About 90 minutes ago, our 26-month-old d
For reference only. Not medical advice.
Question
About 90 minutes ago, our 26-month-old daughter fell off our 3-foot adult bed onto the hardwood floor, landing hard on the side of her head. She cried inconsolably for about 10 minutes, and we noticed a prominent, boggy swelling ("goose egg") above her right ear (temporal/parietal region).
Over the last 45 minutes, she has vomited twice (large volume of undigested dinner and bile), and she now appears unusually lethargic and glassy-eyed. She keeps closing her eyes and slumping on the sofa.
My mother-in-law told us:
"Every toddler falls and gets a bump on the head! She cried so hard she exhausted herself and got an upset stomach. Just let her sleep it off in her crib tonight, she will be fine by morning!"
However, my husband and I are terrified of internal bleeding or concussion complications.
Could you provide:
- The 'Sleep It Off' Myth vs Epidural Hematoma & Lucid Interval:
- The clinical danger of assuming post-trauma sleepiness and vomiting are just "exhaustion from crying".
- What the classic "lucid interval" represents in pediatric intracranial hemorrhage (middle meningeal artery tear / epidural hematoma vs subdural hematoma).
- PECARN Head Trauma Clinical Decision Rule (Ages 2 and Older):
- How the PECARN pediatric head injury algorithm stratifies risk for Clinically Important Traumatic Brain Injury (ciTBI).
- High-risk predictors present in this scenario (fall from bed, repeated vomiting >= 2 episodes, altered mental status / lethargy, non-frontal temporal/parietal scalp hematoma).
- Emergency Action Protocol Tonight:
- Why immediate emergency department evaluation and non-contrast pediatric head CT scan are indicated.
- What NOT to do right now (do not give ibuprofen or sedating antihistamines, do not let her sleep unmonitored at home).
Answer
I'll start by reading the clinical cards this case needs, and checking the family profile.
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The existing files are stale leftovers from a previous session — the user_text and ems-lookup don't match this turn's story. Let me write a fresh draft, validate it, then send.
Lint returned PASS. Let me read the draft back to make sure I send it exactly as written.
Call your local emergency number now, or drive straight to the closest pediatric emergency department. Do not let her fall asleep in the crib unmonitored, and do not stop to look anything else up — go.
Why this is not "exhaustion from crying."
After a head knock, the danger signs pediatric head-injury rules group together are: repeated vomiting (twice or more), acting abnormally or not waking properly, a fit, loss of consciousness, severe headache, a visible skull dent, blood or clear fluid from the ear, bruising behind the ear, and a scalp swelling that is not on the forehead — at the side, back, or temple. Your daughter has several of these at once:
- Vomited twice in the last 45 minutes, large volume, with bile.
- Now lethargic, glassy-eyed, eyes closing, slumping on the sofa — that is altered mental status, not tiredness.
- The swelling is temporal/parietal (above the right ear), which is exactly the location pediatric rules flag — a non-frontal scalp hematoma.
- Mechanism: ~3-foot fall onto a hardwood floor, the lower edge of a "severe mechanism" in the under-2 rule.
The sequence you described — cried hard, then settled, then started vomiting and became drowsy — is the classic *lucid interval* pattern of an intracranial bleed, most often an epidural hematoma from a tear of the middle meningeal artery (the artery runs just under the temporal bone, so a temporal swelling is the named red flag). A child with an expanding epidural bleed can look roughly okay for minutes to a few hours, then deteriorate quickly as blood accumulates inside the skull. A subdural bleed more often has a slower, lower-pressure decline and is more common in infants, but the early hours look the same to a parent: quiet, then sick. The "let her sleep it off" advice your mother-in-law is giving is the exact pattern pediatric head-injury guidance warns against — a child who is becoming drowsy *because of a brain bleed* looks identical to a child who is becoming drowsy because she cried herself out.
What to do in the next minutes
| Do now | Do not |
|---|---|
| Keep her gently roused or stay at her side watching every breath; write down the time of each vomit and each change in how alert she is | Put her to bed to "sleep it off" |
| Hold her still and support her neck — a head knock can come with a neck injury even when you can't see it | Twist or rotate her neck to "check" it |
| Nothing by mouth — she may need sedation for imaging, and she may vomit again | Give ibuprofen, or any sedating antihistamine (diphenhydramine / Benadryl, doxylamine, hydroxyzine) |
| Photograph the swelling with the time on the photo | Give acetaminophen-as-a-sleep-aid to "take the edge off" |
A sedating antihistamine or a "wait and see" dose of ibuprofen blurs the one exam the ED team will keep re-checking — her level of consciousness, and how it changes minute to minute. Acetaminophen (paracetamol) for pain, in the dose on the bottle, is the only fever-or-pain medicine that does not muddy that exam.
What not to do tonight
- Do not let her sleep unmonitored. If she falls asleep in the car or on the way, stay beside her, watch her breathing, and be ready to gently rouse her.
- Do not give any more sedating medicine — no children's Benadryl, no gravol, no melatonin, no chamomile "to calm her."
- Do not dismiss this because she cried at first. Crying at impact is not the reassuring sign; the trend over the next hours is.
- Do not wait for a seizure to decide. By the time a seizure happens, the bleed has usually been growing for a while. The window for a clean ED CT is *now*, while she is still rousable.
Tell me your country or city and I will pull the exact local emergency number and the closest pediatric emergency department, so you are not dialing from memory. If a pediatric ED is more than 30 minutes by car, the ambulance is faster — call first, then carry her to the door.
Bring to the team: time of the fall, how long she cried, each vomit with its time, when she became sleepy, every medicine she has been given (including any acetaminophen), her weight if you know it, allergies, prior head injury, and any bleeding-disorder history. The photograph of the swelling with the time on it goes straight to the nurse taking the history.