I would like to post this case scenario to get an input about how people
in Pediatric Emergency Medicine community feel regarding management of
isolated head injury.
A 10 year old boy was playing basketball and subsequently fell from the
height of the net and hit his back of the head. There was no LOC.He was
ambulatory following the incident.However he was taken to the nearest
emergency room.There he was reported to be alert and oriented with a GCS
of 15.Initially skull films were taken and reportedly normal.However as
he started to "throw up", a head CT was orderded by his Pediatrician.The
head CT was reported to be normal.As the facility did not have any
neurosurgery coverage pediatrician decided to observe him overnight in
the hospital. He was kept NPO and was started on IV fluids. His
overnight stay in the hospital was uneventful.
On the following day around noon time, he started to become agitated and
combative.His pediatrician decided to watch him more.In the late
afternoon and early evening as his symptoms continued to have worsened
from agitation to intermittent drowsiness, second CT was orderdered.This
time it showed left temporal lobe subdural hematoma(about 2 cm in size)
with a mass effect localised in the left temporal lobe.There was no
midline shift.Pediatrician now decides to tranfer the patient to a
tertiary care hospital.
Tertiary care tranport team was flown in, which consisted a critical
care fellow and an ICU nurse.Pediatrician at this time reported to the
accepting facility that,apart from the patients mental status change,his
pupils were normally reacting and equal,his respiration was regular,he
was normotensive and although he was not bradycardic he had occassional
sinus arrhythmia.He was advised by the accepting physician to intubate
the child and hyperventilate keeping the Pco2 around 30, till the
tranport team have reached there, unless there were any other changes.
However when the tranport team reached that facility(about 50 mins
tranport each way), they found the child had unequal pupil size with
left pupil being non-reactive. Child was given mannitol 0.25 gm/kg and
transported back to the tertiary care center.
Enroute child's pupillary size were reportedly normal and both were
The child was taken to the operating room, hematoma evacuated and
possibly going to have a favorable outcome.
Now my questions are:
1)how many of you think that the child deserved a full trauma evaluation
and a full trauma work-up before taking him to OR.(please note the
referring hospital had done CBC-Diff twice without any significant drop
in Hb, and electrolytes)
2)how many of you think it was absolutely necessary to clear his C-Spine
radiographically, taking into consideration of his presentation after
the initial injury. Although there was no mention about it,his cervical
spine clearance must have been done by clinical examination.
3) Is there any study which showed radiographic evidence of C-spine
injury where there was no evidence of such an injury by intial clinical
presentation and also by the mechanism of injury, specially ater 24 hrs.
from the original insult?
Any thoughtful comments would be greatly appreciated,
Children's Hospital of Buffalo.
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