Abusive head trauma: Difference between revisions
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*Majority of patients <1 year old | *Majority of patients <1 year old | ||
*History concerning/red flags for [[child abuse]] | *History concerning/red flags for [[child abuse]] | ||
*Retinal | *[[Retinal hemorrhage]] | ||
**Most common manifestation of abusive head trauma (as high as 85% in some retrospective reviews<ref>Morad Y, Kim YM, Armstrong DC, Huyer D, Mian M, Levin AV. Correlation between retinal abnormalities and intracranial abnormalities in the shaken baby syndrome. Am J Ophthalmol. 2002;134(3):354-359. doi:10.1016/s0002-9394(02)01628-8</ref>) | |||
**In infants, virtually pathognomonic for nonaccidental trauma, especially when numerous and multilayered | **In infants, virtually pathognomonic for nonaccidental trauma, especially when numerous and multilayered | ||
**Due to vitreoretinal traction | **Due to vitreoretinal traction | ||
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*Cutaneous ecchymoses: to face/head and other areas where patient grabbed or sustained impact | *Cutaneous ecchymoses: to face/head and other areas where patient grabbed or sustained impact | ||
*Other injuries associated with [[child abuse]], especially long bone and/or [[rib fractures]] | *Other injuries associated with [[child abuse]], especially long bone and/or [[rib fractures]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Template:Child abuse DDX}} | {{Template:Child abuse DDX}} | ||
==Evaluation== | ==Evaluation== | ||
*Skeletal survey for all children < 2 years of age, non-verbal, or severe developmental delay. Note: Follow-up skeletal survey should be performed within 10 to 14 days | *Skeletal survey for all children < 2 years of age, non-verbal, or severe developmental delay. Note: Follow-up skeletal survey should be performed within 10 to 14 days | ||
**Skull AP and lateral view (left and right) | **Skull AP and lateral view (left and right) | ||
**Chest AP and lateral view | **[[CXR|Chest]] AP and lateral view | ||
**Right and left oblique of the chest | **Right and left oblique of the chest | ||
**AP of the abdomen to include pelvis and hips | **AP of the abdomen to include pelvis and hips | ||
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**Consider CPK and platelet function studies if extensive bruising is present | **Consider CPK and platelet function studies if extensive bruising is present | ||
**If trauma labs are abnormal, obtain a CT of abdomen/pelvis with IV contrast | **If trauma labs are abnormal, obtain a CT of abdomen/pelvis with IV contrast | ||
*Consider a dilated fundoscopic exam if under 2 years | *Consider a dilated [[fundoscopic exam]] if under 2 years | ||
*Photograph injuries | *Photograph injuries | ||
*Obtain a social work consult | *Obtain a social work consult | ||
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*PTH, iCa, 25-hydroxy-Vit D, 1,25-dihydroxy-Vit D | *PTH, iCa, 25-hydroxy-Vit D, 1,25-dihydroxy-Vit D | ||
*vW panel (vW AT, ristocetin cofactors, factor VIII) | *vW panel (vW AT, ristocetin cofactors, factor VIII) | ||
==Management== | ==Management== | ||
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==Disposition== | ==Disposition== | ||
* | *Dependent on severity of injuries and safety upon discharge | ||
==See Also== | ==See Also== | ||
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==References== | ==References== | ||
<references/> | <references/> | ||
*Tintinalli's | |||
*Current Diagnosis & Treatment: Pediatrics, 24e, | |||
*[[https://bestpractice.bmj.com/topics/en-gb/688 BMJ Best Practices]] | |||
[[Category:Pediatrics]] | [[Category:Pediatrics]] | ||
[[Category:Trauma]] | [[Category:Trauma]] | ||
Latest revision as of 16:35, 4 February 2021
Background
- Current term for constellation of injuries that result from nonaccidental trauma involving forcefully shaking infant and/or any direct head impact
- may be referred to as "shaken baby syndrome" in lay press or old literature
