Index of Suspicion in the Nursery

Abstract

A 2-day-old male infant is transferred urgently from another hospital to the emergency department for sudden onset of cyanosis, tachypnea, retractions, and hypoactivity. Head swelling is noted. The infant was born by cesarean section to a G3P2L2 mother whose pregnancy and delivery were uneventful by report. Prenatal course was unremarkable. Maternal serologies were not available. On arrival, the infant is noted to have generalized severe pallor; he is unconscious and flaccid with extended extremities. His heart rate is 69 beats per minute and falling; his capillary refill is delayed with nonpalpable peripheral pulses. He has no spontaneous movements and is unresponsive to painful stimuli. His pupils are fixed, dilated, and nonreactive to light bilaterally. Head examination reveals open anterior and posterior fontanelles, with a left frontoparietal fluctuant edema extending to the neck. Immediate resuscitation is initiated, including endotracheal intubation, chest compressions, medications (epinephrine), and fluid resuscitation with normal saline then O negative packed red blood cells via an intra-osseous line. Placement of an umbilical venous line is not attempted because of dry umbilical stump. Attempts at obtaining arterial or venous blood gas fail due to poor perfusion. Further details in the history, physical examination, and imaging studies reveal the diagnosis. Further details reveal a history of head trauma 2 hours before presentation. The infant had fallen on the concrete ground during routine bathing care. Immediately after the fall, the infant was reported to be active; however, shortly thereafter, he became less active and cyanotic requiring oxygen support. Upon presentation, detailed examination reveals a boggy fluid collection on the left frontoparietal area extending to the neck with a ballotable fluid wave beneath the scalp. Skull radiograph reveals two comminuted and displaced fractures of the left parietal …