The Infant
Case 2.7 Fall off Changing Table
54 The Infant
Family m edical h istory: Vance ’ s mother has no health problems. His father is 17 - years - old and has no history of chronic medical conditions. His maternal grandmother (38 years of age) has a history of high blood pressure. His maternal grandfather (39 years of age) also has high blood pressure. His paternal grandmother (48 years of age) is healthy with no health problems, and his paternal grand- father ’ s health history is unknown.
Medications: Vance is not currently taking any over - the - counter, prescription, or herbal medications.
He has no known allergies to food, medications, or the environment. He has not yet received any recommended immunizations other than the hepatitis B vaccination received at 1 day of age.
OBJECTIVE
Vance ’ s vital signs are taken, and his weight in the offi ce today is 5.24 kg. His temperature is within the normal range at 37.1 ° C (rectal). He is alert, active, and playful. He appears well hydrated and well nourished.
Skin: His skin shows a 1.5 × 1.0 cm area of ecchymosis over the left forehead. The area appears mildly tender to touch. There is no cyanosis of his skin, lips, or nails. There is no diaphoresis noted, and he has good skin turgor on examination.
HEENT : Normocephalic with no swelling of the scalp. His anterior fontanel is open and fl at (2 cm × 2 cm). Vance ’ s red refl exes are present bilaterally; and his pupils are equal, round, and reactive to light. He is able to fi x and follow the examination past midline. There is no ocular discharge noted.
The external ear reveals that the pinnae are normal. On otoscopic examination, the tympanic mem- branes are gray bilaterally with positive light refl exes. Bony landmarks are visible, and there is no fl uid noted behind the tympanic membrane. Both nostrils are patent. There are no nasal discharge and no nasal fl aring. Vance ’ s mucous membranes are noted to be moist when examining his orophar- ynx. He has no teeth, and there are no lesions present in the oral cavity.
Neck: Vance ’ s neck is supple and able to move in all directions without resistance. He has no cervical lymphadenopathy.
Respiratory: Respiratory rate is 24 breaths per minute, and lungs are clear to auscultation in all lobes.
There is good air entry, and no retractions or grunting are noted on examination. No deformities of the thoracic cage noted.
Cardiovascular: Heart rate is 116 beats per minute with a regular rhythm. There is no murmur noted upon auscultation. When palpating, brachial and femoral pulses are present and 2 + bilaterally.
Abdomen: Normoactive bowel sounds are present throughout; soft and nontender. There is no evi- dence of hepatosplenomegaly.
Genitourinary: Normal male genitalia. Vance is uncircumcised and his testes are descended bilaterally.
Neuromusculoskeletal: Good tone in all extremities; full range of motion in all extremities. His extremities are warm and well perfused. Capillary refi ll is less than 2 seconds, and his spine is straight.
CRITICAL THINKING
Which laboratory tests should be ordered as part of a workup after a fall from a height?
What is the most likely differential diagnosis and why?
What is your plan of treatment, referral, and follow - up care?
Does this patient ’ s psychosocial history affect how you might treat this case?
Fall off Changing Table 55
What if the patient lived in a rural setting?
Are there any demographic characteristics that might affect this case?
Are there any standardized guidelines that you should use to assess or treat this case?
RESOLUTION
Diagnostic t ests: Since Vance hit his head, any laboratory tests or imaging studies would be geared toward diagnosing an intracranial bleed. There is no clear consensus regarding whether all patients with mild head injuries should have neuroimaging. Patients who have lost consciousness should, in general, receive a computed tomography ( CT ) scan. While magnetic resonance imaging ( MRI ) has been demonstrated to be more sensitive than CT scans, it has usually been reserved for patients who have mental status abnormalities that are unexplained by CT scan fi ndings. Electroencephalogram ( EEG ) testing has been shown to be of limited usefulness in patients with head injuries. Skull radio- graphs are rarely used in patients with a closed head injury. Cerebral angiography is rarely used in the evaluation of acute head injury.
