Head Injury: Inflicted or Accidental? Robert Allan Shapiro, M.D. Children’s Hospital Medical...
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![Page 1: Head Injury: Inflicted or Accidental? Robert Allan Shapiro, M.D. Children’s Hospital Medical Center Cincinnati, Ohio 513-636-7966.](https://reader036.fdocuments.net/reader036/viewer/2022062718/56649e7b5503460f94b7c9ed/html5/thumbnails/1.jpg)
Head Injury: Inflicted or Accidental?
Robert Allan Shapiro, M.D.
Children’s Hospital Medical Center
Cincinnati, Ohio
513-636-7966
![Page 2: Head Injury: Inflicted or Accidental? Robert Allan Shapiro, M.D. Children’s Hospital Medical Center Cincinnati, Ohio 513-636-7966.](https://reader036.fdocuments.net/reader036/viewer/2022062718/56649e7b5503460f94b7c9ed/html5/thumbnails/2.jpg)
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
Mechanism of Injury
• distance fallen
• propelled
• free or “broken” fall
• landing surface characteristics
• spread of energy (% body involved, fractures)
• Primary vs. Secondary brain injury
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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)
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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)
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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%)
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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%)
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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)
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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%
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
Mechanism of retinal hemorrhages
• Raised intraocular venous pressure– from sudden rise in ICP– raised CVP
• Rapid deceleration (whiplash)
• Cycles of rapid accelerations & decelerations
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
Family Risk Factors
• Substance abuse
• Lack of support
• Economic stress and poverty
• Lack of knowledge of child development
• Domestic violence
• Male perpetrators
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Robert A Shapiro, MD, Patricia A. Myers, MSW
Morbidity of Shaken Baby Syndrome
• 10 - 20 cases / year in Cincinnati
• death rate: 30-40%
• developmentally handicapped: 80-90%
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Robert A Shapiro, MD, Patricia A. Myers, MSW
National Prevention Organizations
• Children’s Trust and Prevention Funds
• Don’t Shake the Baby
• Parents Anonymous
• National Committee to Prevent Child Abuse
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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
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Robert A Shapiro, MD, Patricia A. Myers, MSW
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.