Abusive Head Trauma Controversies
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- Esmond McCormick
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1 Abusive Head Trauma Controversies Carole Jenny, MD, MBA, FAAP Professor of Pediatrics Warren Alpert Medical School of Brown University Providence, Rhode Island
2 Is there Credible Evidence for Abusive Head Trauma? Shaken baby syndrome is a theory only Not true multiple people have told every doctor who takes care of abused children that they have shaken their babies and the babies collapsed in my arms. Research confirms this--
3 Is there Credible Evidence for Abusive Head Trauma? The biomechanical literature demonstrates to a reasonable degree of scientific certainty that injuries seen in abusive head trauma cannot be caused by shaking alone.
4 Role of biomechanics in evaluating cases Difficult in pediatrics INJURY THRESHOLD LEVELS HAVE NOT BEEN ESTABLISHED FOR INFANT BRAINS.
5 Role of biomechanics in evaluating cases Difficult in pediatrics INJURY THRESHOLD LEVELS HAVE NOT BEEN ESTABLISHED FOR INFANT BRAINS. Injury levels in adults were largely derived from adult animal models.
6 Role of biomechanics in evaluating cases Difficult in pediatrics INJURY THRESHOLD LEVELS HAVE NOT BEEN ESTABLISHED FOR INFANT BRAINS. Injury levels in adults were largely derived from adult animal models. INFANTS ARE NOT LITTLE ADULTS to scale adult injury thresholds to infants on the basis of brain mass alone is not valid.
7 Characteristics of effective animal models for biomechanical modeling 1. The geometry of the structures must be similar. FALSE 2. The composition of the materials must be representative. FALSE 3. The deformation and biomechanical characteristics of the materials must be similar. FALSE 4. The brain s response to injury must be the same. FALSE
8 Many things are different in infant brains Infants have different biochemical response to trauma. They have been shown to have more cell death from trauma than adults. (Johnston MV: Neurotransmitters and vulnerability of the developing brain. Brain & Development 1995; 17: ) The immature nervous system has poor autoregulation of cerebral blood flow. Following rotational injury, infant animals experience a severe, prolonged drop in cerebral blood pressure. (Margulies S, et al)
9 Many things are different in infant brains Secondary metabolic response to injury is fundamentally different in young infants APOPTOSIS OR PRUNING OF BRAIN CELLS Metabolic response to injury is not comparable!
10 Many things are different in infant brains 1. Infants are not small adults. 2. Injury thresholds for infants have not been established. 3. THERE IS OVERWHELMING EVIDENCE THAT THE RESPONSE TO A GIVEN INJURY IN AN INFANT IS MUCH WORSE THAN THAT OF A SIMILAR INJURY IN AN ADULT.
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12 SDH are common after birth (46%?) in asymptomatic babies. Most are posterior fossa, around the tent In prospective studies all heal without symptoms or persistence.
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15 Many children re-bleed into old subdurals. Re-bleeds are low-pressure oozes into old clots. Rarely are children ever symptomatic with rebleeds, unless a large amount of blood accumulates over time (theoretical?). Low-pressure, re-bleeds into existing subdurals from minor trauma do not present as serious brain injury.
16 Re-bleed of an Old Subdural It could be: A re-bleed of an old subdural
17 Re-bleed of an Old Subdural It could be: A re-bleed of an old subdural. A hyperacute subdural hematoma.
18 Re-bleed of an Old Subdural It could be: A re-bleed of an old subdural. A hyperacute subdural hematoma. An old injury, unrelated to the acute injury, especially a birth injury.
19 Re-bleed of an Old Subdural It could be: A re-bleed of an old subdural. A hyperacute subdural hematoma. An old injury, unrelated to the acute injury, especially a birth injury. A new assault on a previously abused, headinjured child.
20 THERE IS NO CREDIBLE SCIENTIFIC EVIDENCE THAT REBLEEDING OF AN OLD SUBDURAL CAUSES RETINAL HEMORRHAGES.
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22 Hypoxia and anoxia Dysphagic choking type of ALTE causes SDH and RH. A BS HYPOTHESIS BASED ON A SINGLE FALSIFIED CASE REPORT.
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24 THEY LOOK VERY DIFFERENT ON X-RAY!
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30 What about SDH resulting from benign extraaxial effusions of infancy Benign collections of extraxial fluid collections are common in infants.
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35 What about SDH resulting from benign extraaxial effusions of infancy Benign collections of extraxial fluid are common in infants. Fluid is subarachnoid rather than subdural.
36 What about SDH resulting from benign extraaxial effusions of infancy Benign collections of extraxial fluid are common in infants. Fluid is subarachnoid rather than subdural. There is no evidence in the medical literature that subdural hematomas result from benign extraaxial fluid of infancy (in the subarachnoid space). Might cause small localized SDH at site of impact, but not bad brain injury.
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40 What do we know about the onset of symptoms after violent abusive head trauma?
41 Conventional Wisdom 1. After head injury, an evolution of symptoms occur speed of change depends on severity of injury.
42 INJURY STUNED APPEARANCE DECREASED LEVEL OF CONSCIOUSNESS ALTERED BREATHING VOMITING CONVULSIONS DEATH COMA
43 Conventional Wisdom 1. After head injury, an evolution of symptoms occur speed of change depends on severity of injury. 2. Infants demonstrate symptoms immediately after injury look for the time the baby changes---
44 Conventional Wisdom 1. After head injury, an evolution of symptoms occur speed of change depends on severity of injury. 2. Infants demonstrate symptoms immediately after injury look for the time the baby changes Symptom course can progress over time getting better or worse or can wax and wane.
