Penetrating head injury in a paediatric patient caused by an electrical plug

Child's Nervous System, Feb 2006

Introduction Penetrating head injuries are rare especially in the paediatric age group. Relatively minor falls over common household objects can cause potentially life-threatening brain injuries. Case report We describe a penetrating head injury caused by a household electrical plug in a 6-month-old child. The two rounded pins of the plug were embedded in the posterior parietal area of her head, very close to the cranial midline. There was no neurological deterioration or bleeding. Radiological investigation showed a depressed skull fracture underneath the two pins. One of them came very close to the superior sagittal sinus but there was no evidence of intracranial bleeding. The electrical plug was extracted under general anaesthesia in the operating theatre. The penetrating fracture segments were removed. The sagittal venous sinus was fortunately undamaged. Conclusions Household objects like electrical plugs may constitute a risk for children. It may be worthwhile to reconsider the design of electrical plugs.

A PDF file should load here. If you do not see its contents the file may be temporarily unavailable at the journal website or you do not have a PDF plug-in installed and enabled in your browser.

Alternatively, you can download the file locally and open with any standalone PDF reader:

http://link.springer.com/content/pdf/10.1007%2Fs00381-005-1141-5.pdf

Penetrating head injury in a paediatric patient caused by an electrical plug

Childs Nerv Syst Penetrating head injury in a paediatric patient caused by an electrical plug Antonio López González Antonio Gutiérrez Marín José Andrés Álvarez Garijo Manuel Vila Mengual 0 0 A. López González Introduction: Penetrating head injuries are rare especially in the paediatric age group. Relatively minor falls over common household objects can cause potentially life-threatening brain injuries. Case report: We describe a penetrating head injury caused by a household electrical plug in a 6-month-old child. The two rounded pins of the plug were embedded in the posterior parietal area of her head, very close to the cranial midline. There was no neurological deterioration or bleeding. Radiological investigation showed a depressed skull fracture underneath the two pins. One of them came very close to the superior sagittal Electrical plug; Paediatric head injury; Penetrating head injury; Perforating head injury; Superior sagittal sinus; Stab wound Introduction sinus but there was no evidence of intracranial bleeding. The electrical plug was extracted under general anaesthesia in the operating theatre. The penetrating fracture segments were removed. The sagittal venous sinus was fortunately undamaged. Conclusions: Household objects like electrical plugs may constitute a risk for children. It may be worthwhile to reconsider the design of electrical plugs. Case report In Spain, it is estimated that 5% of all the paediatric-age A 6-month-old baby accidentally fell from a 1.5-m-high patients treated in emergency wards have suffered a head table while she was being dressed by her mother. Unforinjury [ 8 ]. Falls are the cause of 21% of head injuries in tunately, her head fell onto an upturned electrical two-pin patients between 0 and 15 years old [ 17 ]. Approximately plug that was lying on the floor. The two rounded pins were 57% of all children under 7 years of age with a head injury embedded on impact in her right posterior parietal area are male; and this percentage increases to 86% in children very close to the cranial midline (Fig. 1a,b). There was no between 7 and 14 years old. Of all head traumas suffered by loss of consciousness and she did not suffer from any paediatric-age patients, 80% are mild and 20% are mod- neurological or general deterioration. Urgent medical assiserate or severe [ 8 ]. tance was required. The electrical cord was cut to release Sixty percent of traumatisms in children under 3 years of the child from the household appliance and she was taken age happen at home [ 17 ]. Many of these accidents could be to the nearest hospital. From there, the patient was referred prevented with adequate adult care. Relatively minor falls to our department of paediatric neurosurgery. over uncontrolled common household objects can cause When the baby arrived, neurological examination was potentially life-threatening brain injuries. We describe the done and results were completely normal. The proximity of case of a penetrating head injury caused by a household the pins to the posterior head midline was very remarkable. electrical plug in a 6-month-old child who fell from a Neither bleeding nor cerebrospinal fluid (CSF) leakage was 1.5-m-high table. observed through the stab wound. Fig. 1 a, b Posterior and superior view of the 6 month-old child with a plug firmly embedded in the posterior parietal area of her head, very close to the cranial midline Radiographs of the skull in anteroposterior and lateral views were obtained. The plug structure and the two