EMS call: 3yoM coming by ambulance for a large and deep facial laceration that occurred after he fell off the bed at home. GCS currently 15 and his vitals are otherwise normal.

You decide to wait and evaluate the child on arrival. On arrival, the charge nurse pulls calls you to examine the child. EMS provides the same story. No other injuries were noted. His forehead is wrapped in kerlex. Pupils are equal and reactive to light. GCS remains 15.

You move the child to the first available room and the following HPI is obtained:.

HPI: 3yoM with no past medical history was at home when his mother heard a loud crash in the other room where the patient and his sister playing. They were jumping on the bed and the patient fell off and hit his head on the wooden bed frame. No apparent LOC following episode. Caretaker reports he is a quiet kid and is acting himself but seems “somewhat shocked.” She denies vomiting since the incident. ROS otherwise normal and vaccines are up-to-date.

PMHx: no past medical history

PSHx: no past surgical history

FHx: no family history of bleeding disorders

Social History: lives at home with his family

Physical Exam:

VS: T 36.9, HR 98, BP 98/55, RR 26 SpO2 100%

            General:  Quiet but alert 

            Skin:  Warm.  Dry.  

            Head:  Jagged 8 cm laceration extending from the right forehead to just superior to the left eyelid, gaping open with skull exposed. No appreciable depression or fracture of the skull. No active bleeding.

            Neck:  Supple. No C-spine ttp. Full ROM without pain or limitation.

            Eye:  Pupils are equal, round and reactive to light.  Extra-ocular movements are intact.  Normal conjunctiva.  

            Ears, nose, mouth and throat:  No hemotympanum. No septal hematoma. No injuries apparent in the oropharynx. Dentition intact.

            Cardiovascular:  Regular rate and rhythm.  No murmur.  Normal peripheral perfusion. 

            Respiratory:  Lungs are clear to auscultation.  Breath sounds are equal. 

            Gastrointestinal:  Soft.  Non distended.  Normal bowel sounds.      

            Back:  No spinal ttp

            Musculoskeletal:  No deformity. No bony ttp. Normal ROM. Moves all extremities.

            Neurological:  GCS 15. Alert.  L forehead  with drooping skin but neurologically intact. Full strength in all 4 ext. Follows commands.

            Psychiatric:  Cooperative.  Quiet.

A maxillofacial CT was obtained which showed a non-displaced glabellar fracture. Neurosurgery was consulted and stated no indication for emergent neurosurgical involvement and no indication for antibiotics. The patient’s status is unchanged.

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