A 2 month old reportedly rolled off the bed and EMS was called for change in mental status.  The child had seizure en route. A cat scan was obtained in the evaluation of this child.  What's the diagnosis?  Scroll down for answer.

Answer:  Subdural hematoma and skull fracture, likely secondary to abuse

Consider abuse when mechanism does not match injury or injuries are not age appropriate (Infants start to roll over at about 4 months)

Management of SDH involves

• Assess / address airway, breathing, circulation
• Stat neurosurgical consult
• Consider possiblity of concomitant injury (especially cervical spine with head injury)
• Reversal of any coagulopathy
• Control seizures with benzodiazepines (e.g. lorazepam, midazolam or diazepam), load antiepileptics (e.g. keppra, pheonobarbital, valproic acid)

Any patient with concerns for abuse

• In infants, consult ophthalmology for dilated eye exam / evaluate for retinal hemorrhages
• skeletal survey to assess for fractures (if fractures found check calcium, phosphate, vitamin D 25-OH, PTH alkaline phosphatase)
• consider abuse with odd bruises on soft parts of the body  (abdomen, ears, neck); if atypical bruising noted check PT/INR, PTT, fibrinogen, thrombin time, VWF, Factors 8 and 9 prior to transfusion if possible
• Report to local child protective services
• Admit patients when concerned for abuse