cylindrical pins penetrating the skull could be seen, as well as the relationship between the pins and the cranial sutures (Fig. 2). A three-dimensional computed tomography (CT) was also obtained: neither brain haemorrhages nor epidural or subdural haematomas were detected (Figs. 3 and 4). The CT also showed that the left electrical pin seemed to be located on the superior sagittal sinus (Fig. 4). Prophylactic antibiotics were administrated and the baby was immediately taken to the operating theatre. Under general anaesthesia, a semicircular skin incision that included the plug in the skin flap was made (Fig. 5). As the skin flap was being gradually elevated, the two pins were easily extracted from the skull. Neither bleeding nor CSF leakage was observed through the two skull orifices. Finally, the periosteum was elevated and the small segments from the penetrating fracture were removed. The superior sagittal sinus was undamaged. Small tears in the dura were covered with a duraplasty. The surgical wound was closed and the stab wound was sutured Fig. 3 Sagittal reconstruction of the CT scan showing a pin penetrating the skull and a depressed skull fracture underneath the pin Fig. 4 A three-dimensional CT. The left electrical pin seems to be located on the superior sagittal sinus after debridement. During the immediate postoperative period, the patient suffered only a single seizure episode but no anti-epileptic medication was administrated. The baby was discharged few days later and remains asymptomatic more than 1 year after the traumatism. Discussion Penetrating wounds caused accidentally by common objects have occasionally been described in the medical literature. Stab wounds to the cranium are usually caused by knives, harpoons and nails. Other bizarre injuries reported are those caused by pencils, keys, power drills, glasses, chopsticks, animal claws and iron bars [ 2, 3, 5, 9–11, 13– 15, 21 ]. Intrauterine stab wounds to the head of a foetus have also been reported [20]. Because of severe legislation controlling firearms possession, gunshot wounds to the head are very uncommon in this country, especially among children. In the case we describe, the two pins of an electrical plug caused a penetrating head injury. There are only three similar cases reported in which an electrical plug caused a penetrating head injury in a child [ 4, 18, 22 ]. Stab wounds typically produce a slot fracture of the skull with an underlying tract haematoma. Unless there is an associated haematoma or infarct, cerebral damage caused by stabbing is largely restricted to the wound tract [ 16 ]. The severity of the brain injury is mainly dependent on the site and depth of the stab. Frontal stabs are accompanied by the lowest rates of morbidity and mortality [ 16 ]. Stab wounds to the temporal fossa are more likely to result in major neurological deficits because of the thinness of the temporal squama and the shorter distance to the deep brain stem and vascular structures [ 12 ]. In transorbital stabs, the wounding instrument may pierce the thin floor of the anterior fossa and tend to direct itself to the weak points in the bone, often toward the internal carotid artery, resulting in carotid–cavernous fistulae [ 16 ]. Dural venous sinuses can be damaged in penetrating wounds, with disastrous consequences. In the case we describe, one of the two pins that were embedded in the child’s head was extremely close to the superior sagittal sinus. The two most common late complications of penetrating injuries are infection and secondary haemorrhage [ 1, 6 ]. Meningitis and brain abscesses are possible, especially if the air sinus is penetrated. Posttraumatic epilepsy is relatively common in patients after traumatic brain injury and specifically after penetrating head trauma, but the prophylactic use of anticonvulsants has not been demonstrated to prevent the development of late posttraumatic seizures [19]. Posttraumatic aneurysms and arteriovenous malformations are also possible [ 7 ]. If a penetrating head injury does take place, a close monitoring of the child’s vital and neurological parameters is essential [ 22 ] until the patient can be examined as soon as possible by a neurosurgeon. Under no circumstances should any effort be made to remove the object until the patient has had a thorough clinical and radiological examination. Sudden removal can cause loss of tamponade effect and subsequent catastrophic intracranial haemorrhage [ 22 ]. Radiological examination involves skull radiographs and CT. Skull radiographs offer valuable information about the shape of the penetrating object and the existence of depressed skull fractures or intracranial foreign bodies. CT scanning remains the most useful tool for investigation. It provides information about the relationship between the penetrating object and intracranial anatomical structures. It also shows the presence of skull fractures and intracranial haematomas. The metal artefacts caused by the penetrating foreign body may limit the information provided by the CT. Three-dimensional CT offers