Abusive Head Trauma Cindy W. Christian, MD, FAAP The Children’s Hospital of Philadelphia Professor, The Perelman School of Medicine at The University of Pennsylvania
Robert Sege, MD, PhD, FAAP Boston Medical Center Professor, Boston University School of Medicine
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Objectives
Define abusive head injury. Discuss epidemiology of abusive head injury. Review anatomy of infant head and brain. Identify the types of injuries seen in AHT. Review the medical workup of a patient with suspected AHT.
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Epidemiology
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Incidence/Prevalence Most common cause of death and disability in physical child abuse. 33% to 56% of brain injuries in infants are due to abuse. Estimates in infants 20-30 / 100,000 6 infant deaths / 100,000
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AHT Hospitalization
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Situations That Trigger Abusive Events The most commonly described and well documented trigger is infant crying..
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The Period of PURPLE Crying •Educational based program: •11 page handout •10 minute video •Available in 8 different language •Three simple action steps: (1) “Increase carry, comfort walk, and talk response” (2) “Crying can be frustrating. If so, walk away, calm yourself, return to infant.” (3) “Never shake or hurt your infant” © AAP 2013
• Skills-based video • NICHD funded • Released in 2011
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Protecting the Brain: Layers
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Blood Vessels run between layers
Injury Mechanics
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Forces Acting on Brain
Strain (deformation over time) Direct contact forces Inertial forces Many clinical situations contain contact and inertial forces
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Forces Acting on Brain Strain (deformation over time) causes tissue damage when the strain exceeds the tolerance of the tissue
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Forces Acting on Brain Direct contact forces Damage at the point of contact Skull fractures, scalp bruising, focal bleeding, brain contusion
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Forces Acting on Brain Inertial forces Due to motion Concussion, SDH, axonal injury
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The Range of Injuries
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Subdural and Subarachnoid Small Veins May Hemorrhage Break During Shaking
When the brain suffocates (Hypoxia-Ischemia) Blood delivers oxygen to brain tissue. Decreased blood supply makes the cells suffocate, and they may swell up Breathing is controlled by the brainstem – often injured during shaking. When swelling occurs inside the skull: Raised pressure inside the skull Vicious cycle – increased pressure reduces blood supply . . . © AAP 2013
Pathophysiology • Primary Injury – Subdural, subarachnoid hemorrhage – Cerebral contusions – Shearing injuries
• Secondary Injury – Hypoxic- Ischemic Injury – Seizures – Excitotoxicity, metabolic mismatch – Brain edema
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Adamsbaum, et al. Pediatrics, 2010 : • Studied 112 cases of abusive head trauma adjudicated • 29 with confessions compared to 83 without confessions • All 29 perpetrators described having shaken the child violently. – 5 reportedly were followed by impact. – 7 showed signs of impact. • Comparing confessions with nonconfessions, the nature and severity of injuries were no different.
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I was feeling really bad I was at the end of my rope from not sleeping. I shook him several times a week, I don’t know exactly, always at night He was crying; it drove me crazy, I shook him . . . maybe 10 times, and threw him on the sofa.” “I had fits of anger. She would cry; sometimes, when she did that, I’d shake her . . . I got worked up and twisted her arm; I was slapping her hard for more than 2 months.”
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Of 173 children with AHT: 31.2% seen by a physician misdiagnosed 27% of those children were re-injured, 5 fatally © AAP 2013
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Sentinel Injuries in Infants Evaluated for Physical Abuse • Case-control study of 400 infants – Abused, intermediate concern, no abuse
• 28% of abused infants had previous sentinel injury • 30% of infants with AHT • None of the infants not abused had a previous sentinel injury © AAP 2013
Normal MRI of Cervical Spine
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Retinal Hemorrhage
Rib Fractures
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Growth Plate Injuries in Infants Metaphyseal long bone fractures Most common in the leg and upper arm Disc-like fracture through growth plate results from torsional, shearing or longitudinal forces.
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Diagnostic Evaluation • Skeletal Survey – Most common fractures in abused INFANTS are rib, skull and metaphyses – Repeating SS in 2-3 weeks
• Ophthalmic examination • Laboratory Evaluation – To evaluate for consequences of injury – To evaluate for mimickers of abuse © AAP 2013
Other Diagnoses We Consider • Accidental trauma, birth trauma • Coagulopathy • Metabolic Diseases – Glutaric Aciduria I, Menkes
• Collagen Vascular Diseases – OI, Ehlers Danlos
• Malignancies – Leukemia, HLH, CNS tumors
• Folk Remedies • Medical and surgical therapies
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Addressing Alternative Theories • Short Fall theory of Plunkett and others – A short fall caused the injury – The child had a prolonged lucid interval
• Universal Failure of Neck theory (Bandak) – Beware of MATH
• Geddes’ Theory of paroxysmal coughing • Dr. Barnes’ Vitamin D Theory © AAP 2013
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Distribution of injury mechanism by age 80%
60% Int Inj Falls
40%
MVC
20%
0% all ages (n=324)
0-11 mo (n=90)
12-23 mo (n=110)
24-35 mo (n=70)
36-48 mo (n=54) © AAP 2013
Most Children were Comatose GCS
