1420 SECTION XII Pediatric Critical Care Environmental Injury and Trauma AHT is the leading cause of fatal head injuries in children and responsible for 53% of severe or fatal TBI cases 9,12–15 TBI fr[.]
1420 S E C T I O N X I I Pediatric Critical Care: Environmental Injury and Trauma AHT is the leading cause of fatal head injuries in children and responsible for 53% of severe or fatal TBI cases.9,12–15 TBI from accidental causes are typically either blunt or penetrating In cases of inflicted injury, the mechanisms have a broader range AHT can be secondary to blunt impact, shaking with blunt impact, or shaking alone Whiplash shaking and jerking subjects the brain to significant rotational acceleration and deceleration forces, which explains brain injury and retinal hemorrhage in the absence of external signs.16 While the acute medical and surgical management of injury from AHT is not unique,17 other considerations related to the mechanism and time course of AHT (e.g., delay in seeking care and diagnosis) often differs from TBI due to accidental mechanism Presentation The clinical presentation of AHT can vary widely While AHT can present as severe acute TBI or death, victims may present with more subtle clinical signs: irritability with poor feeding, apnea, seizures, suspicious marks or bruises in unusual locations, or respiratory compromise Other features may include unsuspected finding on imaging, failure to thrive, developmental delay, or other neurologic concerns An important point to keep in mind is the lack of specificity: one review found that 35% of AHT cases presented without neurologic signs or symptoms and only with nonspecific complaints such as irritability or vomiting.18 In another review by Jenny et al of 173 AHT cases in children younger than years of age, practitioners initially missed 54 of those cases (31%).19 This highlights the need for the practitioner to maintain a high index of suspicion and to keep in mind the broad spectrum of presentations This is only magnified by the fact that the circumstances and mechanisms involved in AHT generally cause greater neurologic disability and death when compared with accidental trauma • Fig 121.5 Associated subdural hematoma from case shown in Fig 121.4 Diagnosis As with any other medical or surgical diagnosis, AHT can be determined only after examining all of the historical, physical, laboratory, and radiologic data One of the hallmarks of NAT is a history that is inconsistent with the clinical findings The two most common stories proffered are a short fall or no history of trauma Hettler and Greenes examined the diagnostic utility of certain historical features for identifying cases of AHT.18 Forty-nine cases of abuse were identified by radiologic, ophthalmologic, and physical examination findings; the investigators then examined the histories associated with the injuries Having no history of trauma had a positive predictive value (PPV) of 0.92 and a specificity of 97% for abuse In the patients discharged with persistent neurologic abnormality, having a history of no or low-impact trauma had a specificity of 100% and a PPV of 1.0 for abuse Therefore, in a child presenting with moderate to severe TBI with no history of trauma, NAT must be high on the differential diagnosis Short falls, from less than feet, are unlikely to cause moderate to large subdural hematoma (SDH) in children and are rarely fatal In a classic study, Chadwick et al reported that the incidence of a fatality after a fall from less than feet was 0.48 in million.20 The most common injury from a short fall is focal scalp contusion or laceration Skull fractures are known to occur; however, these are typically linear, parietal, and usually without intracranial hemorrhage In the event that intracranial bleeding occurs, it is more • Fig 121.6 Classic metaphyseal lesion Bilateral chip fractures are indicated by arrows The oval encircles an area of periosteal reaction most likely due to a healing fracture in that location (Courtesy Rachel Berkovich, MD.) often epidural or a focal SDH In either case, the hemorrhage is located at the fracture site (Figs 121.5 and 121.6) Retinal Hemorrhage Retinal hemorrhages (RHs) are estimated to occur in up to 85% of patients with AHT and are more predictive when they are bilateral and multilayered.21 A prompt evaluation of the retina is warranted within 24 to 48 hours of presentation, as hemorrhages can fade rapidly depending on their location Binenbaum et al CHAPTER 121 Child Abuse 1421 reviewed the records of 52 children younger than years with AHT and RH on fundus examination who had or more followup examinations They found that intraretinal hemorrhages clear rapidly but preretinal hemorrhages