Scope of this summary
Adults and children after blunt head injury, emphasizing mild traumatic brain injury, selection for acute imaging, discharge safety and recovery. Penetrating injury, polytrauma, moderate or severe traumatic brain injury, suspected abusive head trauma, spinal injury and definitive neurosurgical management remain separate emergency pathways. Adult recommendations come from ACEP 2023; pediatric recommendations come from CDC guidance updated in 2025.
The Bottom Line
- Stabilize airway, breathing and circulation first and identify falling Glasgow Coma Scale, focal deficit, seizure, skull-fracture signs, anticoagulant exposure and dangerous mechanism before applying a mild-injury rule.
- Use validated age-appropriate decision rules to select imaging rather than routine CT for every mild injury; ACEP gives the Canadian CT Head Rule priority in eligible adults, while CDC advises against routine CT or MRI to diagnose pediatric mild TBI.
- Do not use a clinical decision tool by itself to exclude CT in an adult taking anticoagulants or antiplatelet medication other than aspirin, and do not apply a rule outside its validated inclusion and exclusion criteria.
- Provide written and verbal danger signs, expected recovery and a symptom-guided return plan; after no more than one to two days of relative rest, children should resume tolerable nonsport activity gradually and avoid contact risk until appropriately cleared.
Practical clinical workflow
1
Establish injury time and mechanism, loss of consciousness, amnesia, vomiting, headache, seizure, intoxication, medicines, bleeding risk and baseline cognition, then document GCS, pupils, focal examination, skull signs and cervical-spine findings.
2
Apply the relevant validated adult or pediatric rule only after confirming eligibility; image or observe when clinical risk warrants and involve trauma or neurosurgery for abnormal imaging or deterioration.
3
For an adult with baseline neurologic examination and a negative initial CT who is taking an anticoagulant or antiplatelet agent, ACEP advises that routine repeat imaging or admission is not automatic; decide from other clinical reasons and provide explicit delayed-bleed precautions.
4
At discharge, confirm responsible observation and comprehension, give return-to-work, school, driving and sport advice, arrange follow-up for higher-risk or persistent symptoms and reassess children not recovering as expected within two to four weeks.
Safety boundaries and escalation
- Worsening headache, repeated vomiting, increasing confusion or drowsiness, new weakness or incoordination, seizure, slurred speech, unequal pupils or inability to awaken requires immediate emergency reassessment.
- A normal early CT does not prove that every symptom is benign or remove the need for discharge precautions, particularly with bleeding risk, intoxication, unreliable observation or another injury.
- Do not return an athlete to contact sport on the day of injury; progression follows successful return to regular nonsport activity and must stop or step back if symptoms recur.
- Consider nonaccidental injury when mechanism, developmental ability or injury pattern is inconsistent, especially in infants and young children, and activate the safeguarding pathway without delaying medical stabilization.
Localization
ACEP 2023 applies to selected adults in US emergency departments and CDC provides the national pediatric mild-TBI framework. State return-to-play laws, school accommodations, trauma-system criteria and local imaging access vary. The named Canadian CT Head Rule is a validated clinical rule endorsed within US ACEP policy, not a Canadian jurisdictional care pathway.
Source documents
Use the linked source documents for complete recommendations, evidence grading, exclusions and implementation detail.
- American College of Emergency Physicians Clinical Policies CommitteeClinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Mild Traumatic Brain InjuryDOI 10.1016/j.annemergmed.2023.01.014 路 published 2023-05-01 路 accessed 2026-08-20view source
- Centers for Disease Control and PreventionClinical Guidance for Pediatric Mild TBIupdated 2025-07-29 路 accessed 2026-08-20view source
- American Academy of Pediatrics Committee on Child Abuse and NeglectThe Evaluation of Suspected Child Physical AbuseDOI 10.1542/peds.2015-0356 路 2015 clinical report; reaffirmed with reference and data updates November 2021; reaffirmed March 2026 路 published 2015-05-01 路 accessed 2026-08-20view source
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