Pediatric Case of the Week 23: No More Monkeys Jumpin' On The Bed!

Yet another weekend overnight shift is upon you.  Your partner has signed out his last patient (nothing to do).  The pediatrician is long gone carrying most of the western-suburban viral strains home with her.  You carefully sanitize your keyboard and dictaphone hoping to avoid inoculation with one of the gagillion summer enteric viruses coating all things in your vicinity. You then glance at the board to see your first case of the night, a "two-fer."

Your next patient(s) are a 3 year old and 7 month old brother and sister.

During the family's evening routine (organized chaos), the 3 year old began jumping on his bed.   The 7 month old was (momentarily) left laying next to the bed while father ran out of the room for "another pack of wipes."   Apparently the 7 month old had generated an epic diaper, something akin to  "Mount Vesuvius", and father was left with no better choice than to franticly race for "reinforcements."  

While father was dashing back from the bathroom he witnessed the 3 year old, mid air, confused look on face, hurling off the bed and towards a defenseless cooing 7 month old.  Impact occurred in slow motion: 3 year...old's...knee...struck...7 month...old's... forehead,... then... 3 year... old's... head... struck... side table next to bed.

All cried immediately.   (Father cried mostly because he knew he would have to explain everything to Mom who was downstairs taking "an aspirin" (valium) at the time to the incident.

You decide to evaluate the 7 month old first:

Vital signs are appropriate for age. She cries initially at the sight of your tired face and threatening otoscope. She is however, easily consoled by Mom.   She moves spontaneously and reaches for the light with both hands.  Mom reports that she seems to be acting her normal self.  She has a 3 cm erythematous hematoma squarely placed between her eyes.  There is no boney step off or crepitus to suggest skull fracture.  The rest of her exam is unremarkable.

You evaluate the 3 year old next:

Vital signs are appropriate for age.  He is alert and oriented per parents.  Mom notes that he vomited once initially right after the injury.  She says that sometimes when he cries he begins to cough and gag which occasionally leads to vomiting.  He has a 4 cm hematoma on his right parietal scalp.  His left knee has a small (nearly indiscernible) bruise over the patella.




What would you like to do for these two patients? 

Would you image the head?  (CT or no CT, that is the question.)

What would you like to do for these two parents?

My favorite version of this popular children's song: http://www.youtube.com/watch?v=5zrQdxV24MY
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Pediatric Case of the Week 23: Weekend Update

You will be best served if you watch Dr Reid's Pediatric Head Trauma Lecture.

Most importantly, here is the PCARN Algorithm and a Link the the MDCalc calculator.

LINK to MD CALC:  http://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm/



Based on this algorithm:

I would not CT the 7 month old

I would consider CT in the 3 year old.  Concerns include: Parietal hematoma, Mechanism, and vomiting (although only once).  I think it is reasonable to observe for a period of time to see if child has any additional vomiting or change in behavior.  If parents are capable, I would consider having a risk benefit conversation about the likelihood of bleed requiring surgery versus the risk of radiation.

Risk of radiation could be discussed in two ways depending on how you would like to frame the conversation.

You could say:  "The risk of cancer death due to radiation exposure from head CT in childhood is thought to range from 1/10000 to 8/10000."

Or you could say:  "The Estimated lifetime attributable risk of death from Cancer after a single head CT is about 0.08%."

There are many nuances to this conversation that cannot be captured in a blog posting.  Ultimately, a lot depends on the parents risk tolerance and level of anxiety.  (Physician risk tolerance and level of anxiety also play a role.)

It would also be helpful to know if the Radiologists you work with follow a practice of ALARA (As Low As Reasonably Achievable).  This can significantly reduce the number of millisieverts that a child is exposed to.  If you don't know, talk to your radiologist and 'remind them.'

For the BIG NERDS: here is the 2009 Kuppermann article in the Lancet.  If you are ever going to do a study, this is a great model for quality.  It doesn't get much better than this.

http://www.pecarn.org/documents/Kuppermann_2009_The-Lancet.pdf

For the BIGGER NERDS: here is the Brenner article in the NEJM from 2007:

http://www.nejm.org/doi/full/10.1056/NEJMra072149


Hope you enjoyed this case.  Have a great summer.  Be safe.



And wear your helmet!!! (Correctly)

Examples Helmet wearing (please identify right and wrong):

And some examples of "Designer Helmets"