persisted for weeks.22 For example, if a child presents with too-numerous-to-count intraretinal hemorrhages, the trauma likely occurred in the preceding few days Numerous preretinal hemorrhages and the absence of intraretinal hemorrhages would suggest that the trauma occurred days to weeks prior As the pattern as well as type, location, and number of hemorrhages shift over time, a retinal examination should be performed by an ophthalmologist as early as can be arranged and images captured on a retina camera should there be a need for forensic confirmation of their presence during the legal investigation Imaging Most institutions use noncontrast CT as the initial screening examination in head trauma; computer reconstruction has aided in detecting subtle fracture lines or small extraaxial fluid collections The two classifications of forces involved in AHT are static and dynamic based on the rate that force is loaded onto the head.23 Static injuries involve forces applied over a longer time, as in crush injuries in which a tire runs over the head or a large object falls from a table These forces applied over a longer time period cause comminuted fractures of the basilar skull, calvarium, and facial bones, producing focal lacerations and contusions rather than diffuse injury Dynamic injuries are more common, resulting from either a direct blow or a force applied to the body causing acceleration-deceleration movement of the head Forceful shaking of the body can whip the head back and forth, creating inertial movement of the brain within the skull This differential motion between the brain and the skull creates a movement plane between the skull and dura, tearing bridging veins traveling between the surfaces of the cerebrum and the dura This results in an SDH and, less commonly, subarachnoid hemorrhage (SAH) Rotational acceleration-deceleration causes diffuse nonfocal traumatic axonal injury to neurons These shearing forces causing diffuse axonal injury (DAI) can also tear small vessels in some cases, which present as contusional tears at the cortex–white matter junction, where differences in tissue structure exist (Fig 121.7).24 Some suggest that a significant contributor to parenchymal injury in AHT is hypoxic-ischemic in nature due to disordered breathing caused by neurologic trauma.25 Hypoxic-ischemic injury occurs in trauma from inflicted and accidental mechanisms However, when associated with SDH, RH, and cervicomedullary neck injury, AHT becomes more likely Hypotension and hypoxia can lead to hypoperfusion and ischemia These findings may not be apparent on initial CT scans or may present as hypoattenuation with or without mass effect These findings should warrant evaluation with magnetic resonance imaging (MRI) with diffusion weighted imaging (DWI) DWI measures the motion of water molecules within tissue; when nerve injury and swelling occurs, this restricts motion and diffusion of water This produces a lower diffusion coefficient, which is indicative of ischemic damage These imaging findings are the most predictive of neurologic outcome.24 One must consider spinal injuries when AHT is suspected A recent retrospective study reported craniocervical junction ligamentous injury and spinal SDH in 36% to 78% of AHT cases.26 Infants less than year old experiencing whiplash cranial motion are at risk of incurring damage to ligaments, vertebrae, and dorsal nerve roots; cord laceration and extraaxial spinal hemorrhage have • Fig 121.7 Diffusion weighted image magnetic resonance imaging demonstrating unilateral brain ischemia (Courtesy Rachel Berkovich, MD.) also been reported Cervical MRI should be included in the MRI evaluation of all suspected AHT cases Whole-spine MRI screening may be considered in cases of inflicted trauma, as spine fractures and SDH have been reported in up to 10% of AHT cases.27 Using CT images to date an SDH is difficult; a more specific estimation of the timing may be obtained using MRI Multiple studies, including a comprehensive meta-analysis, have shown that the different appearances of SDHs on both CTs and MRIs are broad and overlapping In addition, time intervals differ significantly between children and adults for iso- and hypodensity Parenchymal hypodensities can appear as early as 1.2 hours and by 27 hours after the injury all such changes were apparent If there are two distant SDHs at different intracranial locations, differences in their appearance is indicative that the injuries occurred at distinct and different times MRI is more accurate in assessing shear injuries, hypoxic-ischemic insult, and the timing of some lesions.28–31 Intensive Care Unit/Surgical Considerations The medical care of AHT does not differ from