Who you are:
You are an FY2 in the paediatric department.Who the patient is:
Alicia, 9-month-old, brought by her mum with hx of fall from the sofa. She has a bruise on her head. The child is well and actively playing in the department.What you should do:
Take hx, address concern and manage.
In any station of a head injury, exclude indications of CT scan and NAI.
NICE recommendations for when to request a CT immediately if < 16 years
• Witnessed loss of consciousness lasting > 5 minutes
• Amnesia (antegrade or retrograde) lasting > 5 minutes
• Abnormal drowsiness
• Three or more discrete episodes of vomiting
• Clinical suspicion of non-accidental injury (NAI)
• Post-traumatic seizure, but no history of epilepsy.
• Age > 1 year: GCS < 14 on assessment in the emergency department.
• Age < 1 year: GCS (paediatric) < 15 on assessment in the emergency department
• Suspicion of open or depressed skull injury or tense fontanelle.
• Any sign of basal skull fracture.
• Focal neurological deficit.
• Age < 1 year: presence of bruise, swelling or laceration > 5cm on head.
• Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist, or vehicle occupant, fall from > 3m, high-speed injury from a projectile or an object).
Questions to ask in any in head injury station
• When did it happen?
• What time did you bring him?
• How did it happen?
• What made you worry about him enough to bring him in?
(Concern)
• What type of floor is it?
• What was he/she doing just before he/she fell?
• How high was the couch?
Questions/ indications of CT:
• Did she LOC?
• Did she have any fits?
• Can she remember what happened (if she is old).
• Any vomiting?
• How big is the bruise?
• Any bleeding or discharge (nose/ ears/ mouth)?
• Do you feel that she is drowsy?
• Did you notice any abnormal behaviour?
• Was she completely fine & playful before.
Don’t forget NAI (if there’s a delay in presentation, suspect NAI)
• Who looks after him/her?
• How do you get on with him/her?
• Any other children at home?
• How do they get along together?
• Was it a planned pregnancy?
• Where is his/her dad?
• Does he look after him/her? How do they get along?
P1 (BEFORE – DURING – AFTER)
First confirm identity, name of child, relationship to child and child’s D.O.B.
Doctor: I understand that your daughter had a fall on her head, can you tell me about that?
Patient’s Relative: I was changing my daughter’s nappy when she fell off the sofa and got a bruise on her head.
D: Oh dear, when did this happen?
P: An hour ago.
D: How far is the sofa from the floor?
P: Not too high.
D: Did she faint or anything?
P: No.
D: Any jerky movements?
P: No.
D: Any vomiting?
P: No.
D: Any bleeding from her nose or ears?
P: No.
D: Have you noticed her looking drowsy?
P: No.
D: How is she right now?
P: She is fine right now
Concern
D: Other than this, is there anything else concerning you?
P: I just want to run a CT scan on her head to make sure she is ok.
D: Is there any specific reason for that?
P: I am just worried about her.
D: Just a few more questions and I will address all of your concerns.
DDs:
Head to toe
D: Did you notice any rash?
P: No.
D: Any fever?
P: No.
D: Any discharge from ears?
P: No.
P2
D: Has she ever fallen from anywhere before?
P: No.
D: Has your baby been diagnosed with any medical condition?
P: No.
BIRD DDD
Don’t forget Dehydration & NAI
D: Is your baby active and playful?
P: Yes.
D: Does she wet his nappies as usual?
P: Yes.
DIET:
D: What do you feed her?
P: She is mostly breastfed, but she eats a little baby food too.
D: Any changes to your diet?
P: No.
D: Is she feeding well?
P: Yes, she is feeding well.
NAI
D: Does anyone else live with you both?
P: Yes, my husband and my other older child.
D: Is that Alicia’s biological dad?
P: Yes.
D: Is everything OK at home?
P: Yes, we are a happy family.
MAF
D: Any medication including OTC medicines?
P: No.
D: Any allergies?
P: No.
D: Any family history of a similar problem?
P: No.
Examination:
➢ Vitals
➢ GCS
➢ Head injury: 2 cm bruise
➢ Head to toe
Provisional Dx:
From the chat we had, let me reassure you that everything is OK with Alicia. As you mentioned you didn’t notice any vomiting, jerky movements or drowsiness. At the moment we don’t need to do any CT
scan; If we did, we would be unnecessarily exposing her to harmful radiation.
Management:
➢ If there is indication of CT (admit + CT)
➢ If there is no indication of CT (observe 24 hours, don’t discharge)
➢ Symptomatic treatment:
- painkillers
- observe 24 hrs
➢ Safety netting: if any of these symptoms happen, bring her back right away:
• LOC
• Fit
• Drowsy
• Difficulty in waking her up
• Weakness
• Vomiting
• Clear fluid nose/ ear