311) A 3 year old male child is brought to the emergency room by his mother after he fell from his tricycle and sustained an injury to his head . The child was found to be alert and awake after the fall, however, he reported mild pain on the right side of his head. His mother noted a small bruise and swelling over the right side of his scalp. There is no history of vomiting or nausea. He has no past history of convulsions or epilepsy. Family history is unremarkable. At this time, child is quiet and reports mild headache. On examination, he is alert and awake. He is not in distress. There is small contusion on the fronto-parietal aspect of his scalp. There is no evidence of hematoma. Palpation does not reveal any depressed fracture. Neurological examination is normal with out any deficits. Rest of the physical exam is normal. Which of the following is the most appropriate management at this time?
A) Contact Child Protection Services
B) Perform Head CT scan
C) Admit to Hospital
D) Observe at home
E) Skull X-rays
8 comments:
Observe at home, no loc, pe neg, clinic ok.
D.
E
this patient needs a skull x ray along with a period of observation...as the patient may be in lucid interval for extradural hematoma..........if any of the danger signs appear like vomiting, deteriorating GCS, convulsions, persistant headache, then go for CT scan
observe at home..
d
observe at home
Answer. Observe at Home.
This child has no clinical evidence of possible major brain injury and does not require any imaging. He needs to be observed at home for 24 hours for development of any warning signs such as persistent vomiting or altered mental status. If such symptoms develop, then Head CT should be pursued. This question focuses on indications for neuro-imaging in children with mild head trauma. Minor Head trauma is very common in children. Careful history taking is important to exclude major head injury. Minor traumatic head injury may be asymptomatic or may be associated with brief loss of consciousness, and one to two episodes of vomiting. Symptoms and signs that may suggest major head trauma include prolonged loss of consciousness, lethargy, behavior changes, convulsions, persistent nausea and vomiting, presence of scalp hematoma, physical examination evidence of depressed skull fracture and focal neurological deficits. In such cases, neuro-imaging with Head CT scan is indicated. When these features are absent, the likelihood of clinically significant traumatic brain injury is less than 0.05 percent. It is important not to perform Head CT scan when these indications are absent in order to avoid unnecessary radiation exposure from Head CT in growing Children
Choice A is incorrect. The patient’s clinical history is consistent with traumatic injury rather than child abuse. The history regarding the method of injury is consistent with the patient’s physical findings of scalp swelling. There are no other physical examination findings to suspect child abuse. Often other injuries or wounds at different sites or evidence of previous abuse ( such as scars, bruises) may be noted on other parts of the body.
Choice B is incorrect. See indications of neuroimaging above.
Choice C is incorrect. Child has sustained trivial head trauma and observation at home will suffice. Persistent headache, persistent vomiting or altered sensorium is indications for neuro-imaging and admission. Admission to hospital is also indicated if child abuse is suspected or if the care-giver is unreliable.
Choice E is incorrect. There is no clinical evidence of a fracture or Hematoma. So, a skull x-ray is not indicated. A careful palpation often reveals a depressed fracture in most cases. Skull X-Rays may be used to screen for fractures in suspected cases with scalp hematomas to evaluate underlying fracture. If Skull X-rays show fracture then a Head CT must be performed.
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