Retro-Clival Hematoma In The Pediatric Emergency Department
Submitted by Richard. Pearson
Retro-Clival Hematoma in the Pediatric Emergency DepartmentWhile working in the pediatric emergency department there was a twelve-month-old child brought in by his parents following a fall approximately three to four hours previously. The exact time was unknown as the child had been with a caregiver while the parents were at work.
The presenting complaint was that the child was lethargic having fallen earlier that day and after the parents had come home from work the child was “not himself”. While this was largely a subjective complaint it is always worth noting that parents generally know their children well and can spot differences in their behavior.
The first indication that there was a problem was when the initial vital signs noted that the core/rectal temperature was 94 degrees. The next indication as to how sick the patient had become was the heart rate noted to in the sixties. Immediately we attached him to a cardiac monitor and the heart was verified as being in the sixties. Blood pressure oxygen saturation and breathing were within normal limits.
As the next part of my exam I looked at the patient’s mental status in relation to the vital signs and while lethargic the patient was alert and responsive to external stimuli including the detachment from his parents. This was a good sign but the vital signs were critical and needed to be addressed immediately before there was any further deterioration.
We established peripheral intravenous access and while I contemplated the use of interosseous access it was not required. Aggressive warming measures were then taken. Warm blankets and wrapped compresses applied. Warmed crystalloids infused as a bolus through a pump and a bear hugger applied. Close attention was taken to cardiac arrhythmias as this can be a side effect of rapid warming.
The next stage was to find out the possible cause. There were no obvious injuries from the fall and the doctors interviewed the parents about the events leading up to the presentation. Based on the information we had a metabolic cause was suspected but a CT scan of the head and neck was also ordered.
Blood cultures, metabolic profile, complete blood count as well as ammonia, thyroxine levels, urinalysis, urine culture and urine drug screen via a straight cath were ordered.
The initial suspicion was sepsis or another metabolic cause as well as a possible accidental overdose. The team and I acquired the blood and urine for testing as I felt that this was the most probable cause. The CT scan was delayed at my request until the patient had become hemodynamically stable.
Eventually the core temperature normalized, and the heart rate appeared to follow a direct correlation and normalized within an hour. At this point the patient was taken to CT scan with monitor and a registered nurse.
The resulting CT scan showed something very surprising – a retro clival hematoma. Literature studies show that retro clival hematomas account for about 0.3% of acute extra-axial hematomas with the majority being in the pediatric population. The hematoma from this injury is around the brain stem and C1 vertebra and result normally from a flexion/extension injury although other causes such as coagulopathy and aneurysm rupture have been reported. The main risks of these injuries are hydrocephalus, symptomatic brainstem compression and occipito-cervical instability which can result in an internal decapitation.
Spinal stability was immediately prioritized with a C-collar and the patient was laid flat.
Neurosurgery promptly arrived and recommended an MRI. The importance of the MRI was to evaluate for any ligamentus injury which would cause occipital instability.
The ongoing assessment of the patient showed normal neurological and hemodynamic assessments. The next day while on the PICU an MRI was performed under anesthesia which showed no ligament injury.
The rest of the hospital course was uneventful and lasted approximately seven days with a C-collar in place.
The hypothermia and resulting bradycardia were somewhat of a mystery. Neurosurgery felt that the hypothalamus is too superior to the brain stem to be affected by pressure from the hematoma. The literature makes no mention of hypothermia.
What may have been the cause is that after the patient fell he then went into shock which resulted in a lower resting metabolism. Spinal shock with secondary neurogenic shock is a possibility but more remote as the child had been supervised.
The outcome was good given the unusual presentation and the risk of further injuries.
References:Isolated traumatic retroclival hematoma: case report and review of literature.
Ha Son Nguyen, Saman Shabani and Sean Lew