Hot Seat #74: 9 yo head injury coming via EMS

Posted on: May 3, 2016, by :

Katie Donnelly, Children’s National Medical Center

The Case
You receive a phone call ahead about a 9 year old coming via EMS. Per their radio report, the patient was riding his bike on the train tracks and fell, hitting his head. There is no concern for being struck by a car. The child is upset but they were able to successfully board and collar him. He has a laceration to the forehead. They have a heart rate of 110, O2 sat 100% on room air. They have not yet obtained a blood pressure. They are not asking for any medications. Their ETA to your ED is 20 minutes.

Question for you:

You, the physician, elect to evaluate the child yourself and do not call a trauma stat activation. On arrival in the hallway the child is yelling, stating that “this hurts” while grabbing at the collar. He is awake and can tell you his name but needs prompting to tell you he is in a hospital. He has a large bandage to the front of his right forehead with blood seeping through. You attempt to calm him down to try and clear him from the board and collar but he continues to yell. His mother, who is now with him, states that when he had a laceration repaired one year ago, he had the same agitated reaction to being restrained for a painful procedure.

Another question:

You elect to call a trauma stat on this patient and you move to the code bay. On exam he remains agitated. He tries multiple times to sit up and remove his collar and he needs to be restrained by the staff. His primary survey is only notable for a GCS of 13-14. His secondary survey notes a 5 cm laceration to the right forehead with bone visible, bleeding controlled with dressings. His HR is in the 120’s and BPs are 130/80s. You feel this child needs a CT and are considering how to accomplish this.

One last question:

How would you approach this case? Please share your opinions by clicking on “What do you think?” below.

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3 thoughts on “Hot Seat #74: 9 yo head injury coming via EMS


  1. C-collars have never been proven to be efficacious in an evidence-based fashion, and there are many case reports of them leading to more harm than good. I’m very liberal about removing them and observing the child in the ED. If they guard their neck or if they don’t calm down and I can’t assess them, then I’d put the collar back on.


  2. Brad’s comment actually is rich just from the perspective of our system and Fairfax where our fellows rotate on trauma. This case is the perfect blend of trauma and pediatrics where the two can have a prickly relationship.

    Depending on a number of factors (room availability, busy-ness of the ED, trauma fellow vs. resident availability/approach) any of the options could be pursued. As with Dewesh, I’m more of a minimalist and would have taken the patient to a room to consider clearing C-collar myself and letting him calm down in a chair with mom before deciding next steps. CT head would still not be out of my realm of practice even in a room, given the agitation and the large lac keeping the possibility of a skull fracture and related bleeding a real possibility. However, talking to the patient, using various soothing/calming techniques could go a very very long way. A room where I can peer in without being in the room can go a long way to observe his actual mental status without all of us upsetting him.

    Though the potential for badness (head bleeding requiring intervention) exists, even in that case, agitating the child further will only exacerbate the pathology, so a period of calming effects may be the most judicious approach.

    Let’s see what happens….

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