~Teachingcenter的醫學筆記~

3個月大的女嬰從約1公尺高的餐桌上摔落跌至地板，頭部撞到地板，立刻嚎啕大哭，父母不確定小寶寶是否曾有意識喪失，期間曾嘔吐了一次，在急診室小寶寶四肢活動及行為大致正常，她的左頂葉頭皮處有一3公分大小的挫傷；下列何項處理方法最為適當？

A. 頭部電腦斷層掃描（CT）

B. 在急診室觀察30分鐘

C. 照頭部X光片、放置顱內壓監測器，隨後住院觀察

D. 照頭部X光片，如果影像報告是陰性的，可以立即放心回家

E. 照頭部X光片，如果影像報告是陰性的，請患者在急診室觀察2小時

Ans: A.

Tintinalli's Emergency Medicine, 2016, 8th Edition
Chapter 110 Pediatric Trauma, p707~709

Chapter 138 Head Injury in Infants and Children, p907~908

原文：

Ch 110:
Plain films of the skull have limited use in the evaluation of pediatric head trauma except in children less than 2 years old in whom they are an acceptable screening tool for fractures when there is a large, usually boggy scalp hematoma noted on physical examination. However, if a skull fracture is identified by plain film, obtain a CT scan to rule out an intracranial injury, as there is a four- to six-fold risk of intracranial pathology associated with skull fracture. A four-view series is recommended and consists of anteroposterior, right and left lateral, and Towne (30-degree caudal angulation) views. Plain films can be difficult to interpret due to normal cranial sutures and may miss as many as 25% of skull fractures, and plain films have a low sensitivity for intracranial injuries.

Ch 138:
The Canadian Assessment of Tomography for Childhood Head Injury (CATCH) study identifies factors associated with high risk for significant intracranial injury requiring neurosurgical intervention among 3866 children <16 years of age presenting to the ED within 24 hours of minor head injury defined as GCS of 13 to 15 with witnessed loss of consciousness, vomiting, amnesia, and disorientation or irritability. High-risk children were those with GCS <15 2 hours after injury, suspected open or depressed skull fracture, worsening headache, or irritability. Medium-risk children were defined as those with signs of basilar skull fracture, a large, boggy scalp hematoma, or a dangerous mechanism of injury (fall >1 meter or five stairs, motor vehicle collision, or fall from a bicycle without a helmet). Using these criteria, the CATCH rule had a sensitivity of 100% and specificity of 70% for identifying highrisk patients who require surgical intervention and 98% and 50% for identifying a CT abnormality among medium-risk patients.

結論處置(簡略翻譯)：在小於2歲的病童，顱骨X光有其診斷的價值，要照前後、左右和Towne view (背對桌面，OML垂直桌面，X光放射端(tube)向腳轉30度)，但要注意會有25%的顱骨骨折可能無法由X光判斷，而且有顱骨骨折的病童，「一定」要做腦部電腦斷層，此為高風險。

※OML = Orbitomeatal line = 眼眶耳道線

所以…與其糾結X光的判讀，以下情形，直接做CT吧！

Canadian Assessment of Tomography for Childhood Head Injury (CATCH)

其實…CATCH還有個前提，就是來評估頭部創傷併輕微外傷且GCS介於13到15，還要曾在24小時內失去意識、嘔吐、失去記憶、陷入混亂、無法安撫的躁動哭鬧。但這個很重要嗎？其實在台灣，大概這些「前提」就會讓醫生決定照CT了…，若是有高度風險或中度風險的情形，更是直接去做CT，哪管什麼前提…