NON ACCIDENTAL TRAUMA

Pediatric Critical Care MedicineEmory University

Children’s Healthcare of Atlanta

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Introduction• >40% Of Death in children <12mos• #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 < 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

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

Epidemiology• Perpetrators

»50% fathers»20% step-fathers or male partners»12% mothers»17% female baby sitters

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

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- > with shaking and impact than shaking alone

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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ShakingClassical 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 <4ft

– 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

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

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/deceleration 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• Don’t 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