2nd place Emage Winner: Subgaleal Hematoma beyond the neonatal period

Deepak Choudhary, MBBS, MRCPCH, MD;  Sarah Dipalma, MD; Jessica Strauss, MD; Mary Emborsky, MD; Frank Carnevale, MD

Department of Pediatric Emergency Medicine, Oishei Children’s Hospital, University of Buffalo, New York

A four-year-old African American female presented to our ED with one day history of bogginess of her scalp. The guardian mentioned there were two unwitnessed falls from a trampoline and bunk bed in the last two days. The family denied behavior changes, headache, neck pain, vomiting, numbness or weakness. No bleeding problems were reported by the child or family.

Her vital signs were normal. She was alert and interactive. There was marked diffuse, non-tender and fluctuant swelling on her head taking the shape of a turban, but no obvious abrasions or ecchymosis noted. Her neurological examination was benign. The rest of the exam was unremarkable. Her labs revealed Hb 11.4 g/dL with normal rest of CBC and PT/PTT.

Figure 1: Noncontrast computed tomography scan of head
Figure 2: Limited MRI of brain

Conclusion

The scalp hematoma was defined as subgaleal bleed of 390 ml (27% of her total blood volume). No neurosurgical interventions were required. She had an uneventful observation period. Her repeat CBC showed hb of 10.4 g/dL and rest of parameters remained unchanged. She was discharged with neurosurgical follow up in 1 week.

It was concluded that significant subgaleal bleeding was due to her progressive hair braiding and recent minor head injuries.

Subgaleal hematoma (SGH) is very rare beyond the neonatal period. Very few such cases have been published in which the etiology was secondary to hair combing1, braiding2 or pulling, hematological abnormalities3, child abuse4 and trauma. A very small proportion required neurosurgical interventions. Serious complications include hypovolemia, extension to orbits5 causing proptosis ophthalmoplegia and corneal ulceration. Extension beyond galeal attachment at zygomatic arch can cause airway compromise and skin necrosis6. General management of SGH includes laboratory evaluation for coagulation defects, serial measures of blood count, radiographic imaging, and avoidance of anticoagulant medications. In essence, conservative treatment and close follow-up if sufficient for benign SGH.

References

  1. Falvo CE, San Filippo JA, Vartany A, et al. Subgaleal hematoma from hair combing.

Pediatrics. 1981;68(4):583–584.

  • Vu TT, Guerrera MF, Hamburger EK, et al. Subgaleal hematoma from hair braiding. Case report and literature review. Pediatr Emerg Care. 2004;20(12):821Y823.
  • Rafffini L, Tsarouhas N. Subgaleal hematoma from hair braiding leads to a diagnosis of von Willebrand disease. Pediatr Emerg Care. 2004;20(5):316Y318.
  • Seifert D, Püschel K. Subgaleal hematoma in child abuse. Forensic Sci Int. 2006 Mar 10;157(2-3):131-3
  • Pomeranz AJ, Ruttum MS, Harris GJ. Subgaleal hematoma with delayed proptosis and corneal ulceration. Ann Emerg Med. 1995;26(6):752–754.
  • Nichter LS, Bolton LL, Reinisch JF, et al. Massive subgaleal hematoma resulting in skin compromise and airway obstruction. J Trauma. 1988;28(12):1681–1683.

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