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NON ACCIDENTAL TRAUMA

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NON ACCIDENTAL TRAUMA Pediatric Critical Care Medicine Emory University Children s Healthcare of Atlanta * * * * * * * * * * * * * * * * * * * * * * * * Evaluation ... – PowerPoint PPT presentation

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Title: NON ACCIDENTAL TRAUMA


1
NON ACCIDENTAL TRAUMA
Pediatric Critical Care Medicine Emory
University Childrens Healthcare of Atlanta
2
Introduction
  • gt40 Of Death in children lt12mos
  • 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

3
Epidemiology
  • Most often lt 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

4
Epidemiology
  • 60 of cases with previous history or clinical
    evidence of maltreatment
  • 22 with involvement of child welfare agencies
  • 32 with misdiagnosis
  • - Viral gastroenteritis or influenza
  • - R/O sepsis
  • - Accidental head injury

5
Epidemiology
  • Perpetrators
  • 50 fathers
  • 20 step-fathers or male partners
  • 12 mothers
  • 17 female baby sitters

6
Epidemiology
  • 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 babies

7
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 demyelinated

8
Mechanism of Injury
  • Rotational Impact forces
  • - Angular deceleration (head rotates on its own
    axis) causing SDH axonal injury
  • - gt with shaking and impact than shaking alone

9
Mechanism of Injury
10
Mechanism of Injury
  • Translational deceleration (drop or short fall)
  • Head moves in a straight line
  • Cranial impact
  • Focal injury

11
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

12
Cranial Injury
  • Blunt force trauma
  • Shaking
  • Combination of forces

13
Shaking
  • 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

14
Intracranial Hemorrhage
  • Sub-arachnoid
  • Sub-dural
  • Intraparenchymal
  • Epidural

15
ICH
  • Short vertical fall lt4ft
  • 85 with no evidence or minor injury
  • 7 with skull fracture all with isolated and
    linear skull fracture

16
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

17
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

18
ICH Epidural hemorrhage
  • Less likely with abuse
  • More accidental trauma
  • Focal to the site of impact

19
ICH Subarachnoid hemorrhage
  • Hard to detect
  • Not good correlation with abuse
  • Detected mostly at autopsy

20
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

21
ICH Parenchymal Injury
  • Infarct, atrophy
  • Encephalomalacia with ventriculomegaly

22
Associated Injury Retinal hemorrhage
  • Numerous
  • Multi-layered
  • Extend beyond the posterior pole to the
    peripheral retina

23
Associated Injury
  • Bone fractures
  • Blunt trauma to abdomen and pelvis

24
Skull Fractures
  • Most common parietal
  • Both accidental non-accidental
  • Common sites in abuse
  • Crossing suture lines
  • Multiple
  • Diastatic
  • Growing
  • Depressed
  • Complex
  • Bilateral

25
Skull Fractures
26
Skeletal Fractures
  • 20-50 of abused children associated with
    extracranial skeletal fracture
  • Ribs, long bone and metaphyseal
  • Classic metaphyseal avulsion lesion of long bone
    caused by torsion and traction when extremities
    in twisted or pulled

27
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

28
Rib Fractures
29
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

30
Associated Injuries
  • Pulmonary Injury
  • Pulmonary laceration, contusion or diffuse
    alveolar damage
  • Chylothorax
  • Cause by rupture of thoracic duct from blunt
    trauma or anteroposterior acceleration/deceleratio
    n forces
  • Signs respiratory distress, nutritional
    deficiency, electrolytes abnormality,
    immunosuppression from T-cell depletion

31
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

32
Associated Injuries
  • Abdominal Injury
  • 1 of abused children suffered intra-abdominal
    injury with 50 mortality
  • 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

33
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

34
Evaluation
  • History
  • Physical Examination
  • Laboratory studies
  • Radiographic studies

35
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)

36
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

37
Evaluation History
  • Where did the event occur? Who was there with the
    baby?
  • What would care provider consider normalcy in the
    patient? (behavior, development)

38
Evaluation History
  • Dont forget details of family history
  • Bleeding tendency in family
  • Bleeding at time of circumcision for boys
  • Easy bruising

39
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

40
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

41
Evaluation Opthalmologic Exam
  • Need to have an opthalmologic exam to stand
    legally

42
Differential Diagnosis
  • Accidental injury
  • Birth trauma
  • Apparent Life-threatening event
  • Bleeding disorder
  • Others

43
Differential Diagnosis Accidental Injury
  • A history of traumatic event
  • Retinal hemorrhages are typically fewer in number
    and less extensive
  • Subdural hematomas

44
Differential Diagnosis Birth Trauma
  • Commonly associated with instrumented deliveries
  • Both retinal hemorrhage and subdural hemorrhage

45
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
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