first with a case to think about why we need a whole hour and a half discussion on abusive head trauma. So you're in the ED, a six-month-old comes in. Dad was lifting her up over his head and she fell about five to six feet striking a concrete floor. She initially cried vigorously, was consolable, was kind of grumpy but neurologically intact, comes into the ED with scalp swelling the next day. So we can see on the CT that there is some scalp swelling, there's an underlying fracture and then there's a subdural hemorrhage on CT. So we're presented with the question, does this accident make sense or are we worried about abuse in this case? A different example, an 18 month old is found by the babysitter unresponsive on the carpeted floor next to the coffee table. The baby speculates that the child must have fallen and that this has led to his presentation. All right, well does this make sense? Accident, abuse, what other information do we need? So that's what we're going to dive into today. We're going to talk about the epidemiology of abusive head trauma, risk factors for abusive head trauma, the anatomy of infants that lends them to this type of injury, imaging modalities, can we date hemorrhages or how can we tell how old these injuries are, the differential diagnosis and how to tell, some tools to tell abuse versus accidental injury. So abusive head trauma has had a lot of different names in the past and I'd like to talk about kind of what's in a name and why abusive head trauma are the names or the term that we use to refer to it today. In the 19th century, French forensic physician Ambrose Tardieu described a wide array of physical and sexual injuries that he'd seen on children including meningeal, hemorrhage and brain injuries in fatally abused infants. Fast forward a century to 1972 when John Caffey published the phrase whiplash shaken baby syndrome in his book on the theory and practice of shaking infants, its potential residual effects of permanent brain damage and mental retardation. And then this evolved into Ludwig and Wurman's published work on shaken baby syndrome that appeared in the Annals of Emergency Medicine. A few years later, Duhaime published in the Journal of Neurosurgery on shaken impact syndrome and stated that it's our conclusion that the shaken baby syndrome, at least in its most severe acute form, is not caused by shaking alone and while shaking may be part of the process, it's more likely that such infants suffer blunt impact. The most common scenario may be a child who's shaken then thrown into or against a crib or other surface striking the back of their head and undergoing a large brief deceleration. This child then can have both types of injury, impact with resulting focal damage and severe acceleration deceleration effects associated with impact, causing shearing forces on the vessels and brain. We're going to talk about that more in a minute. So now we have kind of shaking, we have impact and really what it comes down to is that we don't know necessarily when we see a child if there is shaking or if there is impact, but we will get a history from the family about the injury and we'll look at the injuries that we see on exam and on imaging and understand if the history matches the mechanism and we can use the term abusive head trauma rather than a term that implies a specific injury mechanism. So here the goal is not really to detract from shaking as a mechanism of abusive head trauma, but to really broaden the terminology to count for the multitude of primary and secondary injuries that can result from abusive head trauma and we'll talk about what all of those are. So shaken baby syndrome is terminology of the past and I will not be referring to that today. Abusive head trauma is what we what we use now. So how often do we see this? So abusive head trauma is the leading cause of death in infants and young children. The peak range is really these young infants two to three months of age which is when infants cry a lot, kind of correlates to that colicky time. It's most common in children younger than five years of age. The incidence range is 16 to 33 per 100,000 infants annually under one. Mortality rate can be as high as 40 percent. It's usually around 20 percent in most studies. So 18 to 25 percent of children with abusive head trauma will die and many of the survivors live with significant sequelae in terms of learning disabilities, motor disabilities, or cognitive disabilities that can really profoundly impact them for their whole lives. So what are some risk factors? Looking at the literature we know the risk factors specific to the child include male gender, inconsolable infant crying, like I said there's a peak in that colicky time. If there's a feeding difficulty, if parents or caregivers have a challenge getting the child to eat, that can be very frustrating. In older children we may see this with failed toilet training, again an issue with caregivers getting really frustrated. We know that children with complex medical needs including premature children, low birth weight children, are at risk for abusive head trauma. Similarly twins, again more stressful to have two babies and they're more at risk for for complex medical needs, are at risk. And in terms of racial breakdown we do see increased risk in Black and Native American children. And then caregiver risk factors, families with low socioeconomic status which of course contributes to caregiver stress, caregivers with mental health or substance use disorders that just have poorer or less reserve in terms of coping mechanisms. If there's an unrelated caregiver in the home, so this is kind of one way of describing someone watching the child that's that's not their biological parent or grandparent, like mom's boyfriend perhaps could be a risk factor. If there's intimate partner violence, so any kind of domestic violence increases the risk for child abuse, so if there's if there's violence between mom and a partner. And then really unrealistic developmental expectations, so if you have a parent or caregiver who's expecting a child to be kind of easy to take care of. One of the examples I like to use is when I ask parents to tell me about their child and if a parent or caregiver of a four-month-old describes her as being needy, well then we know that there's probably some unrealistic expectations because all four-month-olds are needy. They need support for every single thing that they do, so they're gonna they're gonna burn out a caregiver who doesn't anticipate needing to provide that level of care. Single parents, parents with lack of support, low educational attainment, all are increased risk. Prior CPS involvement and similarly unplanned pregnancy and young maternal age can contribute again to just really lack of coping, lack of support to help the caregiver provide the infant the care they need. And while we always talk about these risk factors and it's something important to think about at the population level, what is important to remember is that if you are in a room with a baby where you are concerned about non-accidental trauma, the risk factors go out the window. It doesn't matter if what race the child is or what socioeconomic status the family is. If you objectively see injuries that do not match the history provided, either because the baby developmentally can't roll off of a couch or because they're they're describing this shortfall and you wouldn't expect this big head bleed from such a shortfall, it doesn't matter. If they're the nicest family that lives next door to you and they have none of these risk factors, we have to think about abuse in these children because otherwise we will miss it. All right, infant anatomy. So infants have a couple of anatomical differences that predispose them to this type of injury. So they have really big heads relative to the size of their body. So a large head-to-body ratio that their head is about a third of their entire body weight. So that's a big head on this little weak neck. We know, you know, infants can't hold up their heads and that's something that they develop over the first few months of life that can contribute to them not being able to stabilize their head if their head is moved backwards and forwards rapidly. So it's kind of like a big cherry on a little cherry stem. It's just gonna fall. Additionally, intracranially, they have big subarachnoid spaces. So the space between one of the spaces between the brain and the skull is is widened so that there's room for the brain to grow but also there may be room for movement of the brain within the skull that can lead to to these