should also be evaluated Obviously, a complete physical examination with attention to possible thoracic, abdominal, pelvic, and extremity injuries should be performed Radiographic Investigation Complications of head trauma may be identified with radiographic studies CT scan of the head quickly provides excellent images of the intracranial contents and is the diagnostic modality of choice when acute intracranial pathology is suspected CT imaging, however, has some disadvantages, including exposure to ionizing radiation and the possible requirement for pharmacologic sedation, especially in younger patients Ideally, CT imaging should be used selectively for patients at higher risk for TBI, limiting potentially unnecessary studies for those who are at low risk Patients at intermediate risk can undergo CT versus observation based on the clinical scenario, provider experience, and parental preference Although MRI is an additional imaging modality for the cranial contents (and has no associated ionizing radiation), limited availability, prolonged study time, and frequent need for patient sedation limit its utility for evaluation of acute trauma at this time though emerging MRI modalities may be increasingly employed for the diagnosis and management of mild TBI Skull radiographs (SR) are of very limited utility as they give no direct information about TBI However, they are useful for demonstrating skull fractures and have the advantages of delivering lower doses of ionizing radiation, being more universally available, less costly, and not requiring sedation Any child for whom there is significant concern for TBI should undergo CT imaging; however, there may still be a very small role for SRs in certain select circumstances when immediate CT is not warranted, yet significant chance of fracture exists to justify the test Examples would include SRs as part of a skeletal survey, to evaluate for the presence of a radiopaque foreign body, and in rare instances to screen for fracture in selected asymptomatic patients to 12 months of age with concerning scalp hematoma or question of depression Those with fractures identified on SR would need to have CT scans performed because they are at increased risk for associated TBI In general, SRs should be performed only if they will be reviewed by a radiologist trained in their interpretation as they can be very challenging to interpret in young children, and the utility of the study depends on an accurate reading All children with significant head trauma should be evaluated for associated cervical spine injuries This evaluation will be clinical, with or without radiographic studies, based on the specific circumstances (see Chapter 112 Neck Trauma ) Approach The goals of management are to define specific anatomic lesions (e.g., skull fracture and TBI) and to prevent secondary brain injury, while limiting unnecessary cranial irradiation Pediatricians and emergency physicians will be the initial clinicians to evaluate and manage most children with head trauma Neurosurgical consultation should be considered for all children with penetrating trauma, abnormal mental status or neurologic examination, skull fractures, and intracranial complications The urgency of neurosurgical involvement varies with the acuity of the patient’s clinical condition One approach to diagnosing complications of head trauma involves determining whether a penetrating injury has occurred If so, brain or vascular injury is likely and emergent CT scanning and neurosurgical consultation are mandated in addition to stabilization If the head injury has resulted from blunt trauma, it must be determined whether a TBI is likely ( Fig 41.1 ) Since preverbal children may have differences in the presenting signs/symptoms of TBI compared to older children, the approach in evaluating for TBI should take age into account In children