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Pediatric Critical Care Medicine

Emory University
Children’s Healthcare of Atlanta
• >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

• 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

• 60% of cases with previous history or clinical evidence of
• 22% with involvement of child welfare agencies
• 32% with misdiagnosis
- Viral gastroenteritis or influenza
- “R/O sepsis”
- Accidental head injury
• Perpetrators
» 50% fathers
» 20% step-fathers or male partners
» 12% mothers
» 17% female baby sitters
• 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
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
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

Mechanism of Injury
• Translational deceleration (drop or short fall)
– Head moves in a straight line
– Cranial impact
– Focal injury

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

Cranial Injury
• Blunt force trauma
• Shaking
• Combination of forces

Classical 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

Intracranial Hemorrhage
• Sub-arachnoid
• Sub-dural
• Intraparenchymal
• Epidural

• Short vertical fall <4ft
– 85 % with no evidence or minor injury
– 7% with skull fracture – all with isolated and linear skull fracture

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

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

ICH – Epidural hemorrhage
• Less likely with abuse
• More accidental trauma
• Focal to the site of impact

ICH – Subarachnoid hemorrhage
• Hard to detect
• Not good correlation with abuse
• Detected mostly at autopsy

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

ICH – Parenchymal Injury
• Infarct, atrophy
• Encephalomalacia with ventriculomegaly

Associated Injury – Retinal hemorrhage
• Numerous
• Multi-layered
• Extend beyond the posterior pole to the peripheral retina

Associated Injury
• Bone fractures
• Blunt trauma to abdomen and pelvis

Skull Fractures
• Most common parietal
• Both accidental & non-accidental

• Common sites in abuse

– Crossing suture lines
– Multiple
– Diastatic
– Growing
– Depressed
– Complex
– Bilateral

Skull Fractures

Skeletal Fractures
• 20-50% of abused children
associated with
extracranial skeletal
• Ribs, long bone and
• Classic metaphyseal
avulsion lesion of long bone
caused by torsion and
traction when extremities
in twisted or pulled
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

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

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

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

Associated Injuries
• Abdominal Injury
– 1% of abused children suffered intra-abdominal injury with 50%
– 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
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

• History
• Physical Examination
• Laboratory studies
• Radiographic studies

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)

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

Evaluation: History
• Where did the event occur? Who was there with the baby?
• What would care provider consider normalcy in the patient?
(behavior, development)

Evaluation: History
• Don’t forget details of family history
– Bleeding tendency in family
– Bleeding at time of circumcision for boys
– Easy bruising

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

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

Evaluation: Opthalmologic Exam
• Need to have an opthalmologic exam to stand legally

Differential Diagnosis
• Accidental injury
• Birth trauma
• Apparent Life-threatening event
• Bleeding disorder
• Others

Differential Diagnosis – Accidental Injury
• A history of traumatic event
• Retinal hemorrhages are typically fewer in number and less
• Subdural hematomas

Differential Diagnosis – Birth Trauma
• Commonly associated with instrumented deliveries
• Both retinal hemorrhage and subdural hemorrhage

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