bleeds with rapid acceleration deceleration of their head. We would not expect any kind of routine handling or care to to cause injury in a typical infant. They also have thin pliable skulls because they need to go through the birth canal and that can limit protection from impact. They have a flat skull base so where the skull sits on the cervical spine is flatter than in older children and adults making it more prone to rotational injury so that forward backward movement is more exaggerated. Again, their cervical spine is is more mobile and deformable so they're less likely to get a bony injury there but they can certainly get spinal cord or ligamentous injury. And then their brains have a very high water content because their brain cells have not gone through the myelination process which happens in the first years of life and so it it's more prone to to these shearing injuries so tearing with rotational forces such as the head moving backwards and forwards in in a shaking episode. The clinical presentation of abusive head trauma is extremely broad and if we don't have it on our differential we will miss it. So it can start with something as benign as vomiting which lots of kids vomit or spit up and don't have abusive head trauma so it's important to get more information about that. Poor feeding, irritability or fussiness again these are very vague symptoms they're not specific so it's important to understand how long this has been going on. Is it spitting up or is it truly vomiting? Because kids with babies don't often truly vomit especially in isolation if they don't have a fever or not they don't have diarrhea or some other sign of viral illness. Vomiting alone is something that's important to think about as a tip-off for for doing additional imaging to look for increased intracranial pressure for whatever reason be it abusive head trauma or some other space-occupying lesion. More concerning presentations can be with breathing abnormalities, rapid breathing, shallow breathing, color change because of insufficient breathing, increased or decreased tone of their extremities if babies present and they're lethargic without other signs or symptoms to point you in a you know more direction of an infectious etiology. Seizures, apnea, and impaired consciousness are the more obvious clinical presentations where we would want to make sure we're getting imaging to look at their brains. But we know that we we miss abusive head trauma and this study is two decades old now but it's actually been repeated and I'll show you the results. Unfortunately results haven't really changed over the last 20 years but in a retrospective review of 173 children who presented with abusive head trauma physicians didn't recognize the diagnosis in about a third of these these babies and the mean time to the correct diagnosis was a week so that's a long time these infants are back in that environment where they were injured and of those kids about 28% were re-injured after the initial presentation so exposed to additional harm. 41% experienced medical complications related to the misdiagnosis and four of the five total deaths may have been prevented if the injury had been recognized on presentation. Like I said that study's old but it's been repeated more recently by Lutzen and colleagues in 2016 did a multi-center study designed to evaluate the number of children with abusive head trauma who had prior opportunities to detect abuse and about a quarter of them had been seen in a medical setting where there's an opportunity to identify abuse and there also been a small percentage 6% had had actually been evaluated by Child Protective Services and so there was another opportunity to identify abuse and vomiting and bruising in these young infants were the most common symptoms that were concerning for for non-accidental trauma so again vomiting alone is a tip-off and bruising of course any bruising in a young infant should prompt evaluation for for abuse because these young infants can't really generate the forces necessary to hurt themselves accidentally. Alright so the next thing I want to talk about is is imaging because it's something that comes up a lot we we see these kids we're trying to figure out how worried we should be we want to balance risk-benefit of some of the imaging modalities ultrasound is certainly pretty easy low risk no radiation so is that something we could do versus CT which more radiation but isn't too hard to get versus MRI which can be hard to get but again no radiation so how do we figure out what imaging to use. So ultrasound is something that's used a lot in in babies getting a head ultrasound because they have that open font now and in the NICU we'll use it with these preemies to look for any kind of intraventricular hemorrhage which is the type of of injury that we or insult that we can see in in these neonates and ultrasound could potentially be a good initial study if you see a baby kind of for routine primary care and we notice that their head circumference is getting a little bit bigger but what's important is to recognize the limitation with ultrasound that probe and if you could see me you would see I'm pointing at the top of my head the probe points down through the font now and it's looking straight down where we see bleeding most commonly an abusive head trauma is in the convexity so now I'm pointing to the both sides of the top of my head and the ultrasound probe can't image into the convexities so we know we will miss head bleeds on on young infants if we solely rely on ultrasound as a diagnostic tool so it may be a place to start for some kids but it's really not reliable for evaluating for abusive head trauma and it should not be used we've certainly I've had patients where ultrasound was negative but on MRI there were those thin layer acute subdural hemorrhages seen in the convexities that were missed so here's some examples of ultrasound and and what we may see we can see kind of the superior sagittal sinus here we may see some intraventricular periventricular hemorrhage but again we're not gonna see we're not gonna be able to visualize the spaces in the convexities where we really need to see to rule out intracranial hemorrhage from abusive head trauma so next is commuted tomography or CT CT looks at tissue density so the wider an area is the denser it looks so bone it lights up bright white this is very sensitive for fractures especially we can we can do that 3d recon that many hospitals use to get that whole 3d view of the skull it's very sensitive for hemorrhages severe cerebral edema and mass effect which of course these are all critical findings that we need to act on quickly CT is available in most EDS very quickly so it's it's something we can get rapidly it is less sensitive for non hemorrhagic traumatic brain injuries so kind of parenchymal injury which we'll talk about in a little bit but those aren't necessarily the images or the injuries that we're gonna have to act on quickly so CT is great for identifying the immediate concern and being able to act on it we can see those small subdurals in the entire space of the intracranial area contrast CT can help with differentiating venous sinus thrombosis and subdural hemorrhage so we do get CT with and without contrast typically and then MRI magnetic resonance imaging is something that we recommend in all children with suspected abuse of head trauma so at our institution once they have a head CT we would recommend a full MRI of the brain and cervical spine to get a better characterization of the injuries that are seen intracranially so first those those hemorrhages those subdural or subarachnoid hemorrhages but then MRI is where we'll see cerebral ischemia so if there's been ischemic injury to any part of the brain shear injury if there's a parenchymal contusion or injury to the to the brain itself we will see that on MRI so we typically at the CT first and MRI now there are some institutions that have gone to using fast MRI as a technology to screen for concern for abusive head trauma in lieu of CT so that's a good option because it spares the child radiation and it's going to really be the institution dependent our institution our radiologists don't feel like the science is quite there yet in terms and the technology is there yet to make sure that we wouldn't miss something on fast MRI so it's not what we do here but I know that there are some institutions that are doing that so it's important to understand what is available at your institution here we do get the MRI on every baby where we have concerning findings on the CT MRI is less sensitive for fractures