Case 41: Sweet dreams
Monday, January 23rd, 2012Author: Dr Ian Stell
This three month baby boy had a history of a head injury the previous evening. His mother was carrying him with one arm when he moved suddenly. His head fell backwards and hit the edge of a kitchen cupboard door. He cried immediately and was otherwise unaffected. In the morning his mother noticed a large swelling on the left side of his head and therefore brought him to the ED.
The NICE paediatric head injury guidelines advocate a CT scan for children under one year with a bruise, swelling or laceration > 5 cm on the head following trauma.
This lively baby was unlikely to keep still for a CT scan. The anaesthetists indicated that they had no-one on duty able to anaesthetise (GA) an infant therefore if a GA was required this would mean a transfer to another hospital.
1. What are the other options?
Click to see the answerAs CT scans are not ‘painful procedures’ options include:
A. Pharmacological options: including etomidate, ketamine, benzodiazepines, chloral hydrate, opiates, and anti-histamines (eg diphenhydramine). Although the use of many of these drugs for infants is restricted in many UK Emergency Departments.
B. Non-pharmacological options include:
Swaddling, calm and quiet environment, ‘non-nutritive suckling’ and oral sucrose.
2. What is the role of oral sucrose in calming?
Click to see the answerSmall amounts of sweet solutions, such as oral sucrose, in an infant’s mouth reduce procedural pain. The mechanism is an orally mediated increase in endogenous opioid. The analgesic effects last 5-8 minutes, making it an ideal strategy for management of short term pain. Sucrose is more effective if given with a dummy as this promotes non-nutritional sucking which contributes to calming. Oral sucrose is most effective in the first month of life, but it has also been shown to have analgesic and calming effects up to 18 months of age.
This infant was given sweet syrup, followed by a short period of breast-feeding. This was sufficient to enable the CT to be undertaken.
This image from the CT shows the skull fracture and associated extracranial swelling:
