An 8-year-old boy with hemophilia A is brought to the emergency department after his family was in a minor motor vehicle accident. The child was restrained in the back seat on the passenger side when the car was hit on the driver's side. The airbag deployed and the boy lost consciousness for approximately 15 seconds. The patient has a headache but no nausea or vomiting. His temperature is 36.7 C (98 F), blood pressure is 114/66 mm Hg, pulse is 88/min, and respirations are 16/min. Physical examination shows a 2-cm right frontal hematoma. No other signs of trauma are seen. Neurological examination is within normal limits. Which of the following is the best next step in the management of this child's condition?

Question

An 8-year-old boy with hemophilia A is brought to the emergency department after his family was in a minor motor vehicle accident.  The child was restrained in the back seat on the passenger side when the car was hit on the driver's side.  The airbag deployed and the boy lost consciousness for approximately 15 seconds.  The patient has a headache but no nausea or vomiting.  His temperature is 36.7 C (98 F), blood pressure is 114/66 mm Hg, pulse is 88/min, and respirations are 16/min.  Physical examination shows a 2-cm right frontal hematoma.  No other signs of trauma are seen.  Neurological examination is within normal limits.  Which of the following is the best next step in the management of this child's condition?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c00a_8d1e_8f63_3ba188dc7cc6_MD0005_00 In a healthy child with normal mental status, Glasgow Coma Scale (GCS) score of 15, and no evidence of basilar skull fracture on examination, the incidence of clinically significant intracranial injury after minor head trauma is low (<1%). However, this child is at increased risk for intracranial hemorrhage (ICH) due to his history of hemophilia A. basilar skull fracture ICH is a significant cause of morbidity and mortality in children with hemophilia. ICH can occur spontaneously in infants and even after minor head trauma in older children with hemophilia. Common presenting symptoms include headache,vomiting, and altered mental status. A head CT scan without contrast must be ordered to look for hemorrhage in children with bleeding diatheses who sustain more than a trivial head injury or are symptomatic. New blood appears white on CT and can be obscured by contrast (also appears white). In addition to imaging, Factor VIII or IX should be replaced as soon as possible following the traumatic injury. white on CT (Choice A) Discharging this patient home is inappropriate given the risk for intracranial hemorrhage based on history of hemophilia and current symptoms. (Choice B) Observation for 4-6 hours prior to discharge would be appropriate if this child did not have a history of hemophilia. (Choice C) Head CT scan with contrast is most useful for identifying abscesses or intracranial masses, but contrast obscures acute bleeding and can confound the workup for intracranial injury. (Choice E) Plain radiographs of the skull can identify skull fractures but cannot detect intracranial injury. If a fracture is suspected, a head CT without contrast should be ordered because risk of intracranial hemorrhage increases with a skull fracture. Educational objective: Children with hemophilia and other bleeding diatheses who are symptomatic at the time of presentation are at increased risk for intracranial hemorrhage after even minor head trauma. A head CT without contrast should be performed emergently. References: Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. (http://www.ncbi.nlm.nih.gov/pubmed/19758692) Intracranial hemorrhage after blunt head trauma in children with bleeding disorders. (http://www.ncbi.nlm.nih.gov/pubmed/21232760) Utility of computed tomography of the head following head trauma in boys with haemophilia. (http://www.ncbi.nlm.nih.gov/pubmed/17880444) Intracranial haemorrhage in haemophilia A and B. (http://www.ncbi.nlm.nih.gov/pubmed/18081890)

An 8-Year-Old Boy with Hemophilia a Is Brought to the Emergency