Clinical scenario 2: Ruby

Teaching/learning points:

You are asked to look at a two month old baby girl, Ruby, who has been brought into the emergency department by her parents after a fall from a sofa. The triage nurse is concerned Ruby is 'not quite right'.

Ruby’s father says she had been on the sofa asleep on her back and rolled off the sofa onto a solid non-carpeted floor. She cried immediately but has since been quieter and more lethargic. Ruby’s father said this is unusual for her because she usually 'cries all the time'. Ruby’s parents did not notice any obvious external injury.

The family is presenting 24 hours after the event. In that time Ruby has had some vomiting. The triage nurse is concerned that Ruby looks pale, is very quiet and slightly irritable on handling.

The following six questions refer to Ruby's clinical scenario.

Question 11

What are the priorities in the assessment and management of this case? Please choose the best order:

A - Disability

B - Neurological status

C - Breathing

D - Airway with Cervical Spine control

E - Circulation with Haemorrhage control

 
E, A, B, D, C
C, E, A, B, D
D, C, E, A, B
A, B, D, C, E
D, C, E, B, A
Check answer

Explanation

D, C, E, A, B

In the rapid assessment of trauma, regardless of mechanism or setting, the assessment strategies remain the same so as to identify the greatest threat to life first.

Question 12

Ruby is breathing fast but without distress and a clear chest. Her heart rate is 190bpm, her blood pressure is difficult to measure and her capillary refill time is 4 seconds centrally. Her abdomen is soft and there are no obvious limb deformities.

Ruby looks pale and is showing clinical signs of shock. However, there is no clinical suggestion of bleeding from her chest, abdomen, pelvis or long bones. Her haemoglobin is 65g/L on the blood gas.

Which one of the following is the approximate circulating blood volume of an infant at this age?
40ml/kg
50ml/kg
60ml/kg
70ml/kg
80ml/kg
Check answer

Explanation

Neonates and small infants have up to 80mls/kg circulating blood volume. In a 3.5 kg baby, this equates to 280mls (less than a can of soft drink).

Question 13

During your assessment, you confirm a tense, open anterior fontanelle. You notice Ruby having some brief subtle abnormal movements, with deviation of both eyes to the right and repetitive lip-smacking, possibly consistent with a brief seizure.

From which one of the following could Ruby be bleeding from?
Retroperitoneal
Intracranial
Renal
Spinal
Check answer

Explanation

Small babies can bleed and accommodate significant volumes intracranially, sufficient to develop shock. A combination of fragile vasculature, hypervascular growing brain, soft unfused skull bones and a small circulating blood volume means the head must be considered as a potential source of hypovolaemic shock in small infants.

Question 14

You call for help and begin to resuscitate and stabilise Ruby, suspecting an intracranial injury. Which one of the following is the most appropriate investigation?
Cranial ultrasound scan
MRI Brain
CT Brain
Skull x-ray
Check answer

Explanation

In an emergency setting such as this, urgent CT brain is the next appropriate step. A CT head will show bony injury, acute bleeding and radiographic evidence of raised intracranial pressure well. It is also likely to be readily available and can be performed quickly.

A cranial ultrasound scan is often used in neonates, exploiting their open fontanelles to visualise the brain. It is very operator-dependant but can show intraventricular haemorrhage very well. It will not, however, assess the peripheries well, potentially missing extra- and sub-dural haemorrhage.

An MRI would be useful, but is still not readily available in all centres, especially out of hours. Scans can be time consuming, enhancing the risk of deterioration in such a patient.

Question 15

An urgent CT scan is performed, as shown in the accompanying image. Brain scan

The scan is reported as showing bilateral non-acute frontal subdural haemorrhages, with no evidence of mass effect or skull fracture.

Which one of the following is the main significance of this finding?

The child does not require neurosurgical intervention
This is a potential Non-Accidental Injury
The child may have a bleeding disorder
Check answer

Explanation

The correct answer is 'potential non-accidental injury'.

It is difficult to adequately explain the presence of these findings in the context given. Unfortunately, some people intentionally harm children and as doctors involved in the care of children, particularly with regards trauma, we have to remain vigilant and consider this possibility

With this information, you can look back at the case to identify potential red flags in the story:

  • While not diagnostic, a delayed presentation of significant injury is a definite red flag in non-accidental injury.
  • The subdural haemorrhages identified are not acute. The injury identified is therefore incompatible with the mechanism given: that of having fallen from a sofa 24 hours previously.

Question 16

At which one of the following ages would you expect a baby to be able to roll?
2 months
3 months
4 months
5 months
6 months
Check answer

Explanation

By six months, infants ought to be able to roll front-to-back, and often also back-to-front. An advanced three month old might be able to role front to back, but not the reverse. It is highly unlikely a two month old would be able to roll at all. The history given is not compatible as the infant is not developmentally capable of rolling in the manner described.

Although small infants can wriggle and squirm and fall off things, a working knowledge of developmental milestones is needed to spot incompatibilities in histories accompanying injuries.

Ruby proceeds to undergo further investigations. Retinal haemorrhages are identified on ophthalmology consult and multiple healing fractures of multiple ages are identified on skeletal survey, consistent with a diagnosis of non-accidental injury.
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