45 Conventional Wisdom 1. After head injury, an evolution of symptoms occur speed of change depends on severity of injury. 2. Infants demonstrate symptoms immediately after injury look for the time the baby changes Symptom course can progress over time getting better or worse or can wax and wane. 4. Can infants look normal after serious head injury???
46 CONFESSION CASE Thursday Dad baby-sits, gets angry, shakes baby violently. Baby falls asleep. Friday Mom is concerned baby is not himself, but he s eating well and alert. Goes to ER. ER doc records full exam and declares baby normal. Monday Mom thinks baby is just fine. Tuesday Dad baby-sits again. Shakes baby violently. Baby collapses and dies immediately.
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48 We need to be extremely cautious when evaluating histories and relating them to injury timing History should be meticulous and detailed. Watch for subtle and not so subtle changes. Consider alternative hypotheses. I STILL THINK THAT SEVERELY INJURED BABIES DON T LOOK NORMAL!!
49 52 (91%) of 57 cases where time of onset of symptoms was described, they appeared immediately. 5 cases (9%), the timing was less clear, but occurred within 24 hours. None of the children were described as behaving normally after the event. Starling SP, Patel S, Burke BL, Sirotnak AP, Stronks S, Rosquist P: Analysis of perpetrator admissions to inflicted traumatic brain injury in children. Arch Pediatr Adolesc Med May;158(5):454-8.
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51 Neck Injuries Subtle changes in the infant neck after shaking may cause hypoxia and affect outcome. Bleeding and axonal injury can occur at C1 at the junction of the brain and spinal cord. Importance of neck injuries still being studied.
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55 Brennan LK, et al: Neck injuries in young pediatric homicide victims. J Neurosurg Pediatr 2009;3(3): infants who died of AHT 29 (71%) had cervical cord injuries. 6 children with AHT had no evidence of impact to head. All 6 had primary spinal cord injury. None of the children had spinal fractures, but 6 of the 29 (21%) had ligamentous and muscular neck injury. 14 of the 29 (46%) had brainstem injury.
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57 The infant may have been dropped. Injury thresholds for infants for subdural hematomas are not precisely known but actual injury scenarios have been analyzed and indicate that head impacts from 1 2 feet can produce subdural hematomas in infants. One such case report, that of Piatt, provided information of an approximate <2 foot fall of a baby who happened to have an extracerebral collection who then suffered an ALTE. It thus appears tat at least for a drop or fall scenario, it would be possible for this baby to have suffered a subdural hematoma and the consequences it ultimately did.
58 SHORT FALLS KILL CHILDREN
59 Chadwick DL, et al: Annual risk of death resulting from falls among young children. Pediatrics 2008;121: Reviewed 5 book chapters 2 medical society statements 7 major literature reviews 3 public injury databases 177 peer-reviewed peer-reviewed papers Every fall/kids paper in the NLM database Short fall = < 1.5 M (4.7 feet); Child = <5 yo
60 Results Risk of death from falls among children under 5 falling < 1.5M is 0.5% per 1 million children per year. In studies of short falls that were reliably witnessed, no deaths occurred.
61 Frequency Clinical Presentation/Severity
62 Frequency Clinical Presentation/Severity
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64 Retinal hemorrhaes occur frequently and have nothing to do with AHT
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67 No credible scientific evidence that shaking produces retinal hemorrhages
68 Other expert opinions Retinal hemorrhages occur as a complication of increased intracranial pressure. Retinal hemorrhages may occur in as many as 20% of cases coming to any autopsy service (adults and children) where there is no history of shaking or abuse.
69 Agrawal S, et al. Prevalence of retinal hemorrhages in critically ill children. Pediatrics 2012; 129:e Did careful opthalmology exams in children admitted to ICU at Great Ormand Street. Excluded children with AHT. 15.1% had RH. Only 3.7% H. 3 had luekemia, 2 has severe accidental head injuries, and 1 had severe coagulopathy.
70 Other expert opinions Retinal hemorrhages occur as a complication of increased intracranial pressure.
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72 Shiau T, Levin AV. Retinal hemorrhages in children: The role of intracranial pressure. Archives of Pediatrics and Adolescent Medicine 2012; Epub ahead of print. Review of the entire worlds literature shows not a single case of extensive RH from increased ICP in the absence of traumatic head injury.
73 You can get retinal hemorrhages from short fall and from seizures.
74 Guo H, et al. Manifestations of ocular fundus in children with febrile seizures. Journal of Ophthalmology and Strabismus 2011; 48: Curcoy AI, et al. Do retinal haemorrhages occur in infants with convulsions? Archives of Diseses in Children 2009; 94:
75 CPR may have caused the retinal hemorrhages.
76 Many papers (prospective studies) have shown this is not the case.
77 Odum A, et al. Prevalence of retinal hemorrhages in pediatric patients after inhospital cardiopulmonary resuscitation: A prospective study. Pediatrics 1997; 99:e3. Gilliland MG, et al. Are retinal hemorrhages found after resuscitation attempts? A study of the eyes of 169 children. American Journal of Forensic Medicine & Pathology 1993; 14: ,
78 Goetting MG, et al. Retinal hemorrhage after -cardiopulmonary resuscitation in children. Pediatrics 1990; 85:
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