Subdural Hematoma
Patient Presentation:
A call was made to the ER by EMS for an "unresponsive infant" approximately 8 months old. The infant arrived with irregular, shallow respirations, and was posturing with painful stimuli. Pupils were sluggish, but equal. Anterior fontanel was tense. No bruising or trauma was noted to the head or body. Petechiae were noted around the eyes. The heart rate was 120, the infant was afebrile. While in the ER, the baby began to have generalized seizure activity which ceased with Ativan® administration.
The mother stated tearfully that she simply fed the infant about 1 hour before and then she found the child "laying like this". The father was not home at the time. The child was previously healthy, born full-term, took no medications.
The only medical history was an occipital skull fracture 3 months before which had no known cause or explained history. It was found when the bogginess of the skull was palpated, during a visit to the primary doctor for a rash. Given the delay in seeking treatment along with the unexplained cause of the fracture, Child Protective Services was notified and did a formal investigation of the family. CPS eventually cleared them of suspicion 1 week prior to this current presentation to the ER.
Differential Diagnoses:
Shaken Baby Syndrome, Head trauma, intracranial hemorrhage, meningitis
Diagnosis:
CBC, CMP, Blood Cx, UA, Urine Cx were obtained and were all within normal limits. A head CT was performed once the infant was stabilized and revealed multiple acute-on-chronic subdural hematomas. The previous head CT done 3 months prior (from the skull fracture) was available for comparison; the previous CT was normal except for the skull fracture. Prognosis for this infant was poor.
Treatment:
IV access was obtained; the patient was quickly intubated to protect the airway. The patient remained in the ER until the necessary tests were performed. The patient became bradycardic and was administered hypertonic saline and mannitol to reduce the ICP, improving the heart rate. The patient was also given multiple anticonvulsants. Upon finding the diagnosis, the patient was transferred to a specialty children's hospital for further intensive care.
Outcome:
The parents denied any knowledge of injury to the infant; the child does not go to a babysitter. The patient was flown to the specialty hospital and remained in the ICU for several days. The patient came under custody of the state as the investigation was reopened. Later that week the patient was downgraded to a non-ICU floor and was no longer intubated.
Case created by Stephanie Wilhelm, 2010.