Case review 3

To manage this case successfully, you have to, at an early stage appreciate that the infant has a serious problem that is being caused by a predominantly caused by a problem in the brain. This needs to be investigated properly and safely. Infection is a strong possibility and broad spectrum antibiotics are indicated. Whatever the investigations or treatment the infant's clinical condition will deteriorate. The more steps that are taken, the more the child will deteriorate.

The 'perfect' route involves a CT and antibiotics immediately, followed by an opthalmology review. This will enable the diagnosis of non-accidental injury to be made before the child requires intubation and ventilation.

If the patient has a lumbar puncture, the infant will cone leading to brain death. Lumbar puncture is a valuable diagnostic test. However, the position required is liable to impair respiratory and cardiac function and increases intracranial pressure. In this case the reduced conscious level is an indicator that the intracranial pressure is already raised.

The other very serious outcome is if the baby is sent home, as you lose contact with the patient. If there is suspicion of non accidental or inflicted injury, the patient should remain in a place of safety.