Head Injury: Inflicted or Accidental?

1
Head Injury Inflicted or Accidental?

• Robert Allan Shapiro, M.D.
• Childrens Hospital Medical Center
• Cincinnati, Ohio
• 513-636-7966

2
What is the minimal trauma that can result in
serious head injury/death?

• Clinical experience - type of injury/fall
• Published studies of head injuries
• short distance falls
• falls out of bed
• falls down stairs
• falls out of walkers
• falls out of shopping carts
• witnessed and un-witnessed falls

3
Mechanism of Injury

• distance fallen
• propelled
• free or broken fall
• landing surface characteristics
• spread of energy ( body involved, fractures)
• Primary vs. Secondary brain injury

4
Deaths from Falls in Children How Far is Fatal?

• Chadwick, et al Journal of Trauma, 1991 (San
  Diego)
• 10' - 45' 118 1 death (CHI)
• 4' - 10' 65 0 deaths
• lt 4' 100 7 deaths (CHI)
• 5/7 had signs of abuse (e.g. RH, fracture)

5
Injuries from witnessed corroborated free falls

• Williams. J Trauma, 1991
• With independent witness
• 106 falls lt 2-70 feet
• 3 small depressed skull fractures
• 1 death after a 70 fall
• Without independent witness
• 53 falls lt 5 feet
• 2 deaths

6
Additional indications of nonaccidental head
injury

• Other injuries
• Bruises rib, long bone other fractures
• Retinal hemorrhages
• present in 70-80 of SBS
• extent of hemorrhage correlates w/ injury
  severity
• intra-retinal hemorrhage
• subretinal / vitreous hemorrhage
• Social/family risk factors

7
Whiplash Shaken Baby Syndrome (Caffey 1972)

• Infants lt 2 y/o with intracranial injury
• Chief Complaint / History
• lethargy, irritability, poor feeding
• trauma, apnea, seizure, DOA
• Exam retinal hemorrhages
• other trauma often minimal or absent
• C-T subdural/subarachnoid hemorrhages

8
Serious Head Injury in Infants Accident or
Abuse?

• Billmire, Myers. Pediatrics, 1985
• Infants lt 1 y/o over a 2 year period
• 19 infants w/SDH or other intracranial injury
• 18 Abuse
• 1 Accident (MVA)

9
Diagnosis of Shaken Baby Syndrome

• Consider SBS in infants with
• intracranial injury after minor trauma
• scan infants with symptoms indicative of head
  injury
• retinal hemorrhages
• Does the history explain the injuries?
• If not
• look for other indications of abuse
• diagnose other illnesses that can be mistaken for
  SBS

10
Injuries resulting when small children fall out
of bed

• Helfer et al Pediatrics, 1977
• 161 children lt 5 y/o fell at home
• 6 fractures (3.7)
• 85 children lt 5 y/o fell in hospital
• 1 fracture (1.2)
• 0 intracranial injuries

11
Falling out of bed A relatively benign
occurrence

• Lyons, Oates. Pediatrics, 1993
• 207 children lt 6 y/o
• fell 25 - 54 from hospital beds
• 1 skull fracture
• 1 clavicle fracture
• 0 intracranial injuries

12
Bunk Bed Injuries

• Selbst, Baker, Shames. AJDC, 1990 (Philadelphia)
• 68 falls from bunk beds (6 feet)
• 37 lt 2 y/o
• 8 concussions (12)
• 1 skull fracture w/SDH (1.5)

13
Infant Walker Related Injuries

• Smith, et al Pediatrics, 1997 (Columbus)
• 271 babies (96 fell down stairs)
• contusions / abrasions / lacerations 192 (72)
• skull fracture 26 (10)
• gt 10 stairs increased incidence of skull
  fracture
• concussion 35 (13)
• intracranial hemorrhage 3 (1)

14
Infant Walker Related Injuries

• Chiaviello, et al Pediatrics, 1994
  (Charlottesville)
• 65 children lt 5 y/o (95 lt 1 y/o)
• skull fracture 10 (15)
• concussion 8 (12)
• intracranial hemorrhage 5 (8)
• C-2 fracture 1

15
Stairway Related Injuries in Children

• Chiaviello, et al Pediatrics, 1994
  (Charlottesville)
• 69 children lt 5 y/o (mean 2 y/o)
• Concussion 11 (16)
• skull fracture 5 (7)
• Intracranial injury (2/3 were carried by adult)
• cerebral contusion 2 (3)
• SDH 1
• C-2 fracture 1

16
Stairway Injuries in Children (including falls
in walkers)

• Joffe, Ludwig Pediatrics, 1988 (Philadelphia)
• 363 children
• head and neck injuries predominated (73)
• only 2.7 had injury to more than one body area
• any fracture 25 (7) (skull fracture 2)
• 40 skull fracture if carried by adult during
  fall
• concussion (1)
• intracranial hemorrhage 0

