Recognise and assess

    • Tools to guide identification of mTBI/concussion include the Concussion Recognition Tool, Sport Concussion Assessment Tool (SCAT6), and the Child Sport Concussion Assessment Tool (Child SCAT6). Tools to identify neck injury that requires investigation in adults include the NEXUS tool for neck assessment and the Canadian C Spine Rule. The PECARN clinical decision rule can be used as a prediction tools for cervical spine imaging in children.

    • CBR 7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head
      injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.
      43. Kuppermann N, Holmes JF, Dayan PS, Hoyle JD, Jr., Atabaki SM, Holubkov R, 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):1160-70. doi: 10.1016/s0140-6736(09)61558-0.
      Kuppermann N, Holmes JF, Dayan PS, Hoyle JD, Jr., Atabaki SM, Holubkov R, 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):1160-70. doi: 10.1016/s0140-6736(09)61558-0.
      44. Davis GA, Purcell L, Schneider KJ, Yeates KO, Gioia GA, Anderson V, et al. The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5): Background and rationale. Br J Sports Med. 2017;51(11):859-61. doi: 10.1136/bjsports-2017-097492.
      45.  Echemendia RJ, Meeuwisse W, McCrory P, Davis GA, Putukian M, Leddy J, et al. The Sport Concussion Assessment Tool 5th Edition (SCAT5): Background and rationale. Br J Sports Med. 2017;51(11):848-50. doi: 10.1136/bjsports-2017-097506.
      46.  Parameswaran A, Heitner S, Thosar D, Fowler A, Marks S, O’Leary F. Trial of life: Well infants presenting more than 24 h after head injury with a scalp haematoma: A 10-year review. J Paediatr Child Health. 2018;54(11):1193-8. doi: 10.1111/jpc.13932.
      47.  Snyder CW, Danielson PD, Gonzalez R, Chandler NM. Computed tomography scans prior to transfer to a pediatric trauma center: Transfer time effects, neurosurgical interventions, and practice variability. J Trauma Acute Care Surg. 2019;87(4):808-12. doi: 10.1097/TA.0000000000002258.
      48. Yengo-Kahn AM, Hale AT, Zalneraitis BH, Zuckerman SL, Sills AK, Solomon GS. The Sport Concussion Assessment Tool: a systematic review. Neurosurgical focus. 2016;40(4):E6. doi: 10.3171/2016.1.Focus15611.
      Adapted7
      Notes:
      1 Severe mechanism of injury: motor vehicle accident with patient ejection, death of another passenger or rollover; pedestrian or bicyclist without helmet struck by motorised vehicle; falls of 1 metre or more for children aged less than 2 years, and more than 1.5 m for children aged 2 years or older; or head struck by a high-impact object.
      2 A case of a single isolated vomit can be assessed in general practice.
    • EBR (strong)30. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
      40. Patricios J, Fuller GW, Ellenbogen R, Herring S, Kutcher JS, Loosemore M, et al. What are the critical elements of sideline screening that can be used to establish the diagnosis of concussion? A systematic review. Br J Sports Med. 2017;51(11):888-94. doi: 10.1136/bjsports-2016-097441.
      41. Davis GA, Makdissi M, Bloomfield P, Clifton P, Echemendia RJ, Falvey EC, et al. International consensus definitions of video signs of concussion in professional sports. Br J Sports Med. 2019;53(20):1264-7. doi: 10.1136/bjsports-2019-100628.
      52. Broglio SP, Harezlak J, Katz B, Zhao S, McAllister T, McCrea M, et al. Acute sport concussion assessment optimization: a prospective assessment from the CARE Consortium. Sports Med. 2019;49(12):1977-87. doi: 10.1007/s40279-019-01155-0.
      53. Coscia A, Stolz U, Barczak C, Wright N, Mittermeyer S, Shams T, et al. Use of the Sports Concussion Assessment Tool 3 in emergency department patients with psychiatric disease. J Head Trauma Rehabil. 2021;36(5):E302-E11. doi: 10.1097/HTR.0000000000000648.
      54. Dagher JH, Richard-Denis A, Lamoureux J, de Guise E, Feyz M. Acute global outcome in patients with mild uncomplicated and complicated traumatic brain injury. Brain Inj. 2013;27(2):189-99. doi: 10.3109/02699052.2012.729288.
