What is the recommended emergency department workup for a patient who fell from 20 inches, is sleepy but acting normal, 2 months post-injury?

Emergency Department Workup for a 2-Month-Old with Fall from 20 Inches

A 2-month-old infant who fell from 20 inches and is sleepy but acting normal requires a comprehensive emergency department evaluation including vital signs, detailed neurological assessment, and consideration for head CT imaging to rule out traumatic brain injury. 1

Initial Assessment

• Obtain detailed information about the fall circumstances, including exact height (20 inches), surface landed on, first body part to make contact, and time since injury 1, 2
• Assess for loss of consciousness, altered mental status, or any changes in behavior since the fall 2
• Perform complete head-to-toe examination to rule out occult injuries, with special focus on head examination for signs of trauma 1
• Measure vital signs including heart rate, respiratory rate, blood pressure, and oxygen saturation 2
• Calculate Glasgow Coma Scale (GCS) score, modified appropriately for infant age 2

Neurological Evaluation

• Perform detailed neurological assessment including:
  • Pupillary response and eye movements 2
  • Fontanelle examination (bulging or depression) 1
  • Muscle tone and symmetry of movement 1
  • Level of alertness and responsiveness to stimuli 2
• Assess for signs of increased intracranial pressure such as irritability, lethargy, vomiting, or seizures 2, 3
• Document any abnormal posturing, which could indicate severe brain injury 3

Imaging Considerations

• Consider head CT scan if any of the following are present:
  • Abnormal neurological examination 2
  • Signs of skull fracture (scalp hematoma, depression, etc.) 2
  • Persistent vomiting 1
  • Altered mental status or decreased level of consciousness 2
• Falls from <1 meter (3.3 feet) can cause skull fracture if the fall occurred on a hard surface, making imaging consideration important even for relatively low-height falls 2
• For a 2-month-old with a fall from 20 inches who is sleepy but otherwise normal, a period of observation (4-6 hours) with serial neurological examinations may be appropriate before deciding on imaging 1

Additional Considerations

• Assess for non-accidental trauma by evaluating injury mechanism plausibility and consistency with developmental capabilities 1
• Consider social work consultation if there are any concerns about the circumstances of the fall 1
• Evaluate for other injuries that may have occurred during the fall, including extremity injuries 2

Disposition Planning

• If neurological status remains normal after observation period and no imaging was performed or imaging was negative, discharge may be appropriate with close follow-up 1
• Provide caregivers with head injury education, including signs and symptoms that should prompt return to the emergency department 1
• Consider admission for continued observation if:
  • Abnormal neurological examination persists 2
  • Imaging shows any acute findings 2
  • Reliable follow-up cannot be ensured 1

Special Considerations for Infants

• Infants have higher risk of serious injury from seemingly minor mechanisms due to their proportionally larger heads and thinner skulls 2
• Falls from <1 meter can cause significant injury in children under 2 years 2
• Sleepiness in an infant after head trauma requires careful evaluation as it may represent altered mental status 2
• Serial neurological assessments are particularly important in infants who cannot verbalize symptoms 1