so CT will catch that most of these babies would be getting a skeletal survey so x-ray is also a way to look for fractures there are many many many different series of imaging with MRI so they use the magnet in different ways t1 and t2 are kind of the most common and I am not trying to teach anyone how to be a radiologist or neuroradiologist here I just put these details in to highlight the importance of involving a pediatric neuroradiologist if at all possible and talking to them directly which we do on all of our cases of abusive head trauma can be really helpful and understanding what we're seeing. So in the T1 sequence, the protons that realign quicker cause greater signal, and then the protons in fat realign quickly, so that causes fat to have hyperintensity, so it'll look bright, so that myelinated sheath would look bright. Versus T2, where the protons that deflates slower have greater signal. So protons in the water phase deflates slow, causing water to look bright on imaging. So it's kind of the flip-reverse image. So to see if something is fluid-filled, like that subdural space, you'd want to check T1 and T2 to, again, contrast the material that's being seen there. Again, this is not a course on radiology, and we want to make sure we're talking to our radiologist about this. So here's an example of T1. We can see that the surface of the brain is darker. There is some space in here that is bright white, versus T2, where it's kind of reverse. So the surface of the brain where we have that myelination is bright white. At our hospital, we image the brain and cervical spine. There are other hospitals that will image the entire spine, and I think that is good practice, because we can certainly see spinal cord injury in these infants that have abusive head trauma, and getting the MRI of the whole spine will help look for those other injuries. This is an example of different MRI sequences in the spinal column of this young patient, and on this STIR sequence, we can actually see a fracture of the lumbar spine. Present, which is certainly concerning for non-accidental trauma in a young infant. This is another sequence, the FLARE sequence, that can be used to help look for small bleeds in the subdural and subarachnoid space. All right, and then one of the other things that we get asked very commonly from law enforcement and children's services, and our partner agencies who are trying to help protect the child is, well, when did this happen? Who was with the child? And we would obviously like to be, as medical providers, like to be as specific as we can to help protect these children, and unfortunately, we're just limited by science. So we can kind of give some general windows with acute or early subacute injuries, so that's in the first couple days to week. We're more likely to see scalp edema, so swelling if there was impact, cerebral edema, so again, swelling of the brain, either from impact or from acceleration-deceleration, or ischemia, so lack of oxygen to the brain. So we start seeing signs of that pretty early on, and that would be on MRI where we see ischemia. As the injuries evolve into late subacute, so a week to 10 days out, to chronic, which is several weeks out, we can start seeing larger extra axial hemorrhages, we'll see membranes form, so if there is a bleeding in that space between the brain and skull, we'll see membranes form as the blood starts to clot in there. The edema and ischemia will start to resolve, so we won't see those, but we will see brain atrophy, so there may be death of the cells in the area where there was ischemia that can lead to encephalomalacia, so kind of a softening of that area as those injuries evolve. If we do see that organizing membrane, that suggests the hemorrhage is at least one week old, and these different age injuries are gonna look different depending on which imaging you're using, so CT will look, the subdural hemorrhage can be isohypodense, so it'll be darker at the very beginning, and then as it gets a little bit older, it gets brighter white, and then with MRI, again, you can have evolution of how those injuries appear. So this is a table, again, this is for radiologists to use, I'm just putting it here so that you are aware that there are ways that the radiologist can look at the injury, and the way you can kind of ask them to help you if you are trying to date injury, on get an idea, or at least a general timeframe of when these injuries might have happened, and again, they're pretty broad, so acute is hours up to three days, early subacute, three to 10 days, late subacute, 10 days to three weeks, and chronic is over three weeks. All right, now I wanna talk about primary versus secondary injury, which I alluded to when I was talking about the definition of abusive head trauma. So primary injury is direct mechanical force from direct impacting or rotational force. So a baby falls and bumps their head, and they have swelling right where they hit their head, that's a primary injury. With impact, you could have scalp swelling, scalp edema, deeper down into the brain, we could have a focal parachromal contusion, so where the brain kind of hits the skull will lead to a contusion or kind of bruise to the brain itself. And then in terms of the rotational forces, the primary injury is a subdural hemorrhage that we'll talk about. The other thing that rotational forces can lead to are diffuse axonal injury or concussion. So as there's acceleration and deceleration, if a head is kind of moving back and forth on the neck, that will tear those and cause sheer injury to the axons, the brain cells causing injury to them. And so those are the primary injuries, direct forces, and those are in contrast to secondary injuries where we have indirect mechanical forces from either hemodynamic or metabolic derangements. So if there's an injury to the child and now their brain isn't getting enough oxygen, then they'll have ischemic or hypoxic brain injury. So hypoxia, ischemia, in these injuries or when these forces are acting on their brain, often there's vasospasm. So there's decreased cerebral blood flow that can lead to hypoxia, ischemia. If babies are seriously injured and get very sick and they start bleeding, they may go into DIC, which is an acquired coagulopathy. So then they're not delivering blood and oxygen effectively. Because of these rotational forces or impact, the brain will start swelling leading to cerebral edema. And there can also be space occupying hemorrhages. So a hemorrhage that is so big that it puts pressure on the brain, causing the brain to shift downward, and that can lead to herniation. All right, so now we're gonna talk about specific types of injuries. Subdural hemorrhage is the most common intracranial hemorrhage in abusive head trauma. It's often crescent shaped, and it can lead to pressure on the adjacent gyri and sulci of the brain. So it should not extend to the sulci. There's a barrier between the bleed and the actual surface of the brain, but it can displace the veins inward against the surface of the brain. And put pressure on the brain. Let's look at how this happens. So here's some physiology. We have the skin at the very top of this picture, and then the bony skull, and then there's a bridging vein. So a vein that traverses in the space between the skull and the brain that carries blood to this area. The bridging vein goes through the meninges, so through the dura, into the arachnoid space, down to the brain. Now the actual subdural space itself, here it's shown in this light blue kind of color, but it's a potential space. There's normally nothing in this space. If there is something in this space, then that is pathologic. So it could be enlarged because of inflammation, because of an infection. It could be because there has been some kind of trauma, and there's bleeding in the space. So if we see something in the subdural space, so below the dura mater and above the arachnoid membrane, then something has gone on. And so in abusive head trauma, what happens is the acceleration-deceleration forces on the brain cause the brain to rotate within the cerebrospinal fluid in the skull, and it tears these bridging veins. And that's what we see in this picture on the right here. That bridging vein breaks, and it bleeds into that subdural space. So now this potential space is filled with blood, and that is what we're seeing on the CT and MRI. If we do kind of a histologic view of it, we see that there's really this rent or tear in these border cells between the dura and the arachnoid in that subdural space that's causing the blood to come into that space. So