17
Injuries to children related to shopping carts

• Smith Pediatrics, 1996 (Columbus)
• 62 children
• head injuries (79)
• skull fracture 5 (8)
• LOC (4 - 10)
• intracranial injury 0 (14 had C-T)

18
Summary Intracranial injury from known trauma
19
Injuries that result in intracranial trauma
falls lt 3 falls gt3 lt6 falls gt 6 couch,
bed kitchen counter porch standing,
chair changing table top of slide coffee
table bunk bed, stairs baby walker Highly
Unexpected Reasonableunlikely but possible
20
Exceptions

• Epidural hemorrhage
• Hemorrhage with pre-existing intracranial defect
• increased extra-axial spaces
• prior intracranial bleed
• cerebral atrophy
• Bleeding disorder
• Ruptured AVM or other vascular malformation

21
Mechanism of retinal hemorrhages

• Raised intraocular venous pressure
• from sudden rise in ICP
• raised CVP
• Rapid deceleration (whiplash)
• Cycles of rapid accelerations decelerations

22
Retinal findings after head trauma in infants
young children

• Buys, et al Ophth 1992
• 79 children lt 3 y/o
• Retinal hemorrhages present in only 3
• all abused
• None of the children with accidental trauma had
  retinal hemorrhages

23
Accidental head trauma and retinal hemorrhage

• Johnson, et al Neurosurgery, 1993
• 161 children
• 21 excluded because of suspected abuse
• MVA, falls, assault, other
• skull fractures or intracranial injury
• 2 children with accidental trauma had RH
• high speed MVA
• back seat of car with side impact

24
Anecdotal reports of accidental trauma causing
retinal hemorrhages

• Child died from CHI after being kicked by horse
• Child's head and chest crushed by car
• Children in MVA with intracranial injury
• Child fell down stairs in walker with SDH

25
Other causes of retinal hemorrhages

• Ruptured AVM, CNS infection tumor
• Birth trauma
• flame hemorrhages resolve in 1 week dot/blot 6
  weeks
• Coagulopathies, liver disease
• Endocarditis, vasculitis
• Hypertension
• Carbon monoxide poisoning
• CPR

26
Case reports of RH following CPR

• Pre-resuscitation exam revealed no RH
• Kramer, Clinical Peds 17 mo old with 15
  dehydration fever
• No pre-resuscitation exam available
• Bacon, BMJ near miss SIDS
• Kirschner, AJDC 3 mo old after vigorous CPR
• Weedn Am J Forensic Path 4 mo old burn victim

27
Retinal hemorrhage after CPRor child abuse.

• Kanter, J Pediatrics 1986
• 6/54 children had RH after CPR
• 55 lt 2 y/o
• 4 children with head injury from abuse
• 1 child with head injury following MVA
• 1 child with severe hypertension

28
Retinal hemorrhage after CPR An etiologic
reevaluation.

• Goetting, Pediatrics 1990
• 20 children admitted to PICU after CPR
• 2wk - 17 y/o
• 2 children had retinal hemorrhages
• 2 y/o near drowning in tub (abuse w/u negative)
• multiple, large, bilateral RH
• 6 w/o infant r/o sepsis, died 38hr after
  admission
• single, small unilateral RH, otherwise -
  postmortem

29
Prevalence of retinal hemorrhage after
in-hospital CPR

• Odom, Pediatrics 1997 (Memphis)
• 43 children had CPR
• mean age 23 months
• mean duration of chest compressions 16 minutes
• all patients survived CPR until ophthalmologic
  exam
• 93 had elevated PT /or PTT 50 low platelets
• only one patient had small punctate hemorrhages

30
Significance of retinal hemorrhages in head
injured children

• Very unusual after accidental head injury
• high velocity injuries
• injuries with high rotational component
• stairway fall in walker?
• CPR may rarely cause small punctate hemorrhages
• Other conditions may cause RH but abuse is most
  likely if head injury is also present

31
Family Risk Factors

• Substance abuse
• Lack of support
• Economic stress and poverty
• Lack of knowledge of child development
• Domestic violence
• Male perpetrators

32
Morbidity of Shaken Baby Syndrome

• 10 - 20 cases / year in Cincinnati
• death rate 30-40
• developmentally handicapped 80-90

33
National Prevention Organizations

• Childrens Trust and Prevention Funds
• Dont Shake the Baby
• Parents Anonymous
• National Committee to Prevent Child Abuse

34
Individual Prevention Efforts

• Recognition of high risk families
• Support of new parents
• Recognition of frustration exhaustion
• Parenting materials and group supports
• Development of an escape plan
• Referral to community resources
• Lobby for more prevention programs
• Speak at local community groups

35
Conclusion

• Differentiating inflicted from accidental head
  injury is challenging.
• Infants rarely sustain intracranial injury after
  falls at home.
• Intracranial injury with retinal hemorrhages is
  usually child abuse.
• Infants will sustain contusions / fractures /
  epidural hemorrhages from minor falls.