MORNING REPORT

JANUARY 2, 2012 DAVID LEVY

HPI: 6 year-old girl with acute onset of vomiting. Started about one hour ago and has had six episodes of non-bilious, non-bloody emesis. Witnessed fall from grandfathers shoulder 3 hours ago. No LOC. Immediately started crying and has been awake but more irritable since. No eye deviation, no extremity twitching. PMH: No hospitalizations. No surgeries. Birth Hx: NSVD at term. Imm: Up to date ROS: No open bottles around patient. No diarrhea. No fevers. No cough, no congestion, no rashes. No recent weight gain or weight loss. Otherwise negative. Development: Delayed speech (about 18-month level). Otherwise normal Diet: Normal for age

Meds: None Allergies: None Family Hx: No known illnesses Social Hx: Lives in Magna with parents and grandparents. Positive exposure to tobacco smoke. Only in the house. Primarily in the childs room.

VS: Wt 13kg (25%), Ht 91cm (18%) T 36.7, HR 120, RR 32, BP 109/60, SO2 98% on RA O: GEN: Awake, crying, resisting exam. HEENT: 4cm area of swelling palpated over right parietal area. PERRL. EOMI. Conjunctiva clear, sclera anicteric. Ear canals clear bilaterally, no hemotympanum. TMs gray with normal landmarks bilaterally. Nares patent. No nasal discharge. MMM, tonsils non-erythematous, non-enlarged, NECK: Supple. No lymphadenopathy. RESP: Normal WOB with good air entry. CTA bilaterally. CV: RRR, normal S1 and S2. No murmurs, Radial pulses 2+ and symmetric. Cap refill < 2 seconds Abd: Soft, nontender, nondistended, BS+ in all 4 quadrants. No HSM or masses. No guarding, no rebound tenderness. BACK: No tenderness on palpation of cervical, thoracic, lumbar spine. No bruising. EXT: Warm, dry, well perfused, no clubbing cyanosis or edema. SKIN: No rashes, jaundice or petechiae NEURO: CN 2-12 grossly intact. Moves all extremities. Patellar reflexes 2+.

Differential?

Labs:

iSTAT: 7.4/31/43/19/5; Na 140, K 4.2, CO2 20, Gluc 103, iCa 1.27, Hgb 12.2, Hct 36 PT/INR 17.9/1.5 PTT 31

Imaging:

Pediatric Head Trauma

Glasgow Coma Score

Canadian Assessment of Tomography for Childhood Head injury (CATCH) Rule

Study assessing need for head imaging in children with minor head trauma CT of the head is required only for children with minor head injury and any one of the following findings High risk (need for neurologic intervention) 1. Glasgow Coma Scale score < 15 at two hours after injury 2. Suspected open or depressed skull fracture 3. History of worsening headache 4. Irritability on examination Medium risk (brain injury on CT scan) 5. Any sign of basal skull fracture (e.g., hemotympanum, raccoon eyes, otorrhea or rhinorrhea of the cerebrospinal fluid, Battles sign) 6. Large, boggy hematoma of the scalp 7. Dangerous mechanism of injury (e.g., motor vehicle crash, fall from elevation 3 ft [ 91 cm] or 5 stairs, fall from bicycle with no helmet)

A study by our former colonial oppressors:

Study assessing need for head imaging in children with any head injury
History Witnessed loss of consciousness of >5 min duration History of amnesia (either antegrade or retrograde) of>5 min duration Abnormal drowsiness (defined as drowsiness in excess of that expected by the examining doctor) 3 vomits after head injury (a vomit is defined as a single discrete episode of vomiting) Suspicion of non-accidental injury (NAI, defined as any suspicion of NAI by the examining doctor) Seizure after head injury in a patient who has no history of epilepsy Examination Glasgow Coma Score (GCS) <14, or GCS <15 if <1 year old Suspicion of penetrating or depressed skull injury or tense fontanelle Signs of a basal skull fracture (defined as evidence of blood or cerebrospinal fluid from ear or nose, panda eyes, Battles sign, haemotympanum, facial crepitus or serious facial injury) Positive focal neurology (defined as any focal neurology, including motor, sensory, coordination or reflex abnormality) Presence of bruise, swelling or laceration >5 cm if <1 year old Mechanism High-speed road traffic accident either as pedestrian, cyclist or occupant (defined as accident with speed >40 m/h) Fall of >3 m in height High-speed injury from a projectile or an object

Pediatrics article:
Note: Dr. Schunk was an author of this study, so take with a grain of salt
Proposed imaging guidelines (from literature review) for children less than 2 years old with minor head trauma High-risk (CT indicated): 1) Depressed mental status; 2) Focal neurologic deficits; 3) Signs of depressed or basilar SF; 4) Acute SF by clinical examination or by SR (if already done) 5) Irritability; or 6) Bulging fontanelle Intermediate risk (infants and children at some risk for a complication of head injury, in whom imaging or observation is indicated): -2 subgroups 1) Children with clinical indicators of possible brain injury 2) Children with a concerning or unknown mechanism, or who have findings on physical examination that may indicate an underlying SF Low risk (low-energy mechanisms (eg, fall >3 feet) who have no signs or symptoms at least 2 hours after the injury): Can discharge if meets 1. The child has no significant extracranial injuries or other indications (eg, unremitting vomiting) for admission; 2. The child easily alerts and has a normal neurologic examination; 3. There is no suspicion of abuse or neglect; and 4. The child lives in relatively close proximity to health care and has reliable caretakers who are able to return if necessary.

