A 3-year-old girl is brought to the emergency department after a head injury. About 30 minutes ago, she was playing in the backseat of a parked car and leaned against the car door while her mother was loading groceries. When her mother opened the door, the patient fell forward onto the ground, hitting her forehead. The seat was approximately 0.6 m (24 in) from the ground. She cried immediately but has not vomited. Temperature is 37.4 C (99.3 F), pulse is 130/min, and respirations are 24/min. The patient is alert and oriented. During the examination, she is anxious but consolable by her mother. There are abrasions on the forehead and right cheek. There are no step-offs or hematomas. The pupils are equal and reactive. There is no nasal drainage. The tympanic membranes appear clear. Which of the following is the best next step in management of this patient?

Question

A 3-year-old girl is brought to the emergency department after a head injury.  About 30 minutes ago, she was playing in the backseat of a parked car and leaned against the car door while her mother was loading groceries.  When her mother opened the door, the patient fell forward onto the ground, hitting her forehead.  The seat was approximately 0.6 m (24 in) from the ground.  She cried immediately but has not vomited.  Temperature is 37.4 C (99.3 F), pulse is 130/min, and respirations are 24/min.  The patient is alert and oriented.  During the examination, she is anxious but consolable by her mother.  There are abrasions on the forehead and right cheek.  There are no step-offs or hematomas.  The pupils are equal and reactive.  There is no nasal drainage.  The tympanic membranes appear clear.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d162_4d21_bc81_bff7803e1ee0_MD0003_00 This patient has minor head trauma, which is defined as a blunt head injury in an alert patient with no focal neurologic abnormalities. Although most minor head trauma does not result in serious injury, the goal of management is to identify those at risk for intracranial injury while avoiding unnecessary radiation exposure. High-risk features warranting consideration of imaging in children age ≥2 include: Altered mental status Loss of consciousness Severe mechanism of injury (eg, fall >1.5 m [5 ft], high-impact hit, serious motor vehicle collision) Vomiting or severe headache Signs of basilar skull fracture When high-risk features are present, a head CT scan without contrast is typically indicated to evaluate for an intracranial hemorrhage (Choice C). Observation for 4-6 hours can be considered in a patient with normal mental status, no signs of basilar skull fracture, and other high-risk features that have improved or are isolated (eg, resolved vomiting) (Choice A). Patients with no high-risk features (as in this patient) have a very low likelihood of clinically significant traumatic brain injury. Therefore, imaging should be avoided in these patients, and management should include reassurance and discharge home with education regarding symptoms (eg, severe headache) that would require reevaluation. (Choice B) Child Protective Services is notified when child abuse is suspected (eg, inconsistent history, delay in seeking care). In contrast, this patient has a plausible mechanism of injury, was transported immediately for medical care, and was appropriately consoled by her mother. (Choice D) Head ultrasound is used to screen for intracranial hemorrhages in premature infants with an open anterior fontanel, which typically closes by age 9-18 months. Educational objective: Imaging should be avoided in children with minor head trauma and no high-risk features for intracranial injury (ie, altered mental status, loss of consciousness, severe mechanism of injury, vomiting or severe headache, signs of basilar skull fracture). References: Minor head trauma in the pediatric emergency department: decision making nodes. (http://www.ncbi.nlm.nih.gov/pubmed/28393708)

A 3-Year-Old Girl Is Brought to the Emergency Department After