      55. Fuller GW, Cross MJ, Stokes KA, Kemp SPT. King-Devick concussion test performs poorly as a screening tool in elite rugby union players: a prospective cohort study of two screening tests versus a clinical reference standard. Br J Sports Med. 2019;53(24):1526-32. doi: 10.1136/bjsports-2017-098560.
      56. Fuller GW, Tucker R, Starling L, Falvey E, Douglas M, Raftery M. The performance of the World Rugby Head Injury Assessment Screening Tool: a diagnostic accuracy study. Sports Med Open. 2020;6(1):2. doi: 10.1186/s40798-019-0231-y.
      57. Garcia GP, Broglio SP, Lavieri MS, McCrea M, McAllister T, Investigators CC. Quantifying the value of multidimensional assessment models for acute concussion: an analysis of data from the NCAA-DoD Care Consortium. Sports Med. 2018;48(7):1739-49. doi: 10.1007/s40279-018-0880-x.
      58. Hartwell JL, Spalding MC, Fletcher B, O’Mara M S, Karas C. You cannot go home: routine concussion evaluation is not enough. Am Surg. 2015;81(4):395-403. doi:
      59. Miller KJ, Ivins BJ, Schwab KA. Self-reported mild TBI and postconcussive symptoms in a peacetime active duty military population: effect of multiple TBI history versus single mild TBI. J Head Trauma Rehabil. 2013;28(1):31-8. doi: 10.1097/HTR.0b013e318255ceae.
      60. Meares S, Shores EA, Smyth T, Batchelor J, Murphy M, Vukasovic M. Identifying posttraumatic amnesia in individuals with a Glasgow Coma Scale of 15 after mild traumatic brain injury. Arch Phys Med Rehabil. 2015;96(5):956-9. doi: 10.1016/j.apmr.2014.12.014.
      61. Silverberg ND, Luoto TM, Ohman J, Iverson GL. Assessment of mild traumatic brain injury with the King-Devick Test in an emergency department sample. Brain Inj. 2014;28(12):1590-3. doi: 10.3109/02699052.2014.943287.
      Adapted30
    • EBR (conditional)30. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
      76. Cipriano A, Park N, Pecori A, Bionda A, Bardini M, Frassi F, et al. Predictors of post-traumatic complication of mild brain injury in anticoagulated patients: DOACs are safer than VKAs. Intern Emerg Med. 2021;16(4):1061-70. doi: 10.1007/s11739-020-02576-w.
      67. Riccardi A, Spinola B, Minuto P, Ghinatti M, Guiddo G, Malerba M, et al. Intracranial complications after minor head injury (MHI) in patients taking vitamin K antagonists (VKA) or direct oral anticoagulants (DOACs). Am J Emerg Med. 2017;35(9):1317-9. doi: 10.1016/j.ajem.2017.03.072.
      78. Turcato G, Zannoni M, Zaboli A, Zorzi E, Ricci G, Pfeifer N, et al. Direct oral anticoagulant treatment and mild traumatic brain injury: risk of early and delayed bleeding and the severity of injuries compared with vitamin K antagonists. J Emerg Med. 2019;57(6):817-24. doi: 10.1016/j.jemermed.2019.09.007.
      79. Ayaz SI, Thomas C, Kulek A, Tolomello R, Mika V, Robinson D, et al. Comparison of quantitative EEG to current clinical decision rules for head CT use in acute mild traumatic brain injury in the ED. Am J Emerg Med. 2015;33(4):493-6. doi: 10.1016/j.ajem.2014.11.015.
      80. Ip IK, Raja AS, Gupta A, Andruchow J, Sodickson A, Khorasani R. Impact of clinical decision support on head computed tomography use in patients with mild traumatic brain injury in the ED. Am J Emerg Med. 2015;33(3):320-5. doi: 10.1016/j.ajem.2014.11.005.
      81. Klein AP, Tetzlaff JE, Bonis JM, Nelson LD, Mayer AR, Huber DL, et al. Prevalence of potentially clinically significant magnetic resonance imaging findings in athletes with and without sport-related concussion. J Neurotrauma. 2019;36(11):1776-85. doi: 10.1089/neu.2018.6055.
      82. Sharp AL, Nagaraj G, Rippberger EJ, Shen E, Swap CJ, Silver MA, et al. Computed tomography use for adults with head injury: Describing likely avoidable emergency department imaging based on the Canadian CT Head Rule. Acad Emerg Med. 2017;24(1):22-30. doi: 10.1111/acem.13061.
      Adapted30
    • EBR (conditional)30. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
