Question of the week # 311

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

13 Responses

  1. Observe at home, no loc, pe neg, clinic ok.

  2. D.

  3. E

  4. 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

  5. observe at home..

  6. d

  7. observe at home

  8. take head ct scan

  9. b

  10. d

  11. aaa

  12. D…..

  13. CT Scan in Head Injuries[4][5]
    Selection of adults for CT Scan
    Urgent scan if any of the following (results within 1 hour):

    Glasgow Coma Scale (GCS) <13 when first assessed or GCS 1 episode of vomiting (SIGN guidance suggests 2 distinct episodes of vomiting)
    Coagulopathy + any amnesia or loss of consciousness since injury

    A CT scan is also recommended (within 8 hours of injury) if there is either:

    More than 30 minutes of amnesia of events before impact
    Or any amnesia or loss of consciousness since injury if:
    Aged ≥65 years
    Coagulopathy or on warfarin
    Dangerous mechanism of injury
    Road traffic accident (RTA) as a pedestrian
    RTA – ejected from car
    Fall >1 m or >5 stairs.

    Selection of children (under 16 years) for CT Scan

    Urgent scan if any of the following:

    Witnessed loss of consciousness >5 minutes
    Amnesia (antegrade or retrograde) >5 minutes
    Abnormal drowsiness
    ≥3 Discrete episodes of vomiting
    Clinical suspicion of nonaccidental injury
    Post-traumatic seizure (no PMH of epilepsy)
    GCS <14 in emergency room
    (Paediatric GCS <15 if aged <1)
    Suspected open or depressed skull fracture or tense fontanelle
    Signs of base of skull fracture*
    Focal neurological deficit
    Aged 5 cm
    Dangerous mechanism of injury (high-speed RTA, fall from >3 m, high-speed projectile)

    *Signs of basal skull fracture: haemotympanum, ‘panda’ eyes (bruising around the eyes), cerebrospinal fluid (CSF) leakage (ears or nose) or Battle’s sign (bruising which sometimes occurs behind the ear in cases of basal skull fracture).

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