A Four-year Old With an Injury After Playing With a Barbie  Doll

1. A Four-year Old With an Injury After Playing With a Barbie Doll Reza Keshavarz, MD, MPH Mount Sinai School of Medicine

2. Case Presentation • 4-year-old healthy female brought to ED by parents after slipping in her home, landing on an 8x2x2 inch metal display stand meant for a doll. The object appeared to pierce only her scalp.

3. Case Presentation • The child cried immediately, and the object was quickly dislodged by the child’s parent. • Removal of the object was initially associated with bleeding from the puncture site, which resolved with the application of pressure.

4. Critical Questions • Did a penetrating head injury occur? • If so, how do you evaluate and treat the patient? • Should a normal examination dissuade you from doing any further evaluation? • How does your knowledge of closed head injury pertain to the child with a possible penetrating head injury?

5. Case Presentation • Exam • VS normal • Awake/alert, nontoxic, appropriate • Completely Neurologic exam normal • No Amnesia • 1 mm left temporal puncture wound with dried bloody • Rest of examination normal

6. Case Presentation • Management • Wound cleaned • Tetanus given

7. Case Presentation • Head CT without contrast • 3x3x2 cm intraparenchemal hematoma of the left temporal lobe • Surrounding area of cerebral edema • Subarachnoid hemorrhage in the adjacent sulci and in the left sylvian fissure, with slight compression of the atrium of the left ventricle, representing mass effect without any midline shift

8. Case Presentation CT scan without contrast

9. Case Presentation • ED course • IV antibiotics • Loaded with Phenytoin • Admit to pediatric SDU for observation • Neurosurgery consulted

10. Case Presentation • Follow-up • Remained clinically stable • CT brain 2 days later unchanged • Discharged on hospital day 7 • CT brain 2 months later revealed resolving intraparenchymal hematoma • Cranial angiography 2 moths later revealed no vascular abnormalities

11. PHT versus Closed Head Injury • PHT much less common • PHT has been less studied and has less data upon which to make clinical decisions • Significant PHT can occur in the absence of sx or PE finding • PHT is associated with a number of late sequale

12. Penetrating Head Trauma in Children • Modern treatment of PHT dates back to World War I • Few comprehensive reviews in children • Much of clinical practice is based upon extrapolation from adult data

13. Related Recent Literature • The Management and Prognosis of Penetrating Head Injury. Aug 2001 Sup. J Trauma. • Available without charge at www.jtrauma.com. • Contributions from both USA/Intl. Brain Injury Assoc; Amer. Assoc. Neurol Surgeons;Congress of NeurolSurg. • Most complete discussion of penetrating head injury in civilian and military populations. • Does not specifically address children

14. Penetrating Head Trauma in Children • Reports include penetration of a child’s skull by • Pencil, metal rod/wire, nail/needle, table knife/fork, lawn darts, scissors, hair accessories, a garden rake, bullets/ pellets, Barbie® stand • Children are more at risk for penetration of skull and dura than adults because of incomplete ossification of skull

15. Penetrating Head Trauma in Children • History and physical examination often underestimate the degree of brain injury • Recommend a very low threshold for CT scan

16. Complications of PHT in Children • Intraparenchymal lesions • Subdural and epidural hematoma • Cerebral edema • Cerebral contusions • Pneumocephaly • Skull fracture • Infectious complications • Brain abscess • CSF fistulae • Encephalitis/meningitis • Scalp sepsis

17. Complications of PHT in Children • Vascular complications • Aneurysm • Arteriovenous malformation • Neurological complications • Seizures • Focal neurological defects

18. Therapy for PHT in Children • Antibiotic prophylaxis/Debridement • Organic matter which often makes up many of the projectiles in children in prone to infections • Infection rate 40% (children) and 0-25% in adults • Antibiotics and debridement (if necessary) are recommended

19. Therapy for PHT in Children • Prophylactic seizure medications • 3-10% develop early post-traumatic epilepsy(<1 wk) • 30% develop late post-traumatic epilepsy (>1 wk) • Studies suggest a beneficial role of prophylactic antiepileptics to prevent the occurrence of early PTE • Evidence for their use in preventing late post- traumatic seizures is much less convincing

20. Therapy for PHT in Children • Vasospasm • Unclear whether vasospasm plays a significant role in PHT in children • The role of nimodipine in preventing vasospasm in PHT in children remains to be elucidated

21. Therapy for PHT in Children • Vascular Eval. (Angiography/MRA) • Intracranial pseudoaneurysms and arteriovenous fistulae are well-described but uncommon and relatively late occurring sequela of PHI • May contribute to significant morbidity and mortality • Many authorities recommend vascular evaluation in all patients (timing is not clear)

22. Case Presentation • Resolution • At 1 year follow-up, patient is doing well with no neurological deficits

23. Conclusions • PHT relatively uncommon but significant cause of morbidity and mortality in children. • Outcomes can be altered with prompt diagnosis of intracranial injury and appropriate management. • Significant intracranial injury may be overlooked in children if the practitioner relies solely on history and physical examination, as many of these injuries are trivial appearing and not associated with any initial signs of symptoms.