Hot Seat #167 DenouementPosted on: March 11, 2021, by : Mary Beth Howard
The Case: A 14 year old presenting after closed head injury while sledding, found to have pneumocephalus on CT Head and carotid abnormality CTA.
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Discussion: This case brings to light sledding as a potentially dangerous mechanism of injury (a quick pubmed search reveals a plethora of articles on this subject), with measured speeds up to 25mph. In this case, the group was initially divided on watchful waiting vs obtaining a CT scan (with more attendings than fellows initially obtaining imaging).
The majority of the group felt that this case met trauma activation criteria. There was more diversity in the next steps in imaging, with most obtaining a CTA, but some obtaining a CTV or MRA/MRV. Dr. Lindgren pointed out that Consultation with neuroradiology in these cases is always helpful.
Dr. Carr pointed out the major take home points for this case were 1. the severe mechanism of sledding injuries and 2. considering CTA in blunt head injury, particularly if the patient meets the criteria outlined in this algorithm.
Denouement: Neurosurgery was consulted as well as trauma surgery. Neurosurgery recommended admission to their service for observation. We obtained basic trauma labs (Hemoglobin, AST/ALT, UA) which were negative as well. Patient was admitted overnight and discharged in stable condition the next day. He had a follow up MRA of the head which showed previous irregularity in the right carotid artery had resolved and there was no evidence of aneurysm or dissection at that time.
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