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The likelihood on day 4 of having a clinically important bleed seems pretty
low. However, the likelihood of having a skull fracture (prior to the
x-rays) seems reasonably high. While in most cases, there's nothing you'd
do about a non-depressed skull fracture, I think it's still worth knowing
about. There's a low-likelihood but real possibility of non-union, which
puts the child at risk for a growing fracture/leptomeningeal cyst. It'd be
worth it to me to know of the fracture, and monitoring for this outcome as
the fracture heals (my N=1 experience as the parent in this situation
probably informs this opinion to some degree!).

An additional question is how reliable are plain films for determining
depressed vs. non-depressed skull fracture. My guess (and it's exactly
that) is that plain films aren't reliable, which makes me wonder if the CT
might be worthwhile. I could be convinced otherwise, though.

Best,
Chris

On Fri, Jun 1, 2012 at 5:07 PM, Gill Winnik <[log in to unmask]>wrote:

> If those kids would have presented to you, as before, on day 4 with this
> large parietal swelling  and looking good would you have done ANY imaging???
> Giora
> ________________________________________
> From: Pediatric Emergency Medicine Discussion List [
> [log in to unmask]] on behalf of James Wilson [
> [log in to unmask]]
> Sent: Friday, June 01, 2012 2:21 PM
> To: [log in to unmask]
> Subject: Re: mastoiditis imaging
>
> Kathy,
> We punt to CT, with immediate call to ENT.  Slightest sign of neuro
> changes we move to LP.  As a point of note, we've seen quite a bit of
> Pseudomonas, MRSA, and one case of venous cavernous sinosus thrombosis out
> our way.  In regards to MRSA, noting kids getting their ear tubes
> contaminated, which precipitates removal... Then you find out they've been
> sitting in school for a week or so with goo dripping out the ear, onto the
> shirt, on their hands/desk/whatever.
> Jim Wilson, MD
> Pediatrics
> Delta CO
>
> On Jun 1, 2012, at 11:20 AM, Mohammed <[log in to unmask]> wrote:
>
> > The prolonged hx while on antibiotics is worrisome.
> > Our colleagues ENT definitely will ask for CT
> > Best Regards
> >
> > M Alomar
> > Riyadh, Saudi Arabia
> >
> > On Jun 1, 2012, at 5:29 PM, neil mullen <[log in to unmask]> wrote:
> >
> >> DDX exists.  Image.
> >>
> >>
> >>
> >> ________________________________
> >> From: "Goetz, Kathleen" <[log in to unmask]>
> >> To: [log in to unmask]
> >> Sent: Friday, June 1, 2012 12:19 AM
> >> Subject: mastoiditis imaging
> >>
> >> 9 month old healthy immunized child with 17 days OM.  Treated with
> Amoxil x 7 days, cefdinir x 10 days, presents with protruding right ear,
> suppurative ROM, post auricular erythema, fever, otherwise well appearing.
> >> Would you image this child who has clinical mastoiditis?
> >> If so - CT?
> >> Has your practice changed due to increasing concerns about CT/radiation
> exposure in infants?
> >> Kathey Goetz
> >>
> >> Kathleen Goetz, MD
> >> Medical Director
> >> Swedish Pediatric Emergency Services
> >> Office:  206-386-3313  ED:  206-386-2573  Cell: 253-370-7571
> >>
> >>
> >>
> >> For more information, send mail to [log in to unmask] with
> the message: info PED-EM-L
> >> The URL for the PED-EM-L Web Page is:
> >>                http://listserv.brown.edu/ped-em-l.html
> >>
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> >
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-- 
Chris Merritt, MD, MPH, FAAP
Pediatric Emergency Medicine
Hasbro Children's Hospital
Alpert Medical School, Brown University
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