From the Guidelines
The diagnosis for the 4-year-old male is a mild head trauma with no evidence of acute intracranial hemorrhage or displaced calvarial fracture, but with minimal scalp swelling, focal laceration, mild polysinusitis, and prominent adenoids and faucial tonsils.
Recommended Treatment
- The patient's CT scan 2 hours post-injury showed no acute intracranial hemorrhage or displaced calvarial fracture, which is consistent with a mild head trauma diagnosis 1.
- Given the patient's age and presentation, careful clinical observation is recommended, as the risk of clinically important brain injury is low 1.
- The PECARN criteria can be used to assess the risk of clinically important brain injury in children with minor acute blunt head trauma, and in this case, the patient's symptoms and CT scan results suggest a low risk 1.
- CT head without IV contrast may be considered for the initial imaging of children with minor acute blunt head trauma, but in this case, the patient has already undergone a CT scan, which showed no evidence of intracranial injury 1.
- The patient's mild polysinusitis and prominent adenoids and faucial tonsils may require separate evaluation and treatment, but are not directly related to the head trauma diagnosis 1.
- The patient's focal laceration should be cleaned and dressed to prevent infection, and pain management should be considered as needed 1.
- Follow-up with a healthcare provider is recommended to monitor for any signs of worsening symptoms or complications, such as headache, vomiting, or focal neurologic deficits 1.
From the Research
Diagnosis
- The patient, a 4-year-old male, experienced head trauma from a fall and underwent a computed tomography (CT) scan 2 hours post-injury, which showed no acute intracranial hemorrhage or displaced calvarial fracture 2, 3.
- The CT scan results, in conjunction with the patient's symptoms, including minimal scalp swelling, focal laceration, mild polysinusitis, and prominent adenoids and faucial tonsils, will guide the diagnosis and treatment plan.
- The Pediatric Emergency Care Applied Research Network (PECARN) algorithm can be used to identify children at high risk of intracranial injury, although this patient is older than the age group specified in the algorithm 4, 5.
Recommended Treatment
- Given the absence of acute intracranial hemorrhage or displaced calvarial fracture, the patient's treatment plan may focus on managing symptoms and monitoring for potential complications 2, 3.
- The presence of mild polysinusitis and prominent adenoids and faucial tonsils may require additional evaluation and treatment, such as antibiotics or further imaging studies 6.
- The patient's condition should be closely monitored, and follow-up imaging studies or consultations with specialists, such as a neurosurgeon, may be necessary to ensure proper management and treatment 4, 5.