      76. Cipriano A, Park N, Pecori A, Bionda A, Bardini M, Frassi F, et al. Predictors of post-traumatic complication of mild brain injury in anticoagulated patients: DOACs are safer than VKAs. Intern Emerg Med. 2021;16(4):1061-70. doi: 10.1007/s11739-020-02576-w.
      78. Turcato G, Zannoni M, Zaboli A, Zorzi E, Ricci G, Pfeifer N, et al. Direct oral anticoagulant treatment and mild traumatic brain injury: risk of early and delayed bleeding and the severity of injuries compared with vitamin K antagonists. J Emerg Med. 2019;57(6):817-24. doi: 10.1016/j.jemermed.2019.09.007.
      79. Ayaz SI, Thomas C, Kulek A, Tolomello R, Mika V, Robinson D, et al. Comparison of quantitative EEG to current clinical decision rules for head CT use in acute mild traumatic brain injury in the ED. Am J Emerg Med. 2015;33(4):493-6. doi: 10.1016/j.ajem.2014.11.015.
      80. Ip IK, Raja AS, Gupta A, Andruchow J, Sodickson A, Khorasani R. Impact of clinical decision support on head computed tomography use in patients with mild traumatic brain injury in the ED. Am J Emerg Med. 2015;33(3):320-5. doi: 10.1016/j.ajem.2014.11.005.
      81. Klein AP, Tetzlaff JE, Bonis JM, Nelson LD, Mayer AR, Huber DL, et al. Prevalence of potentially clinically significant magnetic resonance imaging findings in athletes with and without sport-related concussion. J Neurotrauma. 2019;36(11):1776-85. doi: 10.1089/neu.2018.6055.
      82. Sharp AL, Nagaraj G, Rippberger EJ, Shen E, Swap CJ, Silver MA, et al. Computed tomography use for adults with head injury: Describing likely avoidable emergency department imaging based on the Canadian CT Head Rule. Acad Emerg Med. 2017;24(1):22-30. doi: 10.1111/acem.13061.
      Adapted30
    • CBR7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head
      injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.
      80. Ip IK, Raja AS, Gupta A, Andruchow J, Sodickson A, Khorasani R. Impact of clinical decision support on head computed tomography use in patients with mild traumatic brain injury in the ED. Am J Emerg Med. 2015;33(3):320-5. doi: 10.1016/j.ajem.2014.11.005.
      82. Sharp AL, Nagaraj G, Rippberger EJ, Shen E, Swap CJ, Silver MA, et al. Computed tomography use for adults with head injury: Describing likely avoidable emergency department imaging based on the Canadian CT Head Rule. Acad Emerg Med. 2017;24(1):22-30. doi: 10.1111/acem.13061.
      89. Gravel J, Gouin S, Chalut D, Crevier L, Décarie J-C, Elazhary N, et al. Derivation and validation of a clinical decision rule to identify young children with skull fracture following isolated head trauma. Can Med Assoc J. 2015;187(16):1202-8.
      Adapted7
    • CBR5. Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ, Haegerich TM, Gioia GA, et al. Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatr. 2018;172(11):e182853. doi: 10.1001/jamapediatrics.2018.2853.Adopted5
    • Risk factors for intracranial injury
      All children
      GCS 14 or other signes of altered mental status
      Abnormal neurological examination
      Severe mechanism of injury*
      Post-traumatic seizures
      Age <2 years
      Palpable skull fracture
      Non-frontal scalp haemotoma
      History of loss of consciousness ≥5 seconds
      Acting abnormally per parent
      Age >2 years
      Signs of base of skull fracture
      History of loss of consciousness
      History of vomiting**
      Severe headache
      Any risk factors: Recommended observation period is up to 4 hours post injury including 1 hour return to normal
      High risk = imagingIntermediate risk = consider imaging or structured observationLow riskVery low risk
      Palpable skull fracture
      OR
      Signs of base of skull fracture
      OR
      Worsening signs or symptoms
      OR
      Persistent GCS 14
      OR
      Persistent signs of altered mental status
      ≥ 2 risk factors
      OR
      Post-traumatic seizure(s)
      OR
      Persistent severe headache or persistent vomiting >4 hours post injury





