A 5-month-old infant arrives at the emergency center strapped to a backboard with a cervical collar in place. The father was holding him in his lap in the front passenger seat of their sedan when the driver lost control and crashed. The child was ejected from the car through the windshield. The paramedics report that his modified Glasgow coma scale score is 6 (opens eyes to painful stimuli, moans to painful stimuli, and demonstrates abnormal extension); they intubated him at the scene. He had a self-limited, 2-minute generalized tonic-clonic seizure en route to the hospital.
Your assessment reveals a child with altered mental status. His endotracheal tube is in the correct position, and his arterial blood gas reflects effective oxygenation and ventilation. He is euthermic and tachycardic. He has no evidence of fractures, and his abdominal examination is benign. He has several facial and scalp lacerations. His anterior fontanelle is bulging, his sutures are slightly separated, and his funduscopic examination reveals bilateral retinal hemorrhages.
What is the most likely etiology for this child’s altered mental status?
What is the most appropriate study to confirm this etiology?
ANSWERS TO CASE 39: Subdural Hematoma
Summary: An unrestrained infant is ejected through the windshield. He has altered mental status, he has experienced seizure activity, and his examination is consistent with increased intracranial pressure (ICP).
• Most likely diagnosis: Subdural hematoma.
• Best study: Emergent computed tomography (CT) of the head.
1. Describe the typical clinical findings in head trauma.
2. Compare the typical findings of subdural hematoma with those of epidural hematoma.
3. Discuss the possible treatment options for intracranial hemorrhage.
This child is younger than 1 year, and subdural hematomas are more common in this age group; epidural hematomas are more common in older children. Seizures are more common with subdural hematomas, occurring in 75% of affected patients; seizures occur in less than 25% of epidural hematoma patients. His altered mental status could be caused by a simple cerebral concussion, but the CT scan would be normal or show nonspecific changes. The infant’s ejection at the crash provides an appropriate mechanism of injury, making other considerations (such as shaken baby syndrome, more recently referred to as abusive head trauma) less likely. This child’s lack of a car seat must also be addressed.
CONCUSSION: Altered mental state immediately after blunt head trauma; no consistent brain abnormality is seen; can cause retrograde and anterograde memory loss.
EPIDURAL HEMORRHAGE: Bleeding between the dura and the skull; commonly occurs with skull fracture and middle meningeal artery laceration but can result from disruption of dural sinuses or middle meningeal veins (Figure 39-1).
Figure 39-1. Anatomy of subdural and epidural hematomas.
GLASGOW COMA SCALE (GCS): A clinical tool developed to assist in head injury severity prediction. For infants and toddlers, several “modified” scales exist that attempt to adapt the verbal portion to reflect language development and modify the motor component to reflect the lack of purposeful movement in early infancy (Table 39-1).
Table 39-1 • MODIFIED GLASGOW COMA SCORE FOR CHILDREN YOUNGER THAN 3 YEARS OF AGE
SUBDURAL HEMORRHAGE: Bleeding between the dura and the arachnoid space; occurs with disruption of bridging veins connecting cerebral cortex and dural sinuses (Figure 39-1).
The child in the case is seriously ill, with evidence of increased ICP and retinal hemorrhages. Some form of cerebral hemorrhage is likely. Initial management follows the ABCs of resuscitation: evaluate the patient’s Airway first, followed by his Breathing, and then his Circulatory status. Care can then be directed at his injuries.
Subdural hemorrhage is more common in children younger than 1 year and is far more common than a supratentorial epidural hemorrhage. Approximately one-third of CT-identified subdural hemorrhages have an associated skull fracture; almost all are venous in origin, and approximately three-fourths are bilateral. The CT images typically show a crescentic hematoma. Seizures occur in 60% to 90% of afflicted patients, and retinal hemorrhages are frequently associated. Increased ICP is typical. Subdural hemorrhage is generally associated with less mortality than that seen with epidural hemorrhage, but long-term morbidity is more significant because the brain parenchyma is more often involved.
Subdural hematomas may be acute, subacute, or chronic. In acute hematomas, symptoms occur in the first 48 hours after injury. Patients with subacute subdural hematoma display symptoms between 3 and 21 days after injury, whereas chronic hematomas cause symptoms after 21 days. Chronic subdural hematomas are more common in older children than in infants; symptoms may include chronic emesis, seizures, hypertonicity, irritability, personality changes, inattention, poor weight gain, fever, and anemia. Magnetic resonance imaging is more useful than CT for evaluating subacute and chronic hematomas because the hematoma age can be estimated by signal intensity.
Epidural hemorrhages occur more commonly in older children and adults and are seen more typically in the infratentorial space. Two-thirds of epidural hemorrhages are associated with skull fracture. Although most adult epidural hemorrhages are arterial in origin, in children approximately half originate from venous injuries. Most epidural hemorrhages are unilateral, are located in the temporoparietal region, and present on CT scan as a lens-like, or biconvex, hematoma. Fewer than 25% of epidural hematoma patients have seizures, and retinal hemorrhages are uncommon. Mortality is greater with epidural hemorrhage than with subdural hemorrhage, but in survivors long-term morbidity is low.
