Katie Donnelly, Children’s National Medical Center

The Case
A 9 year old is brought in after a bike accident on the railroad tracks.  He has a laceration to the forehead and is difficult to calm down.  The questions focused on how you would assess and manage this patient using the resources you had available.

Here’s How You Answered Our Questions

Q2 Other >3 years: Unrestrain him, take his collar off, and see what he does.
Q3 Other <3 years: Pain medicine. Fentanyl. Q3 Other >3 years: If the C-spine can be cleared clinically, then likely redirection and calming.

Denouement:
The patient was able to be reasonably sedated with two doses of benzodiazepine. Head CT showed a depressed skull fracture with subdural hemorrhage. He was taken that day to the OR for washout and repair. He was discharged home 1 week later, doing well, with plans to follow up in TBI/Concussion clinic.

Teaching Points:
Trauma activation criteria will vary from institution to institution and will never capture all the children that have a traumatic injury, nor should they.  Each time you see a child with a traumatic injury, it will be a case by case decision of how you manage that patient. The agitated, anxious patient is a challenging one to manage and may best be done in a quieter environment.  However, don’t forget that agitation and altered mental status may be difficult to distinguish from each other and the patient may be hiding underlying pathology.