The initial resuscitation should proceed in a step-wise fashion to identify all injuries, as well as optimize cerebral perfusion by maintaining hemodynamic stabilization and oxygenation. The initial survey should also include a brief, focused neurological examination with attention to the GCS, pupillary examination, and motor function.

The pediatric GCS is similar to the adult GCS, but the main difference is in the verbal response in which the pediatric GCS assigns a normal verbal score of 5 for babbling, cooing, or smiling appropriately, while subtracting 1 point if crying but consolable, subtracting 2 points for inconsolable crying, subtracting 3 points for moaning or grunting, and subtracting 4 points for no verbal response.

After addressing any airway or circulatory deficits, a thorough head-to-toe physical examination must be performed with vigilance for occult injuries and careful attention to detect any of the following warning signs:

• Inspection for cranial nerve deficits, periorbital or postauricular ecchymoses, cerebrospinal fluid (CSF) rhinorrhea or otorrhea, hemotympanum (signs of base of skull fracture)
• Fundoscopic examination for retinal hemorrhage (potential sign of abuse in children) and papilledema (sign of increased intracranial pressure [ICP])
• Palpation of the scalp for hematoma, crepitance, laceration, and bony deformity (markers of skull fractures). In infants fullness of the fontanelle can be a marker of intracranial hematoma or elevated ICP
• Auscultation for carotid bruits, painful Horner syndrome or facial/neck hyperesthesia  (markers of carotid or vertebral dissection)
• Evaluation for cervical spine tenderness, paresthesias, incontinence, extremity weakness, priapism (signs of spinal cord injury)
• Extremities: Motor and sensory examination (for signs of spinal cord injury)

Non-contrast cranial computed tomography (CT) is the imaging modality of choice for patients with TBI and an abnormal GCS. CT findings associated with a poor outcome in TBI include midline shift, subarachnoid hemorrhage into the verticals, and compression of the basal cisterns. MRI may be indicated when the clinical picture remains unclear after a CT to identify more subtle lesions. Several clinical decision guidelines[2] have been validated and can be applied to determine which children with a normal or near normal GCS can safely avoid CT.

Airway adjuncts are indicated in patients not able to maintain an open airway, or not able to maintain greater than 90% oxygen saturation with supplementary oxygen. Oxygenation parameters should be monitored using continuous pulse oximetry with a target of greater than 90% oxygen saturation. Ventilation should be monitored with continuous capnography with an end-tidal CO2 target of 35 to 40 mm Hg. Placement of a definitive airway is recommended in the patient with a GCS of less than 9.  

Systemic hypotension negatively impacts the outcome in the setting of TBI, and current studies have demonstrated improved outcome in patients with a systolic BP = 120 mm Hg. Isotonic crystalloids should be used to prevent and correct hypotension; colloidal solutions have not been shown to improve outcomes.

Serial neurological examinations allow for early identification of patients with elevated intracranial pressure (ICP), and subsequent implementation of primary bedside interventions to improve venous outflow and reduce metabolic demands. Mortality in TBI is due to elevated ICP.

Initial bedside approaches to increased ICP include:

1. Elevate the head of the bed to 30 degrees.
2. Determine that the cervical collar is not impeding venous outflow.
3. Appropriate analgesics and sedation: Pain and anxiousness can elevate the ICP.  Opiates and benzodiazepines are frequently used, and neuromuscular blockade may be required to prevent maneuvers that increase ICP such as coughing, straining and fighting against the ventilator.[3]
4. Hyperventilation: Routine hyperventilation in TBI is not recommended, but in the setting of impending herniation, it remains one of the fastest, short-term methods to lower ICP.[4] 
5. ICP monitoring may be considered in infants and children with severe TBI.[5]
6. Osmotic agents: Hypertonic saline (3%) or mannitol are the common hyperosmolar agents used to reduce ICP.[4]
7. Barbiturates: Patients with elevated ICP, refractory to other therapies, may benefit from barbiturates which are thought to decrease ICP by decreasing cerebral metabolic rate.[4]
8. Decompressive hemicraniectomy: As part of a surgical procedure to evacuate hematoma, or as a primary treatment of refractory ICP, decompressive hemicraniectomy reduces ICP due to the removal of part of the skull.
9. Hypothermia has not been shown to improve outcomes in children.[6]

A thorough head-to-toe physical examination must be performed with vigilance for occult injuries.

Nearly 90% of patients are discharged home from the emergency department after their head injury,[3] but about 1% of patients with a GCS of 14 to 15 have a clinically significant intracranial injury on CT,[7] and patients with severe TBI have mortality as high as 20%.

The management of pediatric head trauma is done by an interprofessional team that consists of an emergency department physician, neurologist, nurse practitioner, pediatrician, and a radiologist. Most children with mild head trauma are discharged. However, patients discharged after a head injury or concussion should be instructed to return to physical activities in a step-wise approach. The initial step is a period of physical and cognitive rest for no more than 2 to 3 days followed by scheduled increases in activities with close monitoring for recurrence of symptoms. Any recurrence of symptoms indicates the need for further limitation of activities. Recommendations for return-to-activities continue to change as new studies are published, and the CDC website is a helpful source for up-to-date guidelines.[8]