If imaging is determined to be necessary, a CT scan is the diagnostic study of choice in the evalu- ation of a head injury because it has a rapid acquisition time, is nearly universally available, is easily interpretable, and is reliable. Health care providers should consider a CT scan for children with a head injury if they are less than 1 year of age or have a Glascow Coma Scale score ( GCS ) of less than 14/15. An additional indication for a CT in an infant would be the presence of bruising, swelling, or laceration that is more than 5 cm. MRIs have a limited role in the initial evaluation of a head injury because of their long acquisition times and the diffi culty in obtaining them for persons who are criti- cally ill.
What is the most likely differential diagnosis and why?
There are several diagnoses that should be considered for a child with a head injury including minor closed head injury, subdural hematoma, subarachnoid hemorrhage, and epidural hematoma. There are several factors from this case which lead to the diagnosis of minor head injury. Vance ’ s Glascow Coma Scale (GCS) was 15/15, there were no focal neurological defi cits, and there was no seizure activity. These factors support a diagnosis of mild closed injury. Additional factors that support this diagnosis are that there was no vomiting, there was no loss of consciousness, the fall was less than 1 meter, and there was no fl uid or drainage from Vance ’ s nose or ears. Patients with a subarachnoid hemorrhage typically have vomiting and loss of consciousness. There were no focal neurologic fi nd- ings, and there was a GCS of 15/15. Patients with a subdural hematoma generally lose consciousness (this is not an absolute) and typically experience moderate to severe blunt head trauma. Epidural hematoma may present with loss of consciousness, vomiting, and seizures.
What is your plan of treatment, referral, and follow - up care?
Based on Vance ’ s history, physical examination, and likely diagnosis of a mild closed head injury, he should be observed in the offi ce and would likely not need radiographic evaluation or neuroimaging.
There will be no limitations on his activity or diet. His mother can be told to apply ice for 20 minutes at a time (every 2 – 4 hours as needed) to his head wound for 24 hours. This will help to reduce or prevent swelling of the injured area. Vance can be discharged to home if it is determined that he has a reliable caregiver at home who can monitor him for signs of complications related to his head injury.
Vance ’ s caregivers should be given an instruction sheet for head injury care that explains that he should be awakened every 2 hours and assessed neurologically. Vance ’ s caregivers should be instructed to seek medical attention if he develops persistent nausea and vomiting, seizures, unusual behavior, or watery discharge from either the nose or the ears. There are no referrals necessary based on Vance ’ s history and physical examination fi ndings.
Does this patient ’ s psychosocial history affect how you might treat this case?
An aspect of Vance ’ s psychosocial history that might affect the handling of his case is that both of his parents are teenagers. Research has shown that children of adolescent mothers (when compared
56 The Infant
to children of adult mothers) have an increased rate of unintentional injuries during the fi rst 5 years of life (Koniak - Griffi n et al., 2003 ).
What if the patient lived in a rural setting?
A patient living in a rural setting may not be able to access a health care center in a timely fashion for assessment and diagnostic testing of a head injury after a fall.
Are there any demographic characteristics that might affect this case?
There are no specifi c demographics that affect this case. There are no known associations of uninten- tional head injury with ethnicity or gender in the pediatric population.
Are there any standardized guidelines that you should use to assess or treat this case?
National Institute for Health and Clinical Excellence & National Collaborating Centre for Acute Care offer guidelines in the reference below.
REFERENCES AND RESOURCES
Koniak - Griffi n , D. , Verzemnieks , I. , Anderson , N. , Brecht , M. , Lesser , J. , Kim , S. , & Turner - Pluta , C. ( 2003 ). Nurse visitation for adolescent mothers: Two - year infant health and maternal outcomes . Nursing Research , 52 , 127 – 136 .
National Institute for Health and Clinical Excellence & National Collaborating Centre for Acute Care . ( 2007 ).
Head injury. Triage, assessment, investigation and early management of head injury in infants, children and adults. Clinical guideline; no. 56. London (U.K.): National Institute for Health and Clinical Excellence.