on imaging, again, we see this bright white subdural most commonly seen in the convexity, so the curved top of the head. It can be unilateral on one side. It may be bilateral. It just depends on the injuring forces. Here we see subdural bleeding along the parententorial space. Again, you can see it, and this is a different view, so looking sideways through a sagittal view, we see it there. And then similarly on MRI, we can see that bright white subdural fluid. So when we see subdural hemorrhage, we need to think about, just as when we see any kind of disease process, we think about the differential diagnosis. So what could possibly be causing there to be blood in this space that shouldn't have anything in it, right? So we could have a coagulopathy or a bleeding disorder, hemophilia, hypoprothrombinemia, also known as vitamin K deficiency, and we're gonna talk about all of these more specifically, von Willebrand's deficiency. So some kind of bleeding disorder that makes babies bleed more easily. There could be accidental head trauma, like a motor vehicle accident or a substantial angular deceleration, like a baby falling from a second story window, that kind of large angular deceleration. There could be an AV malformation. So the arteriovenous system, for some reason, has formed incorrectly and there's a bleed or a ruptured aneurysm in that space. Those last two will look different on imaging. And when we talk to our neurosurgeons about these bleeds, they will be able to identify very quickly if the bleed is from an AV malformation or ruptured aneurysm. But it's important to note that you can't have bleeding in the space from those. All right. Another type of subdural hemorrhage that you may see a radiologist kind of comment on is a chronic subdural hemorrhage. So again, this means that we're past that acute phase into an injury that's several weeks old. So that's when we start to see those membranes form. So there's subdural membranes and the membranes themselves will actually form blood vessels. So you'll have vascularization of those membranes. And in these cases, when you already have some bleeding into that subdural space and the membrane forms, you get these extra little blood vessels. Now we may see acute bleeding with relatively low forces because you're already in a high pressure situation with that subdural that's there. So we typically see these chronic subdurals about three weeks after injury. Membranes we don't usually see until two to four weeks out. Using IV contrast can help us see the membrane. And you may have older blood, you may have newer blood. If you see a membrane, that's that older subdural hemorrhage. And so that lets you know if you see it that the injury happened three weeks ago. Now you may catch this because of an evolution of injury. If you're following a child over several weeks to months after their injury, it can go from acute to chronic. Or the other thing that can happen when we see these kids is if they're being seen by their PCP or for a well child visit, and they're noted to have an increased head circumference. And on imaging, we get either the CT or the MRI and there's this chronic subdural hemorrhage. And that tells us that something caused bleeding several weeks ago that has led their head circumference to expand and that has caused this chronic subdural. And so then we need to talk to the families about what happened. Was there a large known injury or not? And if not, then we need to be concerned about abusive head trauma. So here's some examples of, this is just a diagram on the left of the chronic subdural and the membranes that form in it. And then again, they'll have blood vessels go through there. Now these blood vessels, you can see, they're kind of stretched over the space that didn't exist. Like you don't see it on the left side of the picture because it doesn't exist in normal, non-injured subdural space. And so they're under a lot of tension and they may break more easily with routine handling and care, or even like a minor bump to the head. You can see on imaging on the right that there's this large black space in the top left picture where there's that chronic subdural hemorrhage. Similarly, you can see in the MRI pictures on the top right that a membrane has formed and there's chronic subdural that can be seen. Now, one of the things that we think about, like we're like, gosh, if these bridging veins are under all this stress because they're spanning this big chronic subdural gap and a kid comes in and they're really sick and we re-image and see that they've had a re-bleed, how do we know if abuse has happened again or not? And like I said, they can re-bleed relatively easily once they have a chronic subdural, but typically they won't be symptomatic. They won't come in with big changes in mental status or seizure activity because these bleeds will be very small and asymptomatic. So again, if we do have chronic subdurals, these kids are at risk for re-bleeding, but the innocent re-bleed, a minor re-bleed doesn't cause cerebral edema. They're clinically stable. A re-bleed that's from an injury will look like that infant with seizures, irritability, poor feeding. They would be symptomatic and that would be when we would have concern for repeated injury. The other thing we may see is mixed attenuation hemorrhage. So this is seen in about half of abusive head trauma victims. And this just means that kind of, there's a lot of mixture of these fluids, a mixture of blood and CSF. And it could be for lots of different reasons. It could be an acute subdural, so a newer bleed with components of older clot and serum. So that's, you kind of had that chronic subdural, but now there's a bleed and they're mixing. Hyperacute and acute subdural hemorrhage. Hematohygroma, so there's been a bleed and it leaves that big space that re-bleeds into. And then subdural hemorrhages of differing ages. So these just make it harder to date, but they're still concerning and we still need to get a good history and understanding of what's going on and who's been taking care of the child. And if there have been accidental injuries that would explain these hemorrhages, but they're all still concerning. It just makes it that much harder for us to give children's services and law enforcement a specific timing. If anything, I would be worried that these kids have been exposed to multiple episodes of abuse that have caused multiple injuries that we're seeing. So here's mixed attenuation subdurals are kind of all different combinations of that bright white and gray fluid mixing. And again, like I said, that just tells us there may be multiple episodes or we just can't really be definitive on timing. Another type of hemorrhage subdural or intracranial hemorrhage that we hear a lot about, but don't see very often in abusive head trauma is epidural hemorrhage. It is uncommon in abusive head trauma, but it can be lethal. So this is caused by a focal skull impact most typically on the side of the head. So kind of by the temples. There's a rupture of that posterior branch of the middle meningeal artery. And it, like I said, is accompanied by fracture 90% of cases. So it will bleed. These bleeds look different because they have this convexity. So it has this big space occupying hemorrhage that's pushing on the brain. These patients will typically present pretty sick. And often these kids will have a clear eye a clear accidental history. Like they fell and landed on the side of their head and cause this epidural hemorrhage. And these are, unless a child comes in with no history or with other injuries, if there is a clear history, these are often accidental and not concerning for abuse. So just to distinguish epidural hemorrhage, since it is something that is commonly seen in older kids and adults from accidental injury. And then we talked a little bit about the other spaces. So there's the subdural space. So that's below the dura, but above the arachnoid membrane. And the arachnoid membrane's one layer closer to the brain. But there can also be hemorrhage below the arachnoid membrane and above the brain. So that's a subarachnoid hemorrhage. And that is most commonly caused from trauma. Could be accidental, could be non-accidental. And this comes again from tearing of those veins that go through that space. So vessels related to those britching veins are torn. And in this case, because we're that much closer to the surface of the brain, the bleeding will fill the fissures and sulci, those grooves in the top of the brain. And that's how we can tell the difference. So we can see bleeding within the sulci or the curves of