An 11-month-old boy is brought to the emergency department following a head injury. About 45 minutes ago, the patient had pulled himself up to stand on the second step of the staircase at home. He attempted to take a step to the side and as his mother approached to grab him, lost his footing and tumbled onto the floor, falling from a height of 0.38 m (15 in). The boy hit his head on the wooden floor and began crying. He did not lose consciousness and has not vomited. The patient was born at 33 weeks gestation. He has no chronic medical conditions. Vital signs are normal. Glasgow Coma Scale is 15. Examination shows a 4 cm hematoma along the right parietal lobe. The anterior fontanel is closed. Neurological examination shows a symmetric face with equal and reactive pupils. The boy reaches out with each hand equally. When the plantar surface of each foot is stroked with a pointed object, the corresponding big toe dorsiflexes while the remaining toes fan out. Which of the following is most concerning for an underlying traumatic brain injury in this patient?

Question

An 11-month-old boy is brought to the emergency department following a head injury.  About 45 minutes ago, the patient had pulled himself up to stand on the second step of the staircase at home.  He attempted to take a step to the side and as his mother approached to grab him, lost his footing and tumbled onto the floor, falling from a height of 0.38 m (15 in).  The boy hit his head on the wooden floor and began crying.  He did not lose consciousness and has not vomited.  The patient was born at 33 weeks gestation.  He has no chronic medical conditions.  Vital signs are normal.  Glasgow Coma Scale is 15.  Examination shows a 4 cm hematoma along the right parietal lobe.  The anterior fontanel is closed.  Neurological examination shows a symmetric face with equal and reactive pupils.  The boy reaches out with each hand equally.  When the plantar surface of each foot is stroked with a pointed object, the corresponding big toe dorsiflexes while the remaining toes fan out.  Which of the following is most concerning for an underlying traumatic brain injury in this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bff1_38a0_8f63_01734d0a44a7_MD0005_00 This patient has sustained minor head trauma, which is defined as blunt trauma in an alert patient with a nonfocal neurological examination. Although the trauma is mild, skull fractures and intracranial injury (eg, hemorrhage) can occur. Children age <2 are at the highest risk for skull fractures; however, clinical assessment of a young, nonverbal child is often challenging. In addition, in infants with open fontanels, intracranial hemorrhage is more likely to be asymptomatic. The evaluation of minor head trauma is based on risk for intracranial injury. High-risk features in children age <2 include: Altered mental status Loss of consciousness Severe mechanism of injury (eg, fall >0.9 m [3 ft], high-impact hit, serious motor vehicle collision) Nonfrontal scalp hematoma Palpable skull fracture This patient has a nonfrontal scalp hematoma, which may indicate an underlying skull fracture. Large (ie, >3 cm) parietal and temporal hematomas have the highest risk. CT scan of the head without contrast is the preferred imaging study to assess for skull fracture or intracranial injury when high-risk features are present. Observation for 4-6 hours in the emergency department may be an alternative option for children at intermediate risk (eg, self-limited emesis, small/isolated scalp hematoma). Patients may be discharged with return precautions if the CT scan is normal or if symptoms improve during the observation period. (Choice A) Patients with closed fontanels are more likely to have symptoms of increased intracranial pressure (eg, headache, vomiting) with intracranial injury, but they are not at higher risk for developing traumatic brain injury. This patient's closed anterior fontanel is a normal finding for age. (Choice B) Fall height >3 ft is a risk factor for traumatic brain injury. This patient fell only 15 in. (Choice D) Focal neurological findings after head trauma raise a concern for intracranial injury. This patient's neurological examination is normal, including a Babinski reflex (ie, great toe dorsiflexion with fanning of other digits when the sole is stroked), which can be seen until age 2. (Choice E) The surface on which the patient landed is not a factor in assessing risk for intracranial injury in minor head trauma. Educational objective: The evaluation of a child following minor head trauma is based on risk for intracranial injury. In children age <2, high-risk features include altered mental status, loss of consciousness, severe mechanism of injury, nonfrontal scalp hematoma, and palpable skull fracture. References: Risk of traumatic brain injuries in children younger than 24 months with isolated scalp hematomas. (http://www.ncbi.nlm.nih.gov/pubmed/24635991) To scan or not to scan: overutilization of computed tomography for minor head injury at a pediatric trauma center. (http://www.ncbi.nlm.nih.gov/pubmed/30463714)

An 11-Month-Old Boy Is Brought to the Emergency Department Following