Pediatric emergency medicine trisk 0829 0829
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should also be evaluated. Obviously, a complete physical examination with
attention to possible thoracic, abdominal, pelvic, and extremity injuries should be
performed.
Radiographic Investigation
Complications of head trauma may be identified with radiographic studies. CT
scan of the head quickly provides excellent images of the intracranial contents
and is the diagnostic modality of choice when acute intracranial pathology is
suspected. CT imaging, however, has some disadvantages, including exposure to
ionizing radiation and the possible requirement for pharmacologic sedation,
especially in younger patients. Ideally, CT imaging should be used selectively for
patients at higher risk for TBI, limiting potentially unnecessary studies for those
who are at low risk. Patients at intermediate risk can undergo CT versus
observation based on the clinical scenario, provider experience, and parental
preference.
Although MRI is an additional imaging modality for the cranial contents (and
has no associated ionizing radiation), limited availability, prolonged study time,
and frequent need for patient sedation limit its utility for evaluation of acute
trauma at this time though emerging MRI modalities may be increasingly
employed for the diagnosis and management of mild TBI. Skull radiographs (SR)
are of very limited utility as they give no direct information about TBI. However,
they are useful for demonstrating skull fractures and have the advantages of
delivering lower doses of ionizing radiation, being more universally available,
less costly, and not requiring sedation. Any child for whom there is significant
concern for TBI should undergo CT imaging; however, there may still be a very
small role for SRs in certain select circumstances when immediate CT is not
warranted, yet significant chance of fracture exists to justify the test. Examples
would include SRs as part of a skeletal survey, to evaluate for the presence of a
radiopaque foreign body, and in rare instances to screen for fracture in selected
asymptomatic patients 3 to 12 months of age with concerning scalp hematoma or
question of depression. Those with fractures identified on SR would need to have
CT scans performed because they are at increased risk for associated TBI. In
general, SRs should be performed only if they will be reviewed by a radiologist
trained in their interpretation as they can be very challenging to interpret in young
children, and the utility of the study depends on an accurate reading.
All children with significant head trauma should be evaluated for associated
cervical spine injuries. This evaluation will be clinical, with or without
radiographic studies, based on the specific circumstances (see Chapter 112 Neck
Trauma ).