      Not intermediate or high risk
      AND
      improving signs and symptoms:
      GCS 15, acting normally, no current signs of altered mental status, vomiting has stopped, severe headache resolved





      No risk factors










      Figure 1: Pediatric Emergency Care Applied Research Network (PECARN) Head Injury Decision Rule

      Notes:     See also Appendix C. 
      *    Struck by a motor vehicle, occupant ejected from a motor vehicle or death of another passenger, motor vehicle rollover; bicyclist without helmet struck by motorised vehicle; falls of 1 m or more for children aged less than 2 years and more than 1.5 m for children aged 2 years or older; or head struck by a high-impact object).
      ** Isolated vomiting, without any other risk factors, is an uncommon presentation of more severe forms of traumatic brain injury. Vomiting, regardless of the number of vomits or persistence of vomiting, in association with other risk factors increases concern for more severe forms of traumatic brain injury.
      Source:    adapted from PREDICT and Kuppermann N, Holmes JF, Dayan PS, Hoyle JD, Jr., Atabaki SM, Holubkov R, 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):1160–70.

      Figure 2: The Canadian CT Head rule for adults with mTBI/concussion

      * Signs of basal skull fracture Haemotympanum, ‘racoon’ eyes, CSF otorrhea/rhinorrhoea, Battle’s sign ** Dangerous mechanism Pedestrian struck by vehicle Occupant ejected from motor vehicle Fall from elevation ≥3 metres or 5 stairsCT head is only required for people with minor head injury with any one of these findings:Rule not applicable if: Non-trauma cases GCS <13 Age <16 years Anticoagulants or bleeding disorder Obvious open skull fracture
      High risk (for neurological intervention) 1.   GCS score <15 at 2 hours after injury 2.   Suspected open or depressed skull fracture 3.   Any sign of basal skull fracture* 4.   Vomiting ≥2 episodes 5.   Age ≥65 years
      Medium risk (for brain injury on CT) 6.   Amnesia before impact ≥30 min 7.   Dangerous mechanism **
      Figure 2: The Canadian CT Head rule for adults with mTBI/concussion

      Source:    Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357(9266):1391-6. doi: 10.1016/s0140-6736(00)04561-x.74
    • For information regarding the need for neuroimaging in children who present to the emergency department in the Australia and Aotearoa New Zealand, please refer to the PREDICT guidelines.

      The GDG endorses PREDICT guideline recommendations 7, 27, PP D, PP C, 22, PP N, 19, 20, 21.