the brain. And that's how we know it's subarachnoid hemorrhage. Again, radiologists will be very helpful with this and can help us see it. And also, without a clear accidental history, if we see bleeding in this space, it's still very concerning. Just because it's not a subdural doesn't mean it's not concerning. Bleeding in the subarachnoid space in a young infant without a clear accidental history is concerning for abuse. Interventricular hemorrhage is another type of hemorrhage. And again, this is not very typical in abusive head trauma, but I mention it because it is what we're often looking for in those preemies in the NICU when they get the head ultrasound to look down into the ventricles because we know that preemies are at risk of IVH. So prevalence on CT is 3%. It can be associated with subarachnoid and subdural hemorrhage in kids that have abusive head injury, but isolated as an abusive injury is very rare. The etiology is shearing of the veins very deep in the brain, and that can come in the birth process in these young infants or premature infants. And so this is what IVH can look like. So we have bleeding within the ventricle. So now we're not looking at the space between the brain and the skull. We're looking within the ventricle inside the brain. So again, isolated interventricular hemorrhage, extremely uncommon in abusive head injury. All right, so now we're moving away from the bleeds and the hemorrhage and more into contusions. So these are lesions directly to the brain. They're more common in older children from severe accidental head injury. So big fall, big bike crash without a helmet, big car crash, rarely seen in young infants. They typically have an associated skull fracture. So some indication of impact that has caused the skull to fracture, there's swelling of the scalp, there's bleeding directly underneath the fracture in the subarachnoid space. There can be multiple contusions, and you can see in those images on the screen that there are these multiple kind of fluffy black areas where there's been bruising or contusion to the brain. We can see coup-contrecoup contusions. So you can see when the impact happens, it's like whiplash. The brain hits the front of the skull and then it's propelled back to the back of the skull. So you have injury on opposite sides of the brain. So compressive forces beneath the site of impact, but then sheer forces at the opposite side of impact. So even if we see multiple or bilateral contusions, that doesn't necessarily mean that it didn't happen from one impact. Location often front and side of the head, vertex or top, corpus callosum in the middle. And these can evolve depending on the depth of the injury. As they heal, they may actually lead to encephalomalacia or softening of the brain with cavitations or atrophic enlargement of that space. So kids with severe contusions can lose some of that brain matter and end up with more space. Here's examples of these contusions kind of in diagram of where they're most common and then how they appear on imaging. So they'll just look like kind of this little darker area on CT, but then on MRI, we can get more specific information about where the contusions are and how severe they are. And then diffuse axonal injury. We talked about a little bit at the beginning. So when there are those acceleration, deceleration forces on the brain, when the brain is rocking back and forth in the skull as the head is moving back and forth, there are rotation or angular forces on the axons, on the brain cells, and that can cause them to tear. And this we'll see eventually on imaging, but one indication about this injury is that the symptoms that we see in the baby can really be out of proportion to imaging findings. So a baby comes in non-conscious or non-responsive altered mental status and the brain doesn't look that bad yet. Oftentimes we'll see this evolve on imaging and it won't look very severe right away. There may be intraventricular subarachnoid hemorrhage and the hemorrhage and swelling that result can resolve and then the axons, because of these injuries will keep degenerating and can lead to significant loss of brain matter. And of course, that's gonna lead to significant injury in terms of prognosis. So a lot of loss of functioning. Here's a diagram again, and then images of diffuse axonal injury. This is in a 10 week old. You can see the diagram on the left of where we most typically see these injuries. And then on the right, how they are seen on MRI. Cerebral edema is the swelling that is caused to the brain. It's seen commonly in abusive head trauma. It's nonspecific and can be seen after any kind of brain injury, but that causes diffuse axonal injury. But it's something we need to watch for because the swelling can cause pressure on the brain that can cause herniation or cause the brain to kind of push down through the spinal cord. Symptoms can be prolonged seizure or altered mental status. And it can be very, very significant. So here's an MRI that's showing edema kind of as it's evolving. And you can see the brain is kind of filling up the space of the skull and that can cause pressure leading to herniation. And then hypoxic ischemic injury is another, these are secondary injuries. So this is the most common cause of parenchymal injury. So injury to the brain itself is most commonly caused by hypoxia rather than by the direct impact or contusion. Contusions are more common than accidental injury. This is multifactorial. It can come because a baby has stopped breathing because of their injury. If they develop secondary hypotension because of their injuries. If there's, like I talked about when we have tearing of those veins or as the brain is bleeding, the blood vessels can spasm so that there's decreased circulation to the brain. And so because of the decreased circulation, there's less oxygenation to the brain and it causes the brain cells to die. Strangulation, so asphyxiation because of compression on the trachea and the carotid artery can lead to hypoxic ischemic injury. And these all cause oxidative stress on these cells. We may also see if a child starts seizing as a result of the injury, that can cause hypoxia. This leads to acute necrosis. So the cells die, they can die immediately. They may die later. So we have delayed necrosis. And that's why oftentimes we won't see this right away but we have to follow these kids as the imaging evolves as these brain injuries evolve. So we can see bilateral hypoxic ischemic injury that is common in abusive head trauma. That's because of the apnea and respiratory instability causes the decreased blood flow and decreased oxygen to the brain. If there is brainstem injury because of shaking, so because of that rapid head movement forward and backwards as the baby's being shaken can cause brainstem injury. So that will suppress the respiratory drive and lead to hypoxic ischemic injury. Unilateral injury is often seen with there's one-sided thin rim subdural or if there's strangulation on one side or with second impact syndrome. So this is an older kids. If they have repetitive concussion they may get unilateral patterns of hypoxic ischemic injury. So here is kind of unilateral hypoxic ischemic injury in a young infant whose father confessed to shaking him. And then on the right, there's bilateral hypoxic ischemic injury, really diffuse. I mean, the entire brain is really, really involved there just sparing of the deep gray nuclei. All right, so those are the many intracranial findings we can see. We wanna think about what other injuries we may see that may help point us in the direction of understanding the forces that have acted on the child to cause the injury scene. And so retinal hemorrhages are also something we look for. So retinal hemorrhages are seen in many cases of abusive head trauma. The ranges reported are wide up to a hundred percent. Typically, it's a little bit more severe typically in literature, it's around 80, 85% of children with abusive head trauma have retinal hemorrhages they're not always present. And the lack of retinal hemorrhages does not exclude a diagnosis of abusive head trauma. So you don't have to have retinal hemorrhages to diagnose abusive head trauma. They may be one-sided, they may be bilateral. They can vary in size and distribution between two eyes. One eye may have a few and the other eye has a lot. It's imperative to describe the number type and pattern of distribution. And we rely on pediatric ophthalmologists to do that. So our ophthalmologists will use a retcam to do dilated ophthalmoscopy of the back of the eye the retina, where they can visualize