NON ACCIDENTAL TRAUMA

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NON ACCIDENTAL TRAUMA
Pediatric Critical Care Medicine Emory
University Childrens Healthcare of Atlanta
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Introduction

• gt40 Of Death in children lt12mos
• 1 cause of death is head injury
• 30 of head injury may be misdiagnosed
• 4 of 5 deaths cause by head injury can be
  prevented if early diagnosis during prior medical
  evaluation

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Epidemiology

• Most often lt 1 yr of age
• Battering is the most common mechanism of injury
  in children 3-5 mos
• Incidence of inflicted TBI is similar in US
  Europe

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Epidemiology

• 60 of cases with previous history or clinical
  evidence of maltreatment
• 22 with involvement of child welfare agencies
• 32 with misdiagnosis
• - Viral gastroenteritis or influenza
• - R/O sepsis
• - Accidental head injury

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Epidemiology

• Perpetrators
• 50 fathers
• 20 step-fathers or male partners
• 12 mothers
• 17 female baby sitters

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Epidemiology

• Risk factors
• Young/single parents (risk increases more with
  presence of step-father or maternal boyfriend)
• Lower education
• Unstable family situation
• Stress to family- financial, food housing,
  domestic violence, alcohol drug abuse, parental
  depression
• Other peri-natal illness, family disruption
  separation, colicky babies

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Mechanism of Injury

• Degree of injury in the absence of significant
  trauma or sign of external injury
• Rotational impact forces
• Translational deceleration
• Repetitive events more damage
• Developmental weakness large head, weak
  unstable neck soft brain with higher water
  contents and poorly demyelinated

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Mechanism of Injury

• Rotational Impact forces
• - Angular deceleration (head rotates on its own
  axis) causing SDH axonal injury
• - gt with shaking and impact than shaking alone

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Mechanism of Injury
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Mechanism of Injury

• Translational deceleration (drop or short fall)
• Head moves in a straight line
• Cranial impact
• Focal injury

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Mechanism of Injury

• Significant of cerebral injury is caused by
  secondary hypoxic ischemic events
• Central apnea from injury to the brain stem or
  cervical spinal cord
• Prolonged seizures
• Aspiration

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Cranial Injury

• Blunt force trauma
• Shaking
• Combination of forces

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Shaking

• Classical pattern
• Diffuse unilateral or bilateral SDH
• Diffuse multilayered retinal hemorrhage
• Diffuse brain injury
• In the absence of
• A history of trauma
• Paucity of external manifestation of injury

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Intracranial Hemorrhage

• Sub-arachnoid
• Sub-dural
• Intraparenchymal
• Epidural

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ICH

• Short vertical fall lt4ft
• 85 with no evidence or minor injury
• 7 with skull fracture all with isolated and
  linear skull fracture

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ICH Sub-dural hemorrhage

• Rare in accidental trauma unless with severe
  forces (MVA or significant height)
• Small and localized to the site of the impact
• Interhemispheric SDH usually posterior
• - 71 of abused children
• - 19 in accidental injury

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ICH Sub-dural hemorrhage

• Mixed density collections of fluid are more
  common and can present both acute or acute on
  chronic
• Clinical silent SDH
• Term infant/neonate with minor birth trauma
• Self resolved or increase in
• size few days to weeks

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ICH Epidural hemorrhage

• Less likely with abuse
• More accidental trauma
• Focal to the site of impact

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ICH Subarachnoid hemorrhage

• Hard to detect
• Not good correlation with abuse
• Detected mostly at autopsy

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ICH Parenchymal Injury

• Contact forces
• Inertia forces with rotational deceleration
• Traumatic Axonal injury
• Sub-cortical white matter, corpus collosum,
  periventricular regions, dorsolateral aspect of
  the rostral brainstem
• Global Hypoxic Ischemic injury
• - May cause primary brainstem damage
• - Prolonged seizure
• - Secondary hypotension

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ICH Parenchymal Injury

• Infarct, atrophy
• Encephalomalacia with ventriculomegaly

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Associated Injury Retinal hemorrhage

• Numerous
• Multi-layered
• Extend beyond the posterior pole to the
  peripheral retina

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Associated Injury

• Bone fractures
• Blunt trauma to abdomen and pelvis

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Skull Fractures

• Most common parietal
• Both accidental non-accidental
• Common sites in abuse
• Crossing suture lines
• Multiple
• Diastatic
• Growing
• Depressed
• Complex
• Bilateral

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Skull Fractures
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Skeletal Fractures

• 20-50 of abused children associated with
  extracranial skeletal fracture
• Ribs, long bone and metaphyseal
• Classic metaphyseal avulsion lesion of long bone
  caused by torsion and traction when extremities
  in twisted or pulled

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Rib Fractures

• Most common posterior and lateral
• 82 associated with abuse
• 8 accidental
• 8 bone fragility
• 2 birth trauma
• Chest compression more commonly causes lateral
  and anterior rib fractures

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Rib Fractures
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Associated Injuries Blunt Trauma

• Thoracic
• Esophageal injury can result from forced F.B.
  ingestion, forced caustic ingestion, blunt
  external trauma, and penetrating trauma
• Sx non specific, pain to the neck and shoulder,
  shortness of breath, dysphagia, abdominal pain
• Early signs tachycardia, dyspnea, abdominal
  guarding, pneumothorax, mediastinal air,
  subcutaneous emphysema

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Associated Injuries

• Pulmonary Injury
• Pulmonary laceration, contusion or diffuse
  alveolar damage
• Chylothorax
• Cause by rupture of thoracic duct from blunt
  trauma or anteroposterior acceleration/deceleratio
  n forces
• Signs respiratory distress, nutritional
  deficiency, electrolytes abnormality,
  immunosuppression from T-cell depletion

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Associated Injuries

• Cardiac Injury
• Dysrhythmias commotiao cordis or cardiac
  concussion causes sudden cardiac arrest (blow at
  upstroke of the T wave associated with v-fib,
  blow at the peak of QRS results in asystole
• Direct trauma impact of the heart against the
  sternum or crushing of the heart due to blunt
  trauma to the anterior chest
• Others traumatic VSD, cardiac aneurysm,
  laceration or rupture

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Associated Injuries

• Abdominal Injury
• 1 of abused children suffered intra-abdominal
  injury with 50 mortality
• Sx tenderness, distension, enlargement of the
  liver or spleen, and/or bruising of the abdominal
  wall
• Liver injury most common organ injured cause
  contusion, subcapsular hematoma, laceration and
  rupture
• Splenic injury less common than liver
• Pancreatic injury
• GI tract
• Perforation more common in NAT
• Hematoma intramural hematomas occur most
  frequently in the duodenum and can cause
  perforation or stricture

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Associated Injuries

• Urinary Tract Injury
• Renal injury contusion or subcapsular hematoma,
  shattered kidney or vasculaar pedicle avulsion
• Hematuria is present in 41-68 of victims with
  renal trauma
• Ureteral injury
• Bladder injury bladder rupture (blunt force to a
  full bladder). Rupture occurs at the dome of the
  bladder, fluid and blood extravasate into the
  peritoneum

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Evaluation

• History
• Physical Examination
• Laboratory studies
• Radiographic studies

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Evaluation History

• Who, what, when and where
• Document your history
• Document inconsistency of the story through
  details
• Help your memory at a later time (across a DA and
  a defense lawyer)

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Evaluation History

• Who was present?
• Who had been taking care of the patient at least
  4 hours prior to the event
• When did the last time the child seem normal?
  When was the event
• Review the event after the child last seen to be
  normal

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Evaluation History

• Where did the event occur? Who was there with the
  baby?
• What would care provider consider normalcy in the
  patient? (behavior, development)

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Evaluation History

• Dont forget details of family history
• Bleeding tendency in family
• Bleeding at time of circumcision for boys
• Easy bruising

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Evaluation Laboratory

• CBC with Platelet
• Coagulation study DIC panel
• Electrolytes, liver function test, and urinalysis
• preliminary evidence of CSF and serum
  measuremenf of biomarkesr of brain injury
  neuron-specifiec enolase, S100B(a calcium binding
  protein found in astrocytes), and myelin basic
  protein

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Evaluation Imaging

• CT brain and bone window is best as an initial
  tool.
• MRI superior to CT for documenting the pattern,
  extent, and timing
• Skeletal survey

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Evaluation Opthalmologic Exam

• Need to have an opthalmologic exam to stand
  legally

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Differential Diagnosis

• Accidental injury
• Birth trauma
• Apparent Life-threatening event
• Bleeding disorder
• Others

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Differential Diagnosis Accidental Injury

• A history of traumatic event
• Retinal hemorrhages are typically fewer in number
  and less extensive
• Subdural hematomas

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Differential Diagnosis Birth Trauma

• Commonly associated with instrumented deliveries
• Both retinal hemorrhage and subdural hemorrhage

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Differential Diagnosis Bleeding Disorder

• ICH can occur in severe bleeding disorer
  (hemophilia) spontaneously or following an injury
• Retinal hemorrhages are small in number and are
  typically confined to the posterior pole
• Boys with hemophilia, ICU occurs most often in
  the neonatal period
• ICH is uncommon in idiopathic thrombocytopenic
  purpura