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Help! I Dropped my Baby!Pamela Coffey, MD FACEP

Pediatric Emergency Medicine

EPMG, Sparrow Hospital

Lansing Michigan

Agenda

• Case of “The boy who fell”

• Risk of being dropped from caretaker arms

• Guidelines and prediction rules

• Imaging options for head injuries

• Mind Mi Head

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The boy who fell

• 16 day old full term male with no previous medical concerns was being carried out of the bathtub by his mom, when she stumbled on a baby toy and flung the baby forward.

• He landed on his back on a tile bathroom floor.

• Mom heard a loud thud when he hit the floor.

• As per mom he (and she) cried immediately. She picked him up to console him and after a few minutes he stopped crying and fell asleep.

• She brought him straight to the ED.

• While waiting to be seen he started to cry so she nursed him and he fell back asleep.

The boy who fell• On exam, VS stable for age

• You palpate his skull and do not feel any depressions or hematomas but notice a red mark on the back of his head. Anterior fontanelle is flat and soft.

• Otherwise no marks, bruises or deformities noted. HEENT, Heart, lungs, abdomen, genitals and tone are normal. He fusses on exam, will open his eyes to moms voice, makes cooing noises at mom, but then falls back asleep easily. You determine the GCS is 14 (-1 for eye opening)

• Mom states he has been sleeping on and off for the past hour, but that is not unusual as this is his naptime.

• You think about the case and realize you have 3 questions:

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Questions you ponder:

1. Is the mechanism of falling from a standing adults arms concerning?

2. Are their guidelines for determining what to do to ensure there is not a concerning injury?

3. I am concerned about the red mark on his head, what are my imaging options?

• You decide to observe him in the ED for a few hours while you figure everything out!

Is the mechanism of falling from a standing adults arms concerning?• Unintentional injury is the 5th leading cause of

death under age 1 year, behind congenital disorders and SIDS. (Centers for Disease Control and Prevention. WISQARS Leading causes of death reports, 1981-2016.)

• Unintentional falls are a significant cause, listed just below major events such as MVC, drowning, fires etc.

• In study looking at infants under age 1 year, falls from being dropped by an adult are more likely to cause a skull fracture than any short distance fall, including off furniture. (Mulligan et.al.)

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Is the mechanism of falling from a standing adults arms concerning?• Burrows et al. looked at 1775 kids younger than age 6, determined

the highest risk mechanism of fall for accidentally acquiring a skull fracture is an infant who is dropped from a caretakers arms.

Is the mechanism of falling from a standing adults arms concerning?• They conclude that being

dropped causes the child to be released at an angle causing a rapid acceleration and quick contact with the ground – ie, more likely to be dropped on head vs a fall off a piece of furniture or out a window where the body will land flat.

• PECARN uses 3 feet as a cutoff for significant mechanism

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Fall from standing (dramatic)Warning: Content might not be suitable for young children and new parents

Fall with standing with momentum

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Fall from standing with momentum (dramatic)

Question 2. Are there guidelines for determining what to do

to determine if there is a concerning injury?

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Pediatric Emergency Care Applied Research Network (PECARN) Prediction Rule• Study published in Lancet 2009

• Prospective cohort study

• 42,412 patients under age 18 years with a history of head trauma and GCS >14. Some had obtained head CT scans.

• Derived and validated a prediction rule for head injury in age < 2 years and > 2 years

• Age < 2 years = Negative predictive value = 100%, Sensitivity = 100%• No clinically significant TBI was missed following this rule

• Age > 2 years = Negative predictive value = 99.95%, Sensitivity = 96.8%• 2 patients with clinically significant TBI were not detected (no surgery)

Pediatric Emergency Care Applied Research Network (PECARN) Prediction Rule• Age < 2 years

• Normal mental status• Acting normal as per parents• No scalp hematoma except frontal• No palpable skull fracture• No LOC or LOC < 5 seconds• Non-severe injury mechanism

• If AMS or skull fracture present – CT recommended (risk of TBI = 4.4%)

• If any other predictor present - CT or observation recommended (risk of TBI = 0.9%)

• If no predictor present – OK to discharge (risk of TBI = 0.02%)

• Age > 2 years• Normal mental status• No LOC• No Vomiting• Non-severe injury mechanism• No sign of basilar skull fracture• No severe headache

• If AMS or basilar skull fracture sign present – CT recommended (risk of TBI = 4.3%)

• If any other predictor present - CT or observation recommended (risk of TBI = 0.9%)

• If no predictor present – OK to discharge (risk of TBI = 0.05%)

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Pediatric Emergency Care Applied Research Network (PECARN) Prediction Rule• Severe mechanism of injury

• MVC with patient ejected• MVC with a death of another

passenger• Rollover MVC• Pedestrian or bicyclist struck

by motor vehicle, no helmet• Fall greater than 3 feet (age <

2 years) or 5 feet (age > 2 years)

• Head struck by high impact object

• Observation vs CT• Physician

experience• Multiple vs

isolated findings• Worsening

symptoms or signs after observation

• Age < 3 months• Parental

preference

5’ 4”

4’4”

CATCH: A clinical decision rule for the use of computed tomography in children with minor head injury• Published in CMAJ 2010

• Prospective cohort study

• Enrolled 3866 patients with a head injury within past 24 hours• GCS between 13-15 who had initial LOC, amnesia, disorientation, persistent vomiting or irritability

• High Risk: 100% sensitive for need for neuro-intervention within 7 days• GCS < 15 at 2 hours after injury• Suspected open or depressed skull fracture• History of worsening headache• Irritability on exam

• Medium Risk: 98.1% sensitive for a positive CT scan• Any sign of basilar skull fracture• Large boggy hematoma of the scalp• Dangerous mechanism of injury

• MVC, fall from >3 feet, fall down > 5 stairs, fall from bicycle with no helmet

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Centers for Disease Control and Prevention Guideline on the diagnosis and management of mild traumatic brain injury among children• Published JAMA Pediatrics 2018

• Systematic Review of literature from 1990-2015

• 19 sets of recommendations

• Recommendations based on:• Level of confidence (Very low, low, moderate, high)

• Strength of recommendation (A – always followed, B- usually followed, C –sometimes followed, U – insufficient evidence, R – research only)

Centers for Disease Control and Prevention Guideline on the diagnosis and management of mild traumatic brain injury among children

• Most important recommendations for our case:• Follow validated clinical rules such as PECARN (Moderate, B)

• Do not use MRI regularly (Moderate, B)

• Do not use Skull X-ray films (High, B)

• Do not use biomarkers (High, R)

• Do screen for high risk factors (ie: abuse) (Moderate, B)

• Remainder of the recommendations involve older children, concussions, etc:

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Infant reassessed

• Over the 2 hours it has taken you to research and see the rest of the department, your infant patient has slept soundly. He has not woken to feed. You ask mom to attempt a feeding, but he only momentarily opens his eyes then squirms a little, grunts and grimaces when she tries to wake him up and then he falls back asleep. Mom thinks this is strange.

• Repeat vitals are still considered normal for age

• You re-examine him and still see the little redness but now there is swelling at his occiput.

• You determine his GCS is 13 (3, 4, 6)

• You do not suspect abuse.

• What should you do?

Guidelines:

PECARN

• Age < 2 years• Normal mental status - No• Acting normal as per parents - No• No scalp hematoma except frontal - No• No palpable skull fracture - Yes• No LOC or LOC < 5 seconds - Yes• Non-severe injury mechanism - No

• If AMS or skull fracture present – CT recommended

• If any other predictor present - CT or observation recommended

• If no predictor present – OK to discharge

CATCH

• High Risk: 100% sensitive for need for neuro-intervention within 7 days• GCS < 15 at 2 hours after injury• Suspected open or depressed skull fracture• History of worsening headache• Irritability on exam

• Medium Risk: 98.1% sensitive for a positive CT scan• Any sign of basilar skull fracture• Large boggy hematoma of the scalp• Dangerous mechanism of injury

• MVC, fall from >3 feet, fall down > 5 stairs, fall from bicycle with no helmet

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What are the imaging choices?

• CDC guidelines:• Recommend CT scan if concerned and prediction rules are positive

• Recommend AGAINST Xray and MRI

• What about ultrasound?

US Encephalography

• Has been widely used in the NICU to detect hydrocephalus and ICH at birth

• Choi et al. demonstrated sensitivities from 77%-100% at detecting skull fracture with bedside US in the ED

• McCormick et al. had a small study that showed promising results in diagnosing ICH with bedside US in the ED• Can be useful tool if done correctly

• Requires open fontanelle

• Increasing research needed

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Case Conclusion

• You CT his head as you do not have POC US established in the ED

• CT shows mild soft tissue swelling but no fracture or ICH

• After a 3 hour nap your child wakes up, opens his eyes and feeds vigorously. Mom thinks he is back to his normal self.

MindMiHead.org

Posters and Badge Buddies available at the MCEP office

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Conclusion

• Severe infant head injuries can happen from seemingly insignificant falls.

• Falls from an adults arms are more likely to cause injury than any other fall.

• Use PECARN decision rule on any child with a suspected head injury.

• When in doubt, observe for changes in behavior, GCS, evolving symptoms.

• Look for POC US in the future as a screening tool for infant head trauma in the ED.

• Thank you

Bibiliography

• Centers for Disease Control and Prevention. WISQARS Leading causes of death reports, 1981-2016.

• Mulligan CS, Adams S, Tzioumi D, Brown J; Injury from falls in infants under one year. Journal of Pediatrics and Child Health. 2017 53; 754-760

• Burrows P, Trefan L, Houston R, et al. Head injury from falls in children younger than 6 years of age. Arch Dis Child 2015 100; 1032-1037

• Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically important brain injuries after head trauma: a prospective cohort study. Lancet 2009 374; 1160-70.

• Osmond MH, Klassen TP, Wells GA et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ 2010. 182(4); 341-348.

• Lumba-Brown A, Yeates KO, Sarmiento K, et al. Centers for Disease Control and Prevention Guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatr. Published online November 01, 2018172(11):e182853. doi:10.1001/jamapediatrics.2018.2853.

• Orman G, Benson JE, Kweldam CF, et al. Neonatal head ultrasound today: a powerful imaging tool! J of Neuroimaging 2015 25(1); 31-55.

• Choi JY, Lim YS, Park WB et al. Accuracy of bedside ultrasound for the diagnosis of skull fractures in children aged 0 to 4 years. Ped Emerg Care 2018 April 24

• McCormick T1, Chilstrom M, Childs J, McGarry R, Seif D, Mailhot T, Perera P, Kang T, Claudius I. Point of care US for the detection of traumatic intracranial hemorrhage in infants: pilot study. Pediatr Emerg Care. 2017 Jan;33(1):18-20.

• MindMiHead.org

• Pedsemmorsals.com

• Emrap.org

• Uptodate.com

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