spectacular skull images but does not give more information than conventional CT. The impacted object must be removed in the operating theatre under general anaesthesia by a neurosurgical team. It may be firmly embedded in the skull and difficult to remove. If necessary, a craniotomy can be performed to control intracranial structures. In our case, the surgery was originally planned as a biparietal craniotomy to enable the neurosurgeon to control any bleeding from the venous sinus after removing the two pins. In the end, it was not necessary to perform the craniotomy because no bleeding was detected. The European Committee for Electrotechnical Standardization determines the characteristics of electrical articles. The standard UNE 20-315-94 establishes certain features for plugs and sockets–outlets destined for household or similar use. The dimensions and shape of plug pins are set forth in detail in different subsections of this standard. Pins must be resistant and rounded. However, no mention is made of the shape of the whole plug. It may be worthwhile to reconsider the design of electrical plugs to make it impossible that a household plug remain in an upturned position. 1. Anderson ID , Woodford M , Irving MH ( 1989 ) Preventability of death from penetrating injury in England and Wales . Injury 20 : 69 - 71 2. Bauer M , Patzelt D ( 2002 ) Intracranial stab injuries: case report and case study . Forensic Sci Int 129 : 122 - 127 3. Bock H , Neu M , Betz P , Seidl S ( 2002 ) Unusual craniocerebral injury caused by a pneumatic nail gun . Int J Leg Med 116 : 279 - 281 4. Couper GW , Boddie DE , Eljamel MS , Kaar GF ( 2000 ) Unguarded electric plugs cause penetrating head injuries in children . J Accid Emerg Med 17 : 55 5. Dinakaran S , Noble PJ ( 1998 ) Silent orbitocranial penetration by a pencil . J Accid Emerg Med 15 : 274 - 275 6. du Trevou M , Bullock R , Teasdale E , Quin RO ( 1991 ) False aneurysms of the carotid tree due to unsuspected penetrating injury of the head and neck . Injury 22 : 237 - 239 7. du Trevou MD , van Dellen JR ( 1992 ) Penetrating stab wounds to the brain: the timing of angiography in patients presenting with the weapon already removed . Neurosurgery 31 : 905 - 911 8. Elorza Arizmendi JF , Marti Aromit G , Cremades Romero B , Leon Sebastia P , Perez-Gramunt MA , Alvarez Angel V ( 1997 ) Pediatric cranio-encephalic trauma in the emergency ward . An Esp Pediatr 46 : 464 - 470 9. Fernandez-Melo R , Moran AF , LopezFlores G , Bouza-Molina W , GarciaMaeso I , Benavides-Barbosas J ( 2002 ) Penetrating head injury from harpoon . Neurocirugia 13 : 397 - 400 10. Gray J , Molloy D , Jenkins MG ( 2004 ) “Glass in a scalp laceration”: an unusual case of penetrating head injury presenting to the emergency department . Eur J Emerg Med 11 : 117 - 118 11. Harlow HM ( 1868 ) Recovery from the passage of an iron bar through the head . Mass Med Soc Publ 2 : 327 12. Haworth CS , de Villiers JC ( 1988 ) Stab wounds to the temporal fossa . Neurosurgery 23 : 431 - 435 13. Hayashi Y , Fujisawa H , Tohma Y , Yamashita J , Inaba H ( 2003 ) Penetrating head injury caused by bear claws: case report . J Trauma 55 : 1178 - 1180 14. Kawamura S , Hadeishi H , Sasaguchi N , Suzuki A , Yasui N ( 1997 ) Penetrating head injury caused by chopstick . Case report. Neurol Med Chir 37 : 332 - 335 15. Kelly AJ , Pople I , Cummins BH ( 1992 ) Unusual craniocerebral penetrating injury by a power drill: case report . Surg Neurol 38 : 471 - 472 16. Khalil N , Elwany MN , Miller JD ( 1991 ) Transcranial stab wounds: morbidity and medicolegal awareness . Surg Neurol 35 : 294 - 299 17. Navascues del Rio JA , Sotelo Martin J , Cerda Berrocal J , Barrientos Fernandez G , Sanchez Martin R , Romero Rodriguez R , Molina Hernando E, de Tomas Palacios E, de Agustin Asensio JC , Luque Mialdea R , Aguilar Tremoya F , Vazquez Estevez J ( 1998 ) Pediatric trauma registry: analysis of 1200 cases . Cir Pediatr 11 : 151 - 160 18. O 'Loughlin M , Criddle L ( 2003 ) A case of penetrating head trauma in an 8-month-old . J Emerg Nurs 29 : 189 - 190 19. Salazar AM , Jabbari B , Vance SC , Grafman J , Amin D , Dillon JD ( 1985 ) Epilepsy after penetrating head injury. I. Clinical correlates: a report of the Vietnam head injury study . Neurology 35 : 1406 - 1414 20. Schultz H , Bretschneider S , Lamme W , Minda R , Canzler E ( 1993 ) Intrauterine stab injury with a knife in the head of a fetus in the 29th week of pregnancy . Kinderarztl Prax 61 : 215 - 218 21. Seex K , Koppel D , Fitzpatrick M , Pyott A ( 1997 ) Trans-orbital penetrating head injury with a door key . J Craniomaxillofac Surg 25 : 353 - 355 22. Tan MH , Choudhari KA ( 2003 ) Penetrating head injury from an electrical plug . Injury 34 : 950 - 953


This is a preview of a remote PDF: http://link.springer.com/content/pdf/10.1007%2Fs00381-005-1141-5.pdf

Antonio López González, Antonio Gutiérrez Marín, José Andrés Álvarez Garijo, Manuel Vila Mengual. Penetrating head injury in a paediatric patient caused by an electrical plug, Child's Nervous System, 2006, 197-200, DOI: 10.1007/s00381-005-1141-5