metres, high speed injury from an object
  • Amnesia (antegrade or retrograde) lasting > 5 minutes (assessment not possible in pre-verbal children and unlikely in any child < 5 years).
• if only one of the above factors present then observe 4 hours

note MDcalc citing this paper has age <2 and some slightly different criteria

I’ve cited APLS 5th below

• use in age <4 (otherwise use the normal one)
• Eyes
  • the same as the big people
• Verbal
  • 1: no response
  • 2: moans to pain
  • 3: cries only to pain
  • 4: less than usual words, spontaneous irritable cry
  • 5: alert, babbles, coos, usual ability
• Motor (pretty much the same as the big people)
  • 1: no response
  • 2: abnormal extension
  • 3: abnormal flexion
  • 4: withdraws from pain
  • 5: localises to pain or withdraws to touch
  • 6: spontaneous or obeys verbal command

• if you’re scanning other areas
• if they’re going for urgent surgery
• if GCS<13
• intubation
• if c-spine injury suspected and
  • any neuro signs or symptoms
  • dangerous mechanisms
  • age >65
• if not already meeting criteria then apply the canadian rule and if failing this then get a c-spine.
• if any issues with the c-spine film then CT

• similar to above but without the dangerous mechanism bit
• if dangerous MOI present then they encourage plain film first
  • note that dangerous MOI for paeds c-spine is 1 m fall but for head injury it’s 3m

(no not that CCR)

(MDcalc)

• Immediate fail
  • Age>65
  • Extremity Paraesthesia
  • Dangerous MOI
    • high speed MVC/rollover/ejection
    • >3ft/5 stairs
    • bicyle
    • motorised recreational vehicle
    • axial load
• If passes that then look for low risk features
  • sitting
  • walking at any time
  • delayed pain
  • no midline tenderness
  • simple rear end
• if ANY low risk feature
  • actively range 45 degrees
  • if passed then no imaging