- Injuries result of repetitive acceleration-deceleration and rotational forces (akin to whip lash) as well as direct blunt trauma from impact with objects or assailant
Clinical Features
- Majority of patients <1 year old
- History concerning/red flags for child abuse
- Retinal hemorrhage
- Most common manifestation of abusive head trauma (as high as 85% in some retrospective reviews[1])
- In infants, virtually pathognomonic for nonaccidental trauma, especially when numerous and multilayered
- Due to vitreoretinal traction
- May lead to retinal detachment
- May also have other eye findings (e.g. subconjunctival hemorrhage, hyphema, ecchymoses
- Signs of traumatic brain injury
- SDH (most common intracranial injury), skull fracture, diffuse axonal injury
- AMS, lethargy, seizure, irritability/inconsolable crying
- Cutaneous ecchymoses: to face/head and other areas where patient grabbed or sustained impact
- Other injuries associated with child abuse, especially long bone and/or rib fractures
Differential Diagnosis
- Bruising
- Mongolian spots (congenital dermal melanosis)
- Bleeding disorders
- Hemangiomas
- Phytophotodermatitis
- Malignancy
- Connective tissue disease
- Cultural healing practices (eg, coining and cupping)
- Osteogenesis imperfecta
- Vasculitis (Henoch-Schönlein purpura)
- Ink stains (e.g. caused by new clothing)
- Burns
- Hypersensitivity reaction
- Friction blisters
- Impetigo (may be confused with cigarette burns)
- Phytophotodermatitis
- Dermatitis herpetiformis
- Accidental laxative ingestion
- Healing practices (eg, coining, cupping, and moxibustion)
- Fractures
- Rickets
- Congenital syphilis (can cause periosteal elevation)
- Birth trauma
- CPR (rarely causes rib fractures and very rarely causes posterior rib fractures)
- Osteogenesis imperfecta
- Caffey disease
- Osteomyelitis
- Subdural hematoma
- Bleeding disorders
- Vascular malformations
- Glutaric aciduria type 153
- Benign extra-axial fluid
- Menkes disease
- Retinal hemorrhage
- Vasculitis
- Vascular obstruction
- Vaginal delivery (generally disappear by 4 weeks of age)
- CPR (retinal hemorrhages are rare after chest compressions and, if present, are usually in the presence of other risk factors for hemorrhage)
Evaluation
- Skeletal survey for all children < 2 years of age, non-verbal, or severe developmental delay. Note: Follow-up skeletal survey should be performed within 10 to 14 days
- Skull AP and lateral view (left and right)
- Chest AP and lateral view
- Right and left oblique of the chest
- AP of the abdomen to include pelvis and hips
- AP and lateral spine to include cervical, thoracic, and lumbar vertebrae
- AP bilateral humerus
- AP bilateral forearms
- AP bilateral femurs
- AP bilateral tibia and fibula
- Posterior view of the hands
- Dorsoplantar view of the feet
- Head CT without contrast for any child < 1 year with suspicion of abuse or >1 year with concerning signs of head trauma
- Trauma labs: CBC, CMP, PT, PTT, lipase, and urinalysis (looking for blood; use bag specimen). Consider urine tox screen
- Consider CPK and platelet function studies if extensive bruising is present
- If trauma labs are abnormal, obtain a CT of abdomen/pelvis with IV contrast
- Consider a dilated fundoscopic exam if under 2 years
- Photograph injuries
- Obtain a social work consult
Inpatient Workup[2]
- CBC
- CMP, Mg, phos
- PT/INR/aPTT, fibrinogen
- PTH, iCa, 25-hydroxy-Vit D, 1,25-dihydroxy-Vit D
- vW panel (vW AT, ristocetin cofactors, factor VIII)
Management
- Treat any identified injuries
- Ophtho consult for retinal hemorrhages
- Report abuse concerns to appropriate authority
Disposition
- Dependent on severity of injuries and safety upon discharge
See Also
External Links
References
- ↑ Morad Y, Kim YM, Armstrong DC, Huyer D, Mian M, Levin AV. Correlation between retinal abnormalities and intracranial abnormalities in the shaken baby syndrome. Am J Ophthalmol. 2002;134(3):354-359. doi:10.1016/s0002-9394(02)01628-8
- ↑ Children's Hospital of Georgia NAT Workup Protocol. Medical College of Georgia at Augusta University. Last reviewed 2016.
- Tintinalli's
- Current Diagnosis & Treatment: Pediatrics, 24e,
- [BMJ Best Practices]