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History of fall from two feet
20%
20/101
History of previous left femoral fracture after tripping
10%
10/101
History of cystic fibrosis
0%
0/101
History of arteriovenous malformation
65%
66/101
History of concurrent gastroenteritis
2%
2/101
Select Answer to see Preferred Response
Non-contrast head CT must be performed after any head trauma in a child with an unreliable neurologic exam or increased risk of intracranial hemorrhage; the latter includes children with arteriovenous malformations (AVMs). Though prediction rules for imaging after head trauma are still evolving in the pediatric population, the risk of intracranial injury and hemorrhage with even minor trauma is increased in those with structural abnormalities such as an AVM. Additionally, children with bleeding diatheses (such as hemophiliacs or those on long-term anticoagulation) must also undergo CT scan for similar reasons. Though intracranial hemorrhage may not initially be symptomatic, concerning findings on physical exam include any evidence of basilar skull fracture as shown in Illustration B below. Kuppermann et al. describe a validated decision rule (PECARN) for imaging in pediatric head trauma based on 42,412 children. The authors report that in children with normal mental status, no loss of consciousness, vomiting, signs of basilar skull fracture, severe headache, or high risk mechanism of injury (fall >5 feet; head struck by high impact object; ejection, rollover, or death in car collision, or pedestrian/helmetless biker struck by car) the risk of clinically important traumatic brain injury is less than 0.05%. Medwid et al. conclude that of the currently available decision rules for neuroimaging in children after head trauma, the PECARN rule is the best validated in both infant (<2 year-old) and child (>2-year old) populations. Using the PECARN rule had a sensitivity of 97% and specificity of 59% for intracranial injury in children and 99% sensitivity and 54% specificity in infants. Illustration A shows hemorrhage due to AVM on head CT. Illustration B shows Battle's sign, postauricular ecchymoses, an indicator of basilar skull fracture. Incorrect Answers: Answer 1: Generally only falls from >5 feet are considered high-risk. Answer 2: Though multiple traumas in a child might raise concern for abuse, a head CT is not indicated with this mechanism of injury. Answer 3: Cystic fibrosis would not predispose to intracranial injury. Answer 5: Gastroenteritis would not predispose to intracranial injury.
3.6
(5)
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