Male patient 3 years old
Male patient 3 years old, from Ashmoun, the 1st sibling of non-consanguineous marriage
Falling from height 30 hours before admission
Gradual loss of consciousness with bleeding per nose and right ear.
No history of vomiting or seizures.
Patient transferred to private Hospital where he ventilated on GCS 7 and CT brain and body scan were done.
GCS improve to 10 and they extubate him Then, patient transferred to our university hospital.
General examination:
- Bad general condition, GCS = 10, pale
- HR: 138, RR: 37, Temp.: 38.2,
- BP: 116/66, SPO2: 98% on RA,
- CRT: 2 sec, RBS: 124
Head and neck
- Extensive sub-galeal hematoma on the right side extending the face with edema down to the Rt. side of the neck with Buffy eyelids.
- There is blood clots per nose and right ear.
- There are two small stitched wounds in Rt. Parietal region and in front of the Rt. ear.
Local CNS Examination
- GCS 10.
- Regular breathing at room air.
- Pupils are rounded, regular, reactive and equal in both sides.
- No squint or nystagmas.
- Intact corneal and gag reflexes.
- No facial asymmetry.
Motor system
- Left side: Hypertonia hyper-reflexia with pathological reflexes (adductor, patellar and +ve babinski sign).
- Right side: normal tone, brisky DTR
- Intact superfacial reflexes.
Pediatric trauma score
|
+1 |
>20 kg |
Size |
|
+2 |
Normal |
Airway |
|
+2 |
116 |
Systolic BP |
|
+1 |
LOC |
CNS |
|
+1 |
Minor |
Open wounds |
|
+1 |
Closed fracture |
skeletal |
|
+8 |
Sum total points |
|
