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Dr. Bandyopadhyay-
 
The risk of your patient having both a slowly developing subdural and a
relatively occult
c-spine injury are astronomically small. Does this mean the patient
should not have a C-spine
film? I would say that the management of your patient was excellent.
Nonetheless, raising the
question of whether or not a c-spine film should be done is definitely
reasonable.
 
Intracranial blood collections developing after a period a period of
observation in which
the patient has a GCS of 15 AND an initial head CT that is negative are
notably infrequent (Davis
et al. Pediatrics 1995;95:345-9). It has also been well documented that
they do occur. (Pietrzak et al. Am J
Emerg Med 1991;9:153-6.).
 
C-spine fractures from falls of low height (< 5 feet) are even more
rare.
(Schwartz et al. Ann Emerg Med 1997;30: 249-252). I am unaware of a case
report in which both
injuries have occurred from a fall of this type. Does this mean it will
never happen?
 
I will bet that this patient does well. The physicians involved should
be commended.
 
 
Jay Fisher MD
Ped Emerg Services
UMC/ Univ of Nev SOM
Las Vegas
 
 
 
Subhankar Bandyopadhyay wrote:
 
> 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
> reactive.
> 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,
> sincerely,
> Subhankar Bandyopadhyay,MD
> Fellow,Emergency Medicine
> Children's Hospital of Buffalo.
> New York
>
> 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://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html
 
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://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html