28 Skull fractures could be associated with non-accidental trauma, and physicians should always consider this potential association. Identification of skull fractures in children is clinically relevant because these fractures may need surgical intervention irrespective of the presence of TBI. 27 Furthermore, in children who are more anxious and easily overstimulated, POCUS may be used by the attending physician at the bedside. It is a rapid, non-invasive and inexpensive diagnostic tool that does not carry the risk of radiation in comparison to CT. POCUS has become an integral part of emergency medicine practice. 23 In mild head-injured children ultrasound might be utilised as a diagnostic tool for identifying skull fracture in children that may otherwise undergo a head CT. вЂMild head injuryвЂ™ patients are, according to the Head Injury Severity Scale classification, initially conscious at first assessment (GCS score 14вЂ“15), may have had a brief loss of consciousness or amnesia, but do not have any focal neurological deficits on admission. 21 The use of CT scanning also adds to the costs of healthcare. 20 Occasionally sedation is needed during the diagnostic study to minimise motion artefacts sedation is also associated with the risk of adverse respiratory events including desaturation and the need for airway intervention. 15вЂ“19 Also, it has been demonstrated that low doses of ionising radiation to the brain in infancy may influence cognitive ability in adulthood.

CT exposes children to radiation that may increase lifetime risk of malignancy. 15 16 The diagnostic standard tool to detect TBI is CT. 11 14 15 In addition, infants with skull fractures rarely present without local signs of head injury on physical examination. 14 The reported rate of skull fracture in children with blunt head trauma ranges from 16% to 63%. 2 4 8 10вЂ“13 Furthermore, TBI in the absence of skull fracture is rare in the paediatric population.

2 7вЂ“9 Most of the clinical decision algorithms include clinical suspicion of a skull fracture because the presence of skull fracture increases the likelihood of an intracranial injury fourfold. 2 POCUS may have a potential role in the evaluation of low-risk paediatric patients, to identify skull fractures and subsequent TBIs.Д¬linical decision algorithms have been developed to identify head-injured children with TBI (eg, Pediatric Emergency Care Applied Research Network, Canadian Assessment of Tomography for Childhood Head injury, National Institute for Health and Care Excellence Head Injury guideline or ChildrenвЂ™s Head injury ALgorithm for prediction of Clinically Important Events ). However, children who appear to have a low risk for traumatic brain injury (TBI) may still have clinically important injury. 3 Severely head-injured children are in general easily identified and treated. 1 Up to 8% of children aged 3вЂ“17 years old have had a significant head injury in their lifetime, 2вЂ“6 and it is one of the leading causes of mortality in children worldwide. The Centers for Disease Control and Prevention in the USA reported 749вЂ‰000 ED visits for injury to the head in children under the age of 15 years old in 2016. Head injuries in children are a common presentation to emergency departments (EDs) point-of-care ultrasounds (POCUS).

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