Lancet article
(We cant get rid of this guy) Study to identify children at low risk of brain injury after head trauma <2 yo: -CT recommended: if GCS <14 or other signs of altered mental status or palpable skull fracture -Observation versus CT on the basis of other clinical factors: (MD experience, multiple vs isolated findings, worsening s/s after ED observation, age <3 mos, parental preference): Occipital or parietal or temporal scalp haematoma, or history of LOC 5 sec, or severe mechanism of injury, or not acting normally per parent -CT not recommended if no to both 2 above >2 yo: -CT recommended: GCS=14 or other signs of altered mental status or signs of basilar skull fracture -Observation versus CT on the basis of other clinical factors: (MD experience, multiple vs isolated findings, worsening s/s after ED observation, parental preference): History of LOC, or history of vomiting, or severe mechanism of injury, or severe headache -CT not recommended if no to both 2 above

PECARN and Friends

Study to identify need for imaging of patients who have TBI with minor blunt head trauma and isolated severe injury mechanisms - Severe injury mechanism: Motor vehicle collision with patient ejection, death of another passenger, or rollover; a pedestrian or bicyclist without helmet struck by a motorized vehicle; falls (at a height of >3 feet for children <2 years and >5 feet for children 2 years); or the head struck with a high impact object PECARN prediction rules consist of 5 clinical criteria: < 2 years: Altered mental status, nonfrontal scalp hematoma, loss of consciousness for 5 seconds or greater, palpable skull fracture, and not acting normally per parents. 2 years: Altered mental status, any loss of consciousness, history of vomiting, clinical signs of basilar skull fracture, and severe headache Conclusion: If children have isolated severe injury mechanism but none of above other criteria and no other initial s/s of TBI, can observe for a period of time before CT decision making, and CT may be obviated if no signs or symptoms appear

In sum: When to image

Definite: - GCS <14 - Physical exam suggestive of skull fracture - Focal neurological deficit - Scalp hematoma (non-frontal) - Irritability - Abnormal mental status - Severe mechanism of injury - Suspicion of NAT Probable (yes, but no consensus on specifics): - Headache - Vomiting - Loss of consciousness

References

Osmond MH, Klassen TP, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. Canad Med Ass Journal 2010. 182: 341-348. Dunning J, Daly JP, et al. Derivation of the childrens head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child 2006. 91: 885-891. Schutzman SA, Barnes P, et al. Evaluation and Management of Children Younger Than Two Years Old With Apparently Minor Head Trauma: Proposed Guidelines. Pediatrics 2001: 983-993. Nigrovic LE, Lee LK, et al. Prevalence of Clinically Important Traumatic Brain Injuries in Children With Minor Blunt Head Trauma and Isolated Severe Injury Mechanisms. Arch Pediatr Adol Med. 2011. E1-E6. Kuppermann N. Pediatric Head Trauma: the evidence regarding indications for emergent neuroimaging. Pediatr Radiology. 2008. 38: 670-674. Martin C, Falcone RA. Pediatric traumatic brain injury: an update of research to understand and improve outcomes. Curr Opin Pediatr 2008. 20: 294299. Bishop NB. Traumatic Brain Injury: A primer for Primary care Physicians. Curr Prob Pediatr Adolesc Health Care 2006. 318-331. Palchak MJ, Holmes JF, et al. A Decision Rule for Identifying Children at Low Risk for Brain Injuries After Blunt Head Trauma. Annal Emerg Med. 2003. 42: 492-506. Kuppermann N, Holmes JF, et al. Identifi cation of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009. 374:1160-1170. Dunning J, Batchelor J, et al. A meta-analysis of variables that predict significant intracranial injury in minor head trauma. Arch Dis Child 2004. 89: 653659.

Pictures from

http://en.wikipedia.org/wiki/File:Gadsden_flag.svg http://www.vitals.com/doctors/Dr_Jeff_Schunk https://securembm.uuhsc.utah.edu/facmaster/Photos/Profile/FM00002829.jpg http://img.medscape.com/article/707/292/707292-table2.jpg http://upload.wikimedia.org/wikipedia/commons/thumb/1/10/IC_engine.JPG/300pxIC_engine.JPG http://classic.motown.com/images/local/umgartists/8394c9d0-f118-4d5d-87b4b30afca20ce5.jpg