Increased ICP, which can be caused by both hemorrhage forms, is important to recognize and treat. Epidural hematomas are frequently rapidly progressive and may require urgent surgical evacuation with identification of the bleeding source. Subdural hemorrhage usually does not require urgent evacuation but may require evacuation at a later date.
39.1 You are the team physician for a local high-school football team. During the first quarter of a district playoff game, you watch as your star quarterback is sacked with a helmet-to-helmet tackle. He does not get up from the initial impact. You sprint onto the field with the trainer and assess the injured player. He is breathing and has a steady pulse, but he is unconscious. As you continue your evaluation, he wakes up. He remembers his name but cannot remember the day, his position in the team, or how he got to the game. He has no sensory or motor deficit suggestive of a cervical spine injury, and you assist him off the field. After 15 minutes he is fully oriented and wants to go back in. The coach tells him he is sitting out for the rest of the game. The player appeals to you. Which of the following is the most appropriate management?
A. Affirm the coach’s decision. Tell the player that he will need sequential evaluations before he can come back to practice.
B. Affirm the coach’s decision. Tell the player he can come back and attend regular practice tomorrow.
C. Refute the coach’s decision. Tell the player he can resume playing now.
D. Refute the coach’s decision. Tell the player he can resume playing after half-time.
E. Strap the player to a backboard and take him to the hospital.
39.2 A 17-year-old adolescent female is brought to the hospital after a motor vehicle crash. She and her boyfriend had been drinking beer and were on their way home when she lost control of the car and hit the side wall of the local police station. She reportedly had a brief loss of consciousness but currently is oriented to name, place, and time. She responds appropriately to your questions. While waiting for her cervical spine series, she vomits and lapses into unconsciousness. She becomes bradycardic and develops irregular respirations. Which of the following brain injuries is most likely in this case?
A. Subdural hemorrhage
B. Epidural hemorrhage
C. Intraventricular hemorrhage
D. Posttraumatic epilepsy
39.3 Several days after emergent management, the adolescent in Question 39.2 is transferred to your general inpatient ward service from the intensive care unit. She is concerned about her prognosis. Which of the following statements is correct?
A. She will need extensive neuropsychiatric evaluation before she can return to school.
B. She will likely have headaches, fatigue, nausea, and sleep disturbances.
C. She will likely develop seizures and needs 2 years of prophylactic seizure medicine.
D. She can no longer be legally permitted to drive because she has had brain surgery.
E. She should have few long-term problems.
39.4 A 7-month-old child presents to the emergency room after reportedly falling from his high chair. The parents report no loss of consciousness, other trauma, or medical problems. Your examination reveals a few old bruises but no evidence of acute trauma or fracture. He is irritable, so you request a CT scan of the brain without contrast. The pediatric radiologist reports bilateral frontal subdural hematomas and notes two healing skull fractures that she estimates to be approximately 2 weeks old. Which of the following is the best next step in this child’s management?
A. Observe him for 6 hours in the emergency center.
B. Assess bleeding time and prothrombin time.
C. Order magnetic resonance imaging of the head.
D. Discharge him from the emergency center with head injury precautions.
E. Order an electroencephalography and a neurology consultation.
39.1 A. Although controversial, the correct answer is for a player who sustains a concussion resulting in loss of consciousness to refrain from play for the remainder of the day. The most recent clinical report from the American Academy of Pediatrics concerning conditions affecting sports participation references the 3rd International Conference on Concussion in Sports from 2008. This report suggests that individualized and frequent reassessment over time, and a stepwise return to play, is more useful than a predetermined length of time to refrain from additional sports.
39.2 B. This teen displays the typical adult course of epidural hemorrhage (an initial period of altered mental status [initial concussion], a period of lucidity, and then redevelopment of altered mental status and symptoms of increased ICP [hematoma effect]). Younger children typically do not display this pattern. Immediate neurosurgical evaluation is required.
39.3 E. The acute epidural hemorrhage mortality rate is higher than that of acute subdural hemorrhage, but long-term morbidity in survivors is less. The complaints in answer B are common after a subdural hemorrhage. A seizure disorder may preclude driving; a cranial surgery history does not.
39.4 C. This child has evidence of old skull fractures with subdural hematomas. Head magnetic resonance imaging would help to determine the hematoma age. If the hematoma blood age correlates with the estimated skull fracture age, child abuse is considered. Neurology may be helpful later, but an immediate consultation would be of limited benefit before additional data were gathered. Discharge with the information presented in the case is dangerous; the child likely requires hospital admission and the involvement of social services. Bleeding studies are unlikely to be helpful initially but may be required at some point if child abuse is suspected and a court case is anticipated. The child has no history consistent with a bleeding disorder, and a bleeding disorder does not explain the old fractures.
Subdural hemorrhage is more common in children younger than 1 year and in the supratentorial space; seizures and retinal hemorrhages are frequently associated findings, and increased ICP is typical.
Epidural hemorrhages are more commonly seen in older children and adults and in the infratentorial space. Fewer than 25% of patients have seizures; retinal hemorrhages are uncommon.
Mortality with subdural hemorrhage is generally less than that seen with epidural hemorrhage, but long-term morbidity is more significant with subdural injury because the brain parenchyma is more often involved.
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