Exploring Paramedics' Perspectives on Paediatric Head Injury in Prehospital Care: Qualitative Study

Paediatric head injury is a common reason for emergency calls. While most cases are mild, a small proportion deteriorates rapidly. Paramedics are often the first point of clinical contact, yet the absence of paediatric-specific tools, infrequent exposure and emotionally charged environments contributes to uncertainty. Paramedic perspectives in this context remain under-represented in the literature.

To explore paramedics' experiences, challenges and decision-making in the prehospital assessment of children with suspected head injuries and explore perceptions of existing hospital-based clinical decision rules and their potential use in out-of-hospital care.

A qualitative study, guided by an interpretivist approach, was conducted with 37 paramedics from the North West Ambulance Service NHS Trust, United Kingdom. Purposive sampling captured a range of clinical grades and experience levels. Semistructured virtual interviews explored clinical assessment, decision-making, communication with families and views on current guidelines and clinical decision rules. The Paediatric Emergency Care Applied Research Network and the Children's Head Injury Algorithm for the Prediction of Important Clinical Events were presented after participants described their usual practice. Interviews were audio-recorded, transcribed verbatim, anonymised and analysed inductively using reflexive thematic analysis.

Four inter-related themes captured the clinical, emotional and systemic realities of paediatric head injury assessment. Paramedics described the challenges in treating children, as developmental differences, limited communication and subtle or delayed symptoms required vigilance and adaptation. These were compounded by the paramedic's own challenges, including low confidence from limited exposure, training gaps and the emotional and ethical pressures of safeguarding. Participants showed frustration over adult-oriented tools, rigid guidelines and remote decision-making that undermined autonomy. The role of clinical decision rules was seen positively for structure and defensibility, but with caution about safeguarding, compensatory physiology, contextual risk and their limited relevance to non-conveyance decisions in out-of-hospital care.

Prehospital paediatric head injury assessment is shaped by intersecting clinical, emotional and systemic pressures. Improving care requires paediatric-specific decision tools, integrated training and system changes that support rather than professional judgement.