that of accidental TBI The primary goal in care is to prevent secondary brain injury, which can occur in the presence of hypotension, hypoxemia, hypo- or hypercarbia, fever, hyperglycemia, and seizures These insults can exacerbate the primary damage incurred, whether it was from blunt trauma or lack of perfusion Neurosurgical consultation is indicated early in the assessment process In severe cases, patients may necessitate decompressive craniectomy, hematoma evacuation, and a method to measure intracranial pressure (ICP) In 2019, the Brain Trauma Foundation published updated guidelines on the treatment of severe TBI in pediatric patients.17 For a more thorough review of the current recommendations for medical and surgical therapy, see Chapter 118 1422 S E C T I O N X I I Pediatric Critical Care: Environmental Injury and Trauma Abdominal Trauma Abusive abdominal trauma (AAT) is the second leading cause of death in abused children after AHT.32 The fatality rate is high because symptoms such as vomiting may be attributed to a medical condition, such as gastroenteritis, and caregivers may delay in seeking medical care While motor vehicle crashes are the most common mechanism for abdominal injuries in children overall, abuse is the most common cause in children under years of age A 2012 study examined a national hospitalization database to estimate the incidence and demographic characteristics of children at highest risk for AAT and found that infants less than year old had the highest rates: among hospitalized children younger than year old with abdominal trauma, 25% of all injuries were a result of abuse.33 For all age groups, rates were higher for males than females and higher for those with Medicaid compared with private insurance As with AHT, children who have experienced AAT have a worse outcome than those with accidental trauma Reports of abdominal injury in abused children cite mortality rates ranging between 9% and 30% as opposed to 4.7% in those with accidental injuries.32,33 Higher rates of surgical intervention occur in the AAT group compared with the accidental group, possibly due to delayed presentation Significant abdominal injuries such as duodenal perforation or hollow viscus rupture are very rare in low- to moderate-level falls A review of falls on stairs concluded that there is no evidence to support an unobstructed fall on stairs as causing significant intraabdominal injury.34 The diagnosis of AAT is challenging, requiring a high index of suspicion Most cases involve multiple events of increasing intensity rather than one single event and, often, there is a delay in seeking care Frequently, symptoms are vague and nonspecific, such as vomiting or irritability Furthermore, because the abdominal wall is highly elastic in young children, a visceral injury may be present with little to no external marks.35 As NAT is typically polytraumatic, it is imperative to perform a thorough examination The child should be fully unclothed, and a systematic head-to-toe evaluation should be performed to identify injuries that were not discovered during the initial examination Any new physical findings require further investigation to rule out other missed injuries While injuries to the oral cavity and esophagus have been reported, the most common injuries seen are to the liver, kidney, spleen, and stomach/intestines Occult injuries without significant bleeding requiring acute resuscitation are most common and can be handled nonoperatively with supportive care The liver is the most commonly injured due to size; splenic and renal injuries are less frequent in AAT possibly due to their relatively protected positions from a midabdominal blow Case: A 2-year-old male presented to the emergency department in full cardiac arrest The physicians were able to achieve spontaneous circulation after minutes of resuscitation The abdomen was distended; a CT scan revealed a large amount of intraperitoneal fluid The hemoglobin was g/dL The patient was rushed to the operating room for exploratory laparotomy In the operating room, the surgeons discovered a lacerated splenic artery to be the source of the blood loss There were multiple liver lacerations, and the bowel showed signs of poor perfusion Despite maximal efforts, the patient ultimately died A review of his records revealed a recent admission to an outside institution for pancreatitis During that past admission, no etiology was found for the pancreatitis; he was discharged home with his mother and live-in boyfriend After an investigation by the child abuse pediatricians, social work, and law enforcement, the boyfriend eventually admitted to striking the child on multiple occasions for crying when his mother was