    • EBR (strong)7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.
      91. Holmes JF, Borgialli DA, Nadel FM, Quayle KS, Schambam N, Cooper A, et al. Do children with blunt head trauma and normal cranial computed tomography scan results require hospitalization for neurologic observation? Ann Emerg Med. 2011;58(4):315-22. doi: 10.1016/j.annemergmed.2011.03.060.
      92. Kreitzer N, Lyons MS, Hart K, Lindsell CJ, Chung S, Yick A, et al. Repeat neuroimaging of mild traumatic brain-injured patients with acute traumatic intracranial hemorrhage: clinical outcomes and radiographic features. Acad Emerg Med. 2014;21(10):1083-91. doi: 10.1111/acem.12479.
      93. Fadzil F, Mei AKC, Mohd Khairy A, Kumar R, Mohd Azli AN. Value of repeat CT brain in mild traumatic brain injury patients with high risk of intracerebral hemorrhage progression. Int J Environ Res Public Health. 2022;19(21). doi: 10.3390/ijerph192114311.
      94. Battle B, Sexton KW, Fitzgerald RT. Understanding the value of repeat head CT in Elderly Trauma Patients on Anticoagulant or Antiplatelet Therapy. J Am Coll Radiol. 2018;15(2):319-21. doi: 10.1016/j.jacr.2017.09.021.
      95. NICE: National Institute for Health and Care Excellence. Head Injury: Assessment and early management (NICE Guideline CG176). 2019.
      Adapted7
    • EBR (strong)7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.Adapted6
      Notes:
      1     The initial head CT should be interpreted by a radiologist to ensure no injuries were missed.
      2     Measured using an age-appropriate GCS, consider post-traumatic amnesia assessment for those that remain amnesic.
    • CBR7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.
      96. Bressan S, Marchetto L, Lyons TW, Monuteaux MC, Freedman SB, Da Dalt L, et al. A systematic review and meta-analysis of the management and outcomes of isolated skull fractures in children. Ann Emerg Med. 2018;71(6):714-7.24E+04.
      97. Arrey EN, Kerr ML, Fletcher S, Cox CS, Jr., Sandberg DI. Linear nondisplaced skull fractures in children: who should be observed or admitted? J Neurosurg Pediatr. 2015;16(6):703-8.
      98. Blanchard A, Cabrera KI, Kuppermann N, Dayan PS. Acute outcomes of isolated pneumocephali in children after minor blunt head trauma. Pediatric Emergency Care. 2018;34(9):656-60.
      99. Hassan S, Alarhayema AQ, Cohn SM, Wiersch JC, Price MR. Natural history of isolated skull fractures in children. Cureus. 2018;10(7):e3078.
      100. Kommaraju K, Haynes JH, Ritter AM. Evaluating the role of a neurosurgery consultation in management of pediatric isolated linear skull fractures. Pediatric neurosurgery. 2019;54(1):21-7.
      101. Marincowitz C, Lecky FE, Townend W, Borakati A, Fabbri A, Sheldon TA. The risk of deterioration in GCS13-15 patients with traumatic brain injury identified by computed tomography imaging: A systematic review and meta-analysis. J Neurotrauma. 2018;35(5):703-18.
      Adopted7
      Notes:     1Measured using an age-appropriate GCS e.g. for infants and non-verbal people.
    • CBR7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.
      96. Bressan S, Marchetto L, Lyons TW, Monuteaux MC, Freedman SB, Da Dalt L, et al. A systematic review and meta-analysis of the management and outcomes of isolated skull fractures in children. Ann Emerg Med. 2018;71(6):714-7.24E+04.
      97. Arrey EN, Kerr ML, Fletcher S, Cox CS, Jr., Sandberg DI. Linear nondisplaced skull fractures in children: who should be observed or admitted? J Neurosurg Pediatr. 2015;16(6):703-8.
      98. Blanchard A, Cabrera KI, Kuppermann N, Dayan PS. Acute outcomes of isolated pneumocephali in children after minor blunt head trauma. Pediatric Emergency Care. 2018;34(9):656-60.
      99. Hassan S, Alarhayema AQ, Cohn SM, Wiersch JC, Price MR. Natural history of isolated skull fractures in children. Cureus. 2018;10(7):e3078.
      100. Kommaraju K, Haynes JH, Ritter AM. Evaluating the role of a neurosurgery consultation in management of pediatric isolated linear skull fractures. Pediatric neurosurgery. 2019;54(1):21-7.
      101. Marincowitz C, Lecky FE, Townend W, Borakati A, Fabbri A, Sheldon TA. The risk of deterioration in GCS13-15 patients with traumatic brain injury identified by computed tomography imaging: A systematic review and meta-analysis. J Neurotrauma. 2018;35(5):703-18.
      Adapted7
  • Practice points for children and adults:

    • 7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.Adapted7
    • 7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.Adapted7
    • 7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021Adapted7
      • 7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.Adapted7
        • PREDICT guidelines for the management of childhood abusive head trauma in the emergency department.
      • 7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.Adapted7
      • EBR (conditional)7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.
        106. Mina AA, Knipfer JF, Park DY, Bair HA, Howells GA, Bendick PJ. Intracranial complications of preinjury anticoagulation in trauma patients with head injury. J Trauma. 2002;53(4):668-72. doi: 10.1097/00005373-200210000-00008.
        107. Cohen DB, Rinker C, Wilberger JE. Traumatic brain injury in anticoagulated patients. J Trauma. 2006;60(3):553-7. doi: 10.1097/01.ta.0000196542.54344.05.
        108. Reynolds FD, Dietz PA, Higgins D, Whitaker TS. Time to deterioration of the elderly, anticoagulated, minor head injury patient who presents without evidence of neurologic abnormality. J Trauma. 2003;54(3):492-6. doi: 10.1097/01.TA.0000051601.60556.FC.
        109. Franko J, Kish KJ, O’Connell BG, Subramanian S, Yuschak JV. Advanced age and preinjury warfarin anticoagulation increase the risk of mortality after head trauma. J Trauma. 2006;61(1):107-10. doi: 10.1097/01.ta.0000224220.89528.fc.
        110. Kuczawski M, Stevenson M, Goodacre S, Teare MD, Ramlakhan S, Morris F, et al. Should all anticoagulated patients with head injury receive a CT scan? Decision-analysis modelling of an observational cohort. BMJ Open. 2016;6(12):e013742. doi: 10.1136/bmjopen-2016-013742.
        111. Lee LK, Dayan PS, Gerardi MJ, Borgialli DA, Badawy MK, Callahan JM, et al. Intracranial hemorrhage after blunt head trauma in children with bleeding disorders. J Pediatr. 2011;158(6):1003-8 e1-2. doi: 10.1016/j.jpeds.2010.11.036.
        112. Bower MM, Sweidan AJ, Shafie M, Atallah S, Groysman LI, Yu W. Contemporary reversal of oral anticoagulation in intracerebral hemorrhage. Stroke. 2019;50(2):529-36. doi: 10.1161/STROKEAHA.118.023840.
        113. Giordano PN, A.; Lassandro, G.; Notarangelo, L.D.; Bressan, S.; Ramenghi, U.; Saracco, P.; Da Dalt, L.; Molinari, A.C. . Head injury in children with coagulation disorders a position paper by the Italian Society of Pediatric Emergency Medicine (SIMEUP) and the Italian Association of Pediatric Hematology and Oncology – Coagulation Disorders Working Group (AIEOP),. Ital J Pediatrics. 2020. doi:
        Adapted7

      • 6. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.Adapted6
      • 6. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.Adapted6
      • 114.          Fuller G, Sabir L, Evans R, Bradbury D, Kuczawski M, Mason SM. Risk of significant traumatic brain injury in adults with minor head injury taking direct oral anticoagulants: a cohort study and updated meta-analysis. Emerg Med J. 2020;37(11):666-73. doi: 10.1136/emermed-2019-209307.
        115.          Park N, Barbieri G, Turcato G, Cipriano A, Zaboli A, Giampaoli S, et al. Multi-centric study for development and validation of a CT head rule for mild traumatic brain injury in direct oral anticoagulants: the HERO-M nomogram. BMC Emerg Med. 2023;23(1):122. doi: 10.1186/s12873-023-00884-w.
        116.          Rajesh S, Wonderling D, Bernstein I, Balson C, Lecky F, Guideline C. Head injury: assessment and early management-summary of updated NICE guidance. BMJ (Clinical research ed). 2023;381:1130. doi: 10.1136/bmj.p1130.
        New
      • CBR7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.
        117. Gunn BS, McAllister TW, McCrea MA, Broglio SP, Moore RD, Investigators CC. Neurodevelopmental disorders and risk of concussion: Findings from the National Collegiate Athletic Association Department of Defense Grand Alliance Concussion Assessment, Research, and Education (NCAA-DOD CARE) Consortium (2014-2017). J Neurotrauma. 2022;39(5-6):379-89. doi: 10.1089/neu.2020.7446.
        Adapted7
      • CBR 7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.Adapted7