the macula optic disc or optic nerve and the retina that surrounds the optic nerve is the posterior pole. The edge of the retina is the aura serrata and then the peripheral retina is the zone from the equator to the aura. This is best done with a dilated pupil exam. If a child is in the PICU and they're very ill and neurology or neurosurgery is relying on the pupil response as part of their neuro exam we may not be able to get a dilated exam right away but it is important to try and get it as quickly as possible because we know that these injuries can resolve very quickly. So this is a simple diagram of the organization of the retina. And basically there are several layers of the retina three layers of the retina that where we may see retinal hemorrhages and the ophthalmologist will be able to describe what layer the retinal hemorrhages are in with abusive head trauma. The most typical presentation is retinal hemorrhages in all three layers, extending out to the perineal extending out to the periphery in all four quadrants of the eye. So those are the kind of words we look to hear or read in terms of retinal hemorrhages that are concerning for abusive head trauma. The other thing we may see is retinoschisis. So that's severe hemorrhage such that the retina has detached from the back of the eye. And that is really specific to abusive head trauma or another crush injury of the child's head like one of the old big box TVs following on a kid's head. But in that case, you would have a history of a big box TV falling on the child's head. So without a history, retinoschisis is very specific for abusive head trauma. Other differential diagnoses for retinal hemorrhages birth trauma can cause retinal hemorrhages in young infants. So we would expect this to resolve within the first few weeks of birth. And we would only see a few, usually in one layer usually not extending out to the periphery in all four quadrants. It would just maybe be a few retinal hemorrhages and that's from compression of the baby's head during the birth process. Motor vehicle accidents. Again, we may see retinal hemorrhages but we would have an external history. In overwhelming sepsis with coagulopathies or hypertension we can see retinal hemorrhages. But again, we're gonna have other symptoms and other signs that point us away from abusive head injury as the cause of these retinal hemorrhages. So here's an example of nonspecific retinal hemorrhages. Just a few little dots that we're seeing here and there not overwhelming, not extending to the periphery in comparison to really lots and lots of retinal hemorrhages in all four quadrants, multiple layers extending to the periphery. And this is a normal retinal exam on the left. All right. So we've talked a little bit about differential with retinal hemorrhages. I wanna go a little bit more in depth with intracranial hemorrhages as well. So with both sepsis, so overwhelming signs of infection accidental head trauma, like we talked about bleeding disorders, if there's vascular abnormalities which we talked about AV malformations or aneurysms or hypertension. With both subdural hemorrhage and retinal hemorrhage non-abusive traumatic events like birth or accidents can be confused. We'll talk about those benign extra axial fluid glutearic aciduria, bleeding disorders and other ones that we're not really gonna discuss today because they have a lot of other findings and they aren't really mimics or Mencken's disease and scurvy. But again, none of these are really a true mimic of abusive head trauma. If we do a good workup, we're not going to confuse them. All right. So birth related injury. Birth is traumatic for all involved. And there certainly the baby can sustain injuries during the process. We may see fractures, clavicle fracture most commonly sometimes a humerus fracture if there is shoulder dystocia and that can result in nerve palsy like a brachial plexus nerve palsy. Traumatic birth related head injuries have been estimated in about 3% of pregnancies. We don't scan every baby that's born. So we don't necessarily know the true prevalence but what is seen is typically subdural hemorrhage. And like I said, there may be a few scattered retinal hemorrhages. So what's the frequency? Again, it's pretty low 5.9 per 10,000 live births in one study, 17 out of 57,600 infants in another study. A more recent study showed 111 infants had MRIs and they were born nine or 8% had subdural hemorrhage. What's important to note is non-required intervention. All nine of them were re-scanned at four weeks of age and it had completely resolved. So these do not persist for a long time and they're generally asymptomatic. So similarly 17 of 97 kids in this study had intracranial hemorrhage, no intervention was required. Again, very small, very unlikely. And what's most important is that they're, like I said, not symptomatic. So if kids come in with a symptomatic presentation of a head bleed, that's more concerning to me than if we incidentally catch it because we're doing head imaging for something else and we see a little bit of a subdural in very young infants. Similarly with retinal hemorrhages, we can see retinal hemorrhages in up to 1 3rd of births. So pretty common, most commonly seen with normal vaginal deliveries because of the pressure from the birth canal on the baby's head. In one study, they were all intraretinal, so all the same layer. They resolved very quickly, it's in 16 days. In another study, all of them had resolved within one month. The key distinguishing factors are they're clinically silent, the location with subdural hemorrhage, they're typically supersentorial. So they're not that thin rim acute subdural in the convexities, it's lower down, it will look different, they resolve quickly. Again, retinal hemorrhages will also resolve very quickly. Benign extra axial fluid is an increased space, an increased subarachnoid space in infants that will often present kind of asymptomatically the one symptom may be an increased head circumference after the first few months of life. So if they're being charted on their growth chart by their PCP and the head circumference bumps up, someone may get imaging and may see this enlarged space. It is important to note that it is typically in the subarachnoid space, not the subdural space. Now, with this increased fluid pressure in the subarachnoid space, these babies may be predisposed to subdural hemorrhage with small axonal injury because those bridging veins are under more tension as you can see indicated by the arrows here, but those will typically be asymptomatic. If a baby comes in with a altered mental status, difficulty breathing, seizure like activity, and has an acute subdural, I'm concerned about abuse in that child, even if there is a large subarachnoid space. Gluteric aciduria is another quote unquote mimic of abusive head trauma, although I don't think it's much of a mimic. So it is an autosomal recessive metabolic disorder from a mutation in the gene that encodes enzyme gluteral CoA dehydrogenase. Initially, their symptoms are pretty minimal. So when babies are born, they may not demonstrate symptoms, but then they'll have like a subtle increase in head circumference, and they may develop a sudden encephalopathy and they end up with cerebral atrophy. So they have death of the brain cells and then subdural hemorrhage. There are retinal hemorrhages seen in some of these cases, and it's diagnosed by testing urine for quantitative organic acids. It's also on the newborn screen in most states. So understanding what your 24-hour newborn screen screens for is important because here in Ohio, this is screened for, and so we would know as long as a baby was born in a hospital and had that 24-hour newborn screen done, we would know if they were at risk of this disease. We've mentioned a couple of times that bleeding disorders or coagulopathies may put babies at increased risk or may be a mimic of abusive head trauma. Vitamin K deficiency can present at three different times early within the first 24 hours of life, classic within the first week, late two to 12 weeks after birth. The most common presentation is intracranial bleeding, and it can be fatal. Other symptoms may be rectal bleeding, bruising, hematemesis, or hemoptysis. So it's important to get a history on these babies and understand if they were born in a hospital and if they received vitamin K at birth, because if they did, they shouldn't have any of these issues because that's why we give vitamin K. If they didn't get vitamin K at birth and they're presenting, that will help us understand that that is the cause. Hemophilia