not home Pancreatitis or pancreatic injury from a reported fall in a child should raise suspicion for abuse In the absence of a history of trauma (e.g., fall into the handlebars of a bicycle), inflicted abdominal trauma in the form of child abuse should be the leading diagnosis Medical causes of pancreatitis in a previous healthy child are exceedingly rare Pancreatic lacerations or contusions are rare; in cases of chronic abuse, pancreatic pseudocyst formation has been reported.36 Alternative Explanations of Injuries In efforts to protect individuals suspected of committing NAT, legal defense counsels have created alternative theories to explain injuries suspicious for abuse, attributing them to a medical condition (Box 121.1) Because the intensivist who cared for the child may be subpoenaed to testify in court, it is helpful to be cognizant of some of the claims that defense counsels invoke to create doubt about the accuracy of the diagnosis of an inflicted injury Birth Birth-related small intracranial hematomas are quite common; however, the great majority are asymptomatic at birth In the context of significant birth-related head trauma, symptoms appear within the first 24 hours However, birth trauma is an alternative explanation for acute collapse and coma months after delivery due to secondary rebleeding in a parturitional SDH Multiple authors have disproved this.37,38 A 2008 study reported MRI findings of 101 asymptomatic neonates, 79 born by vaginal delivery and 22 by cesarean section SDH was present in 46 (46%) of the neonates on initial examination On follow-up MRI, most had resolved at month and all were resolved by months Regarding neurologic outcome, there were no significant differences in neurologic outcome in this group when compared with the normal population.37 In general, asymptomatic birth-related SDHs are relatively frequent and resolve within the first months of life After this period, there is no merit to the proposal that acute neurologic deterioration from an SDH is due to secondary rebleeding of a birth-related intracranial hemorrhage • BOX 121.1 Unsubstantiated Theories Offered as Causative Explanations for Suspicious Injuries Birth Valsalva maneuvers (cough, asthma) Brief resolved unexplained event Cerebral venous sinus thrombosis Benign enlargement of subarachnoid space Lumbar puncture Vaccines Bone mineralization disorders CHAPTER 121 Child Abuse Subdural Hematoma or Retinal Hemorrhage With Valsalva There is a defense counsel theory that attributes Valsalva maneuvers—such as those seen in severe cough, asthma, or vomiting— with SDH, RH, acute collapse, and death While Cherry documented SDH and SAH in the context of paroxysmal coughing in pertussis infection, the hemorrhage typically was not severe enough to cause permanent injury or death.39 In cases in which vomiting is offered as the cause of SDH, it is more likely that the intracranial bleeding precipitated the vomiting Studies examining the incidence of RH in the context of paroxysmal coughing due to pertussis also have not found evidence to support it as a cause of RH.40–42 Regarding retinal hemorrhages, Herr et al examined 100 infants diagnosed with hypertrophic pyloric stenosis who had experienced multiple bouts of forceful vomiting On dilated retinal examinations, none of the infants had RHs, suggesting that Valsalva maneuvers associated with forceful vomiting are not associated with RH.43 presence of RH 7, 14, or 21 days postvaccination.3,49 Intracranial hemorrhage resulting from lumbar puncture is unsupported by the literature and a rare complication If they occur, they are usually the result of an underlying coagulopathy and not associated with SDH and extracranial injury Bone mineralization disorders, such as osteogenesis imperfecta, have been proffered as explanations for fractures The term temporary brittle bone disease has been employed by defense counsels; however, it lacks appropriate grounding in scientific method.50 Mandated Reporting It is the responsibility of physicians to determine whether the injuries and history are suspicious for NAT The law does not require that the reporter be certain or convinced that abuse has occurred Suspicion of abuse mandates a call for child protective services, who will then conduct the appropriate investigation The intensivist may enlist the aid of the institution’s social work department or the child abuse team if one is present Brief Resolved Unexplained Event Approach to Parents Prior or repeat admissions for a brief resolved unexplained event (BRUE; previously termed acute life-threatening event [ALTE]) should raise suspicion for trauma or suffocation.44,45 Hansen et al.45 report that patients who present with BRUE