Thank you to Dr. Chris “This Ain’t No Simulation” Strother.
3 kids, 3 head injuries.
A) 2-month old boy, fell out of baby carriage onto top of head 30 minutes ago. No LOC, seizure, vomiting. Acting normally per mom. Abrasion on superior scalp, no palpable skull fracture, fontanelle flat.
B) 18-month old boy, healthy, fell off slide at playground (about 3 feet) onto padded surface 30 minutes ago. Brief LOC (<5 sec), no seizure. Vomited once shortly after fall. Patient awake and sitting calmly but mom says he “usually is very hyperactive this time of day”. Parietal hematoma on exam, no palpable fracture, no neuro defecit.
C) 5-year old boy. healthy, struck tree while sledding and hit head, 30 minutes ago. No LOC, seizure or vomiting. Calm, will open his eyes when you talk to him. Frontal hematoma, no palpable fracture. Moving all extremities normally.
Who goes to CT?
A) Yes. Age < 3 months is a high-risk feature when coupled with a concerning mechanism or physical exam findings.
B) This would be a reasonable case for observation. Keep the child in the ED for 4-6 hours and if he remains asymptomatic he can be discharged with return to ER instructions to the caretaker. This is a purposefully ambiguous case and if your gestalt was that this was a concerning injury, you wouldn’t be wrong to scan him initially.
C) Yes. GCS<15 on presentation in a child 2 years or older carries a 4.3% risk of clinically important TBI (from PECARN data).
[all pts were male to eliminate gender-bias]
