This case was written by Drs. Diana De Santis, Jennifer Ann Klowak and Quang Ngo.
Dr. De Santis is a 3rd year pediatric resident at McMaster University, Waterloo Regional Campus. She has an interest in medical education and simulation and hopes to pursue a career in general pediatrics in the community setting. Dr. Klowak is a pediatrician and clinician investigator. She is currently completing a fellowship in pediatric intensive care at the Children’s Hospital of Eastern Ontario. Dr. Ngo is an Associate Professor and clinician educator in the Department of Pediatrics at McMaster University and a practicing pediatric emergency medicine physician at McMaster Children’s Hospital. His educational and scholarly interests are in simulation-based education and assessment and feedback. He currently serves as the founding program director for the Pediatric Emergency Medicine subspecialty residency program.
Why it Matters
Most pediatric head injuries do not result in significant traumatic brain injury (TBI). However, this case highlights the importance of early recognition of severe pediatric TBI and aggressive management of increased ICP.
This case takes place in a community hospital setting with limited clinical personnel and therefore allows the team to work through patient stabilization without direct support (i.e. using virtual/telephone communication with pediatric critical care) as well as coordination of disposition. The case also highlights the importance of considering non-accidental injury as a potential etiology of TBI, specifically in cases of unwitnessed traumatic injury.
An 18-month old previously well child presents to the emergency department of a community hospital with a head injury following an unwitnessed fall from significant height on a play structure with initial loss of consciousness. He is awake but irritable in the trauma bay, with obvious head injury.
An 18-month old boy presents to a community ED following an unwitnessed fall from significant height. He is initially irritable with GCS of 11 but quickly develops signs of increased ICP and herniation (secondary to an epidural hematoma). He will require acute management of increased ICP, intubation and adherence to neuroprotective measures. After stabilization, arrangements must be made for transfer to a tertiary care centre for neurosurgical assessment and PICU admission.