and SDH are five times more likely to have associated extracranial injury, which throws significant doubt on the role of the BRUE as a cause of SDH Case Example Cerebral Venous Sinus Thrombosis Spontaneous cerebral venous sinus thrombosis (CVST) has been described in infants and children However, this is frequently due to an underlying condition, such as severe dehydration, presence of a prothrombotic risk factor, infection, or malignancy.46,47 Heller et al.46 reviewed 149 children (neonates to 18 years of age) diagnosed with CVST; 70% had an underlying condition and none had SDH The theory that spontaneous thrombosis of the sagittal sinus causes increased ICP and subsequent SDH and RH has largely been disproven in the literature While CVST is associated with parenchymal infarct, resulting in significant morbidity and mortality, there is no evidence to suggest that it is associated with the story of an acute SDH, collapse, and coma Benign Enlargement of Subarachnoid Space Benign enlargement of the subarachnoid space (BESS) is common in infants with macrocephaly and was previously thought to be associated with SDH with minimal trauma The latest reviews, however, reveal that less than 6% of infants with BESS develop hemorrhagic collections in the area Choudhary et al report that in 712 cases of BESS, 12 (1.7%) were found to have hemorrhagic subdural collections; of 12 (41%) were associated with accidental or inflicted trauma.48 Subdural collections are uncommon in the setting of BESS in infancy and warrant an assessment to exclude inflicted trauma Other Alternatives: Lumbar Puncture, Vaccines, Bleeding, or Bone Mineralization Disorders The literature has overwhelmingly concluded that there is no association between receiving a vaccination injection and the 1423 A 20-month-old presented to the emergency department with severe TBI that required emergent craniectomy The mother stated that the child fell and hit his head while climbing the ladder at an outdoor jungle gym After an initial investigation, her story appeared plausible and consistent with his injuries He was in the ICU for weeks and survived, albeit with significant neurologic deficits that necessitated tracheostomy and gastrostomy tube placement During the last few days of his intensive care stay, Child Protective Services (CPS) performed a home visit and discovered an indentation in the drywall approximately the size of a toddler’s head, located feet above the floor in a hallway Upon closer inspection of the indentation, small bits of hair were seen between the broken parts of the drywall When this was disclosed to the mother, she became tearful and confessed that her boyfriend had thrown her child into the wall while she was in another room She was fearful for her own safety and did not want to disclose the truth NAT cases in the PICU are often emotionally difficult for the entire team The medical care is similar whether the mechanism is nonaccidental or not, but the added layers of uncertainty, forensic assessments, and law enforcement make it far more complex Having strong support from social workers and child abuse specialists is crucial to navigating the medicolegal waters of NAT When the medical findings are not consistent with the history provided, hospital staff involved with the care of the child may form opinions as to how the accident occurred or which visitor potentially caused the injury Because medical and forensic investigations occur in different locations, the entire healthcare team may not be aware of the legal status of the case We have found daily debriefings to be helpful in providing updates on forensic investigation findings, communicating any changes to visitation privileges, and giving the staff a forum to express their emotions For the intensivist, communications with parents or family members should remain within the medical realm If presented with questions as to the possible mechanism for the injuries, it would be fair to offer an answer such as, “I not know how it happened; however, we can discuss the injuries and what we plan to for them.” 1424 S E C T I O N X I I Pediatric Critical Care: Environmental Injury and Trauma Multidisciplinary Diagnosis Conclusions If knowledgeable about the medical findings (e.g., skull fracture, seizures, bruises), the intensivist may render an opinion based on experience about how common such findings are given the circumstances surrounding the injury It is also perfectly acceptable for the critical care physician to say, “I really don’t have sufficient expertise in this area to offer an opinion.” The intensivist will be expected to communicate the medical findings to investigative agencies, including law enforcement and CPS In