A is the most common inherited coagulopathy that causes intracranial hemorrhage. It may be the only presenting symptom of hemophilia. In 2%, it will be the only symptom, but we will have profoundly abnormal coagulation studies, and we get coagulation studies on every child that we see that has an intracranial hemorrhage or a bruise, actually. So we would see derangement of those coagulation studies that would point us in the direction of understanding that there's a true bleeding disorder contributing to the child's presentation. Von Willebrand disease is the most common coagulopathy worldwide. So the majority of those with von Willebrand disease have very mild disease, and it's often detected incidentally. One survey of medical literature found that there were only 23 cases of intracranial bleeding associated with von Willebrand disease, and there've been no reports of retinal hemorrhages. So while this is kind of a mimic, because it's so common, it doesn't actually cause these injuries in most babies, and we can certainly do lab testing to evaluate for von Willebrand. Factor XIII deficiency. So if we all think about the coagulation cascade, you may recall that factor 13 cross-links fibrin monomers and links alpha 2 anti-plasmin to fibrin. So this is for clot stabilization. So without factor 13 deficiency, these babies can't form good clots. It may be classically associated with prolonged bleeding from the umbilical stump. So that's something that we ask all of our families about when we see them is if their babies did have bleeding from the umbilical stump, but that's not going to capture every child that has factor 13 deficiency. So we will get a factor 13 level in babies with concern for abusive head trauma. It is important to note that this is really a one in a million disease. This is not very common, and really most bleeding with this deficiency involves skin and soft tissues. So when we look at the probability of factor 13 deficiency in intracranial hemorrhage, it's one in six million, so very low. So saying all that, the recommended hematologic workup in babies with intracranial hemorrhage concerning for abusive head trauma is CBC with platelet count, PT and PTT to understand their bleeding time, that would help us with hemophilia. Factor 8 and factor 9 levels. We typically only get factor 9 in males, and we consider it in females with a positive family history, D-dimer, fibrinogen, and then the factor 13 level. Here, this is evidence-based and it's supported by the AAP guidelines on evaluating for bleeding disorders in children with abusive head trauma. Locally, our hematologists advise us to also get platelet function analysis on these babies, so we do that here, but it may vary by institution. Then way more commonly than any of those diseases is distinguishing abusive head trauma from accidental trauma. So usually, babies come in with some history of some accident. So then we're left with explaining, does the accident that the family is describing really account for the injuries that we're seeing? So there's been lots of studies trying to establish a difference between serious accidental and inflicted head trauma. A lot of them have a high degree of statistical significance, and a lot of it is looking at what injuries we see and how sick are the babies. Because really, abusive head trauma leads to more injuries and sicker babies. So in this study, looking at children less than 24 months that were hospitalized for a head injury, about 67 were accidental head injuries, 15 with abusive head injury. If we look at the babies with abusive head injury, there were many, many more retinal hemorrhages identified. If they were bilateral, it's much more likely to be abusive. And vitriol hemorrhage was only identified in children with abusive head injury. So retinal hemorrhages are a good place to start. Looking at symptoms and how they evolved, children with abusive head injury were much more likely to be very sick with seizures. 53% had seizures, required anticonvulsants. Over half had abnormal mental status. Over a quarter required an operative intervention. The only thing that was more common in accidental injury is a scalp hematoma, which makes sense because most of these accidents are kids falling and bumping their heads. So then they end up with scalp swelling. Another study looking at children less than two admitted to a PICU for metronic brain injury looked at 152 children, about half abusive, half non-accidental. In the abusive or inflicted injury, the vast history provided was no explanation, which kind of makes it easy because if there's no traumatic explanation to account for a traumatic injury, then it's very concerning for abusive head injury. Falls were the next most common explanation, child being dropped. Or shaken to revive is something we also hear periodically. Compared to accidental injury or non-inflicted falls and motor vehicle collisions were very high as well there. So we really have a history. Most of the time, the babies have a significant enough head injury to require intensive care stay. There's a history provided. There's been a car accident. The child fell significantly. Versus looking at abusive injury, the vast majority of them had no explanation offered at all. So understanding if there's a history, if the history changes, that's also helpful to kind of know that maybe there is a history now, but when they first showed up at the hospital, there wasn't one. So the caregivers may have had time to kind of come up with a story. And then again, looking at the types of injuries sustained, children with abusive head injury were much more likely to have retinal hemorrhage, 76%. More likely to have rib fracture and long bone fracture. And again, with accidental or non-inflicted, they're more likely to have skull fracture because they fall and hit their heads and they have a skull fracture. So abusive head trauma is correlated with presence of subdural hemorrhage, presence of retinal hemorrhage. And accidental history is more likely to have a clear accidental history. All right, so now we're going to go back to those examples and think about how we apply everything we've just talked about, which I know has been a lot, to kind of real-world cases. So the six-month-old falls five to six feet, hits their head on a concrete floor, initially cried right away, was consolable, but now they're here. With this, we get the head CT, they have a skull fracture, there's a subdural that looks like it's probably right below the skull fracture. So what are the specific cranial injuries? The head CT tells us there's localized soft tissue swelling, there's a linear skull fracture, and a small subdural hemorrhage. And you're like, ah, that one lecture I listened to that one time said if there's anything in the subdural space that's concerning, so should we be worried here? And we would say, well, there's a pretty significant fall for this baby, and there's a history of it, and there's other indications of contact injury, like scalp swelling and the skull fracture. So in this case, I think the forces that were needed to cause these injuries were impact, and they described impact as an accident. So does the mechanism described include the necessary forces to explain the injury seen? Yeah, it really does. So the injuries are consistent with the history provided, and this is most likely accidental. The other thing I want to point out with this study is that we'll have babies come in three, four, five days after a fall, and sometimes it will be because they notice scalp swelling, they'll be like, oh, I was giving my baby a bath, and their head felt really squishy, and the only thing, they fell like five or six days ago, but I don't know, could that fall cause swelling now? And the answer is yes. There's often delayed scalp swelling with these bumps, lots of different reasons why, but if there is a history of an accidental fall that makes sense, and the swelling is being seen right where that impact happened, it's not a delay in seeking care, it's just that there may not have been swelling present until that time that the parent noticed it, because the swelling does take time to evolve. So as long as there's no injuries noted that are concerning, I would say that it's consistent, even if they don't come into care for several days to a week. All right, moving on to our other example. This is an 18-month-old found by the babysitter unresponsive on the carpeted floor next to the coffee table. The babysitter speculates the child must have fallen, and this has led to him coming in. So he's unresponsive, posturing, he's having