Emergency Radiology

CT before LP?

EMKF
  • If you think CT will show a cause for the headache, do a CT
  • If a CT is indicated for other reasons (depressed conscious level, focal neurology), do a CT
  • If a GCS 15 patient is to undergo LP for suspected (or to rule out) meningitis, and they have a normal neurological exam (including fundi), and are not elderly or immunosuppressed, there is no need to do a CT first.
  • If you’re seriously worried about meningitis and are intent on getting a CT prior to LP, don’t let the imaging delay antimicrobial therapy.

Detecting Child Abuse in the Emergency Department

EMKF
  1. When there is concern for physical abuse, the physical examination should be completed with the child undressed (in a gown), with specific attention to the skin, scalp and fontanel, mouth and oral cavity (including frena), ears, genitalia, and growth chart.
  2. Any injury in a preambulatory child, including bruises, mouth injuries, fractures, and intracranial or abdominal injury, should raise concern for abuse.
  3. The “TEN 4” rule: bruising of the Torso, Ears, or Neck in children <4 years old and any bruising in children <4 months old should raise concern.
  4. Radiographic skeletal survey should be performed using proper technique for children <2 years old with concern for abuse. Repeating the skeletal survey 2–3 weeks later can identify additional fractures that were not seen initially.
  5. Young (<2 years old) siblings and household contacts of abused children should be examined for abusive injuries and undergo skeletal survey.
  6. Infants evaluated for physical abuse may benefit from neuroimaging even if they don’t have neurological symptoms.
  7. Retinal examination is indicated for children with concern for abusive head trauma but may not be indicated for children without intracranial injury.
  8. Health care providers with a reasonable suspicion of physical abuse have a legal mandate to report their concern to child protective services.