this role, the intensivist should be as precise as possible about the medical findings while realizing that most law enforcement personnel and social workers may not be fully conversant with medical terms The intensivist may be queried about the mechanism of injury; the intensivist should relate one’s opinion or refer to the child abuse experts if they are available The family should be advised of the child’s medical condition and prognosis if appropriate The family should also be advised of the agencies now involved in the investigation In general, families are permitted to visit their child, abiding by hospital and ICU regulations (e.g., number of visitors at bedside) If there are restrictions on any visitors, such restrictions are generally placed by CPS or law enforcement That information must be communicated to all staff and hospital security The critical care physician has an important role in the recognition, evaluation, and management of infants and children with suspected inflicted injuries It is important to keep in mind that medical and forensic examinations are distinct; tests may be required that not serve a medical purpose but support the legal case The intensivist should be aware of subtle findings—for example, nonspecific symptoms such as vomiting and irritability in the presence of sentinel injuries are potential signs of abuse Significant injuries in the context of a history absent of trauma should raise concern for inflicted trauma Finally, recognizing the emotional difficulty in caring for a child suspected to be a victim of NAT, we suggest daily debriefings for the staff directly involved with the medical care in order to keep them up to date on the forensic investigation As these cases are often very difficult, this also provides them opportunity to express feelings associated with the case Treating a child who has suffered abuse is challenging from many aspects It requires experts from many disciplines to work in coordination in an effort to protect whom we have taken an oath to advocate for and protect To achieve the best possible outcome, teamwork and cooperation are essential Coroner Cases The death of a child with suspected abusive injuries mandates notification of the coroner The coroner will arrange to collect the body from the hospital morgue The medical records are reviewed, along with a scene investigation in the company of law enforcement The scene investigation usually involves going to the location where the child was injured Likewise, law enforcement will often be present at the time of autopsy Removing a child from ventilatory support falls under the purview of the hospital’s ethical and medical guidelines Parents can agree to terminate life support, even if they are suspected of being involved in the precipitating trauma Children who succumb to their injuries are eligible to be organ donors In general, a coroner is present in the operating room when organs are being retrieved This then is an opportunity for the coroner to obtain any organs or tissues that might be relevant to the cause of death Key References Berkowitz C Physical abuse of children N Engl J Med 2017;376:1659-1666 Binenbaum G, Chen W, Huang J, et al The natural history of retinal hemorrhage in pediatric head trauma J AAPOS 2016;20:131-135 Chadwick DL, Bertocci G, Castillo E, et al Annual risk of death resulting from short falls among young children: less than in million Pediatrics 2008;121:1213-1224 Choudhary AK, Servaes S, Slovis TL, et al Consensus statement on abusive head trauma in infants and young children Pediatr Radiol 2018;48:1048-1065 Lindberg DM, Dubowitz H, Alexander RC, Reece RM The “New science” of abusive head trauma Int J Child Maltreat 2019;2:1-16 Maguire SA, Upadhyaya M, Evans A, et al A systematic review of abusive visceral injuries in childhood—Their range and recognition Child Abuse Negl 2013;37(7):430-445 Sheets LK, Leach ME, Koszewski IJ, Lessmeier AM, Nugent M, Simpson P Sentinel injuries in infants evaluated for child physical abuse Pediatrics 2013;131:701-707 The full reference list for this chapter is available at ExpertConsult.com ... (DWI) DWI measures the motion of water molecules within tissue; when nerve injury and swelling occurs, this restricts motion and diffusion of water This produces a lower diffusion coefficient, which... outcome in this group when compared with the normal population.37 In general, asymptomatic birth-related SDHs are relatively frequent and resolve within the first months of life After this period,... of the body can whip the head back and forth, creating inertial movement of the brain within the skull This differential motion between the brain and the skull creates a movement plane between