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