recurrent seizures. This baby, unfortunately, ultimately dies 12 hours after admission. So what are the specific cranial injuries we're seeing here? We see the CT, there's a pretty big subdural, causing mass effect on the brain, causing a shift. So large subdural hemorrhage with mass effect, there's diffuse cerebral edema, and on autopsy, there is histologic evidence of diffuse axonal injury. We obviously would not have autopsy findings available to us right away, but that is found. So what forces are needed to cause these injuries? Well, there's no real signs of impact in terms of swelling, in terms of fracture, but rotation would account for the subdural hemorrhage, cerebral edema, the diffuse axonal injury. So these are from rotation. And does the mechanism described of the babysitter speculating that this 18-month-old just kind of rolled off the couch on the carpeted floor, does that explain the necessary forces to explain these injuries? No. So these injuries are very concerning, I would say diagnostic of abusive head injury. Of course, you would want to get a dilated retinal exam, if at all possible, in this child who's very sick. We would want to get a skeletal survey, which is a series of about 24 x-rays looking at every bone in the body, to look for fractures that we may expect to see in these cases. So we want to get other information, but just on the surface of it, no, this is very concerning for non-accidental trauma for abusive head trauma. All right. Far beyond what would be expected. All right. Another example. An 11-week-old in the care of his father. Father is carrying the child and trips in the driveway, falling forward and dropping the child to the ground. It's a tiny little baby. There's no loss of consciousness, but the parents are completely freaked out. Comes to the ED. Vital signs are stable. The baby's fussy. So what are the specifics? So we get an MRI and a CT on this baby, and it turns out this baby has linear non-depressed biparietal skull fractures with an overlying cephalohematoma. So this baby has fractures on both sides of their skull. There's also a left extra axial hemorrhage, so underlying one of the fractures and a small left epidural hemorrhage. Gosh. The dad described one impact with the baby falling out of his arms and landing on his head. Could that account for multiple fractures? What forces are needed to cause these injuries? Impact? Yeah. Well, we have fractures. We have some, an epidural hemorrhage, which we talked about being from impact. Rotation? Well, yeah, there's a subdural hemorrhage. So we're worried about rotation, but dad did say that the kid kind of fell out of his arms, flew up and landed on his head. So we kind of have both there, but could we have two fractures from one impact? And the answer is yes. The accident described accounts for the injuries seen, because if you think about cracking an egg, when you hit the egg on the side of the bowl or the counter, or however you crack the egg, there's a side of impact, but then the cracking spreads in both directions. So it is possible if we, in these young infants, because of the pliability of their skulls, the impact can cause a fracture to spread on both sides. We can have bipedal fractures in these infants. Again, you want to correlate with the history and you want to make sure you're looking for other injuries, but it is possible. All right. So I want to make sure we think about how we can prevent babies from experiencing these injuries. These injuries are obviously very severe. 90% of children with abusive head trauma don't survive. We know that almost 2,000 infants, sorry, 2,000 children die in the United States of non-accidental trauma every year. So we want to think, what can we do to keep this from happening? So primary prevention, or just keeping babies from getting hurt at all. Some of the most evidence-supported interventions are home visitation. So Nurse-Family Partnership is an example that we have locally, but it is a nationwide service. Provides nurse home visitation to first-time low-income mothers. It starts in early pregnancy, goes through the child's second birthday. Nurse-Family Partnership improves pregnancy outcomes by encouraging preventive health practices that enhance child health outcomes. One of the only evidence-based child maltreatment prevention programs. Similarly, Healthy Families America provides home visitation to low-income mothers and fathers from pregnancy through the child's third birthday. It's designed to ensure that children stay healthy and safe and ready to learn with the goal of increasing healthy pregnancies, improving child health development and readiness, improving parenting confidence, and increasing family connectedness to community and social support. So it's important to understand what services are available in your area, especially for young first-time parents that may not have a lot of social support. Any families that kind of do meet those red flags that we talked about, those risk factors, this is a way to help those risk factors stay risk factors and not become actual patients. So we want to provide families what they need to thrive. And these are two great ways to prevent non-accidental trauma. The other thing, and this is now secondary prevention. So we know that children that sustain serious injury or fatal injury from abuse often have had some minor injury in the past. Like in that Letson study that I presented at the beginning of the talk where the babies had had bruising in the past, we know that a lot of times kids will present for medical care or be seen by a medical provider with some very minor injury that doesn't really require any medical intervention to heal or resolve, but should be an indicator that the child may be at risk of additional injury. So a sentinel injury is a visible or detectable minor injury in a pre-cruising infant. So these very young babies, they're not pulling to stand, they're not walking, but there's really no explanation or the explanation doesn't really make sense is therefore concerning for physical abuse. So injuries are bruises. So any bruise on a young non-mobile infant should warrant consideration of abuse. An intraoral injury, so a frenulum tear, so some kind of bleeding from underneath the lip or underneath the tongue should point us in the direction of being concerned about abuse because these young infants really can't generate the forces necessary to avoid injuries accidentally. And recognition of these injuries can result in prevention of subsequent abusive injuries. So we can literally save children's lives by intervening on these very subtle injuries. And what I mean by intervening is reporting to Children's Services and law enforcement to get partner agencies support to help the family get what they need so they can keep their kids safe. There's a mnemonic for these sentinel injuries, 10-4-FACES-P. This is from Mary Clyde Pierce, who's a pediatric emergency medicine physician in Chicago. And she has validated this mnemonic. So bruising to the trunk, ear, or neck, which spells 10, so trunk, ear, or neck, in any child less than or equal to four years old or bruising in any region on an infant less than four months old is concerning. So older kids that can run and jump and play are going to get bruises, and that's fine. But we expect to see those bruises over bony prominences, forehead, chin, elbows, knees, shins. But if we're seeing bruises to the abdomen, to the back, to the buttocks, those are concerning. Ear bruising is always concerning. It's hard to accidentally fall on your ear. So if we're seeing any kind of pinna bruising or ear bruising, we need to get a very specific history for what caused that. We would not expect it just from a clumsy new walker. Bruising on the neck, it's hard to fall on your neck. It's always concerning. Other injuries, injuries to the frenulum, like I said, that intraoral injury, so upper labial frenulum, lower labial frenulum, frenulum under the tongue, without a clear history in a young child is concerning. Now, as babies learn how to walk and fall, they face plant all the time. An 11-month-old who falls and face plants and ends up with an upper labial frenulum tear is not concerning to me. But a one-month-old with an upper labial frenulum tear who can't fall and face plant, that's concerning that someone has jammed something in their mouth, stuck something in their mouth, like a pacifier or a bottle. You can imagine that could happen out of frustration with a screaming baby. Those are worrisome and need the full workup for abuse. Again, auricular area, so anywhere around the ear. Cheek. