Abusive head trauma

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
  • 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

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

  1. ↑ 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
  2. ↑ Children's Hospital of Georgia NAT Workup Protocol. Medical College of Georgia at Augusta University. Last reviewed 2016.
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