Head Injury: Inflicted or Accidental? Robert Allan Shapiro, M.D. Children’s Hospital Medical Center Cincinnati, Ohio 513-636-7966

Head Injury: Inflicted or Accidental?

Robert Allan Shapiro, M.D.

Children’s Hospital Medical Center

Cincinnati, Ohio

513-636-7966

Robert A Shapiro, MD, Patricia A. Myers, MSW

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


Mechanism of Injury

• distance fallen

• propelled

• free or “broken” fall

• landing surface characteristics

• spread of energy (% body involved, fractures)

• Primary vs. Secondary brain injury


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

• < 4' 100 7 deaths (CHI)

5/7 had signs of abuse (e.g. RH, fracture)


Injuries from witnessed & corroborated free falls

Williams. J Trauma, 1991

• With independent witness– 106 falls < 2-70 feet– 3 small depressed skull fractures– 1 death after a 70’ fall

• Without independent witness– 53 falls < 5 feet– 2 deaths


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


Whiplash Shaken Baby Syndrome (Caffey 1972)

Infants < 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


Serious Head Injury in Infants: Accident or Abuse?

Billmire, Myers. Pediatrics, 1985

• Infants < 1 y/o over a 2 year period

• 19 infants w/SDH or other intracranial injury– 18 Abuse– 1 Accident (MVA)


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


Injuries resulting when small children fall out of bed

Helfer et al: Pediatrics, 1977

• 161 children < 5 y/o fell at home– 6 fractures (3.7%)

• 85 children < 5 y/o fell in hospital– 1 fracture (1.2%)

• 0 intracranial injuries


Falling out of bed: A relatively benign occurrence

Lyons, Oates. Pediatrics, 1993

• 207 children < 6 y/o– fell 25” - 54” from hospital beds– 1 skull fracture– 1 clavicle fracture– 0 intracranial injuries


Bunk Bed Injuries

Selbst, Baker, Shames. AJDC, 1990 (Philadelphia)

• 68 falls from bunk beds (6 feet)

• 37% < 2 y/o

• 8 concussions (12%)

• 1 skull fracture w/SDH (1.5%)


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%)– > 10 stairs increased incidence of skull fracture

• concussion: 35 (13%)

• intracranial hemorrhage: 3 (1%)


Infant Walker Related Injuries

Chiaviello, et al: Pediatrics, 1994 (Charlottesville)

• 65 children < 5 y/o (95% < 1 y/o)

• skull fracture: 10 (15%)

• concussion: 8 (12%)

• intracranial hemorrhage: 5 (8%)

• C-2 fracture: 1


Stairway Related Injuries in Children

Chiaviello, et al: Pediatrics, 1994 (Charlottesville)

• 69 children < 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


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


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)


Summary: Intracranial injury from known trauma

Falls out of bed 0%

Falls out of bed 0%

Falls from bunk beds 1.5%

Falls in baby walkers 1%

Falls in baby walkers 8%

Falls down stairs/walkers 0%

Falls down stairs 4%

Falls from shopping carts 0%


Injuries that result in intracranial trauma

falls < 3’ falls >3’ & <6’ falls > 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


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


Mechanism of retinal hemorrhages

• Raised intraocular venous pressure– from sudden rise in ICP– raised CVP

• Rapid deceleration (whiplash)

• Cycles of rapid accelerations & decelerations


Retinal findings after head trauma in infants & young children

Buys, et al: Ophth 1992

• 79 children < 3 y/o

• Retinal hemorrhages present in only 3– all abused

• None of the children with accidental trauma had retinal hemorrhages


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


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


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


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


Retinal hemorrhage after CPRor child abuse.

Kanter, J Pediatrics 1986

• 6/54 children had RH after CPR– 55% < 2 y/o

• 4 children with head injury from abuse

• 1 child with head injury following MVA

• 1 child with severe hypertension


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


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


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


Family Risk Factors

• Substance abuse

• Lack of support

• Economic stress and poverty

• Lack of knowledge of child development

• Domestic violence

• Male perpetrators


Morbidity of Shaken Baby Syndrome

• 10 - 20 cases / year in Cincinnati

• death rate: 30-40%

• developmentally handicapped: 80-90%


National Prevention Organizations

• Children’s Trust and Prevention Funds

• Don’t Shake the Baby

• Parents Anonymous

• National Committee to Prevent Child Abuse


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


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.

Documents

Head Injury: Inflicted or Accidental? Robert Allan Shapiro, M.D. Children’s Hospital Medical Center Cincinnati, Ohio 513-636-7966