From the Guidelines
For a 17-month-old with head trauma from being dropped onto cement, with blood in the right ear canal but no loss of consciousness or vomiting, I recommend close observation in the ED for 4-6 hours, as the normal CT scan is reassuring against serious intracranial injury, and the presence of blood in the ear canal with ear tubes suggests possible tube displacement or local trauma. The child's symptoms and presentation are consistent with a mild traumatic brain injury (mTBI) 1. Given the absence of severe symptoms such as loss of consciousness, vomiting, or severe headache, and the normal CT scan results, the risk of serious intracranial injury is low. However, it is essential to monitor the child closely for any signs of worsening condition, such as persistent vomiting, unusual drowsiness, seizures, or increased bleeding from the ear. Some key points to consider in the management of this patient include:
- Cleaning the ear canal gently with sterile saline-soaked cotton swabs to better visualize the source of bleeding, as recommended for patients with tympanostomy tubes 1.
- Administering acetaminophen (10-15 mg/kg every 4-6 hours) for pain management, as it is a safe and effective option for pain relief in children 1.
- Providing discharge instructions to the caregivers, including warning signs that would necessitate return to the ED, such as persistent vomiting, unusual drowsiness, seizures, worsening headache, or increased bleeding from the ear.
- Recommending follow-up with the child's pediatrician within 48-72 hours, and considering an ENT referral to evaluate the ear tube status if bleeding persists, as suggested by the clinical practice guideline for tympanostomy tubes in children 1. The sinus opacification noted on CT is likely incidental and common in young children, representing normal developmental anatomy or possibly mucus, and does not require specific treatment at this time 1. Overall, the management of this patient should prioritize close observation, gentle ear canal cleaning, pain management, and education on warning signs for potential complications, with follow-up and referral to specialists as needed.
From the Research
Evaluation and Treatment of Head Trauma in a 17-Month-Old Child
- The child presents with a head injury after being accidentally dropped onto cement, with immediate crying but no loss of consciousness or vomiting reported 2, 3, 4.
- The presence of a small amount of dry blood in the right ear canal and complete opacification of the ethmoid and maxillary sinuses on CT head scan suggests potential basilar skull fracture or other complications 2, 5.
- The absence of acute intracranial abnormality on CT head scan is a positive sign, but close monitoring and further evaluation are necessary to rule out potential complications such as meningitis or cerebrospinal fluid leakage 3, 5.
Potential Complications and Treatment
- Basilar skull fractures can lead to complications such as meningitis, particularly in cases with cerebrospinal fluid leakage 5.
- Prophylactic antibiotics are not recommended for the management of basilar skull fractures, but close monitoring and prompt treatment of potential infections are crucial 6.
- The child's history of ear tubes and potential for cerebrospinal fluid leakage or meningitis requires careful evaluation and consideration of potential treatment options, including surgical intervention if necessary 2, 5.
Recommendations for Treatment in the ED
- Close monitoring of the child's condition, including vital signs and neurological status, is essential to promptly identify potential complications 3, 4.
- Further evaluation, including potential imaging studies or laboratory tests, may be necessary to rule out complications such as meningitis or cerebrospinal fluid leakage 2, 5.
- Consultation with a pediatric specialist or neurosurgeon may be necessary to determine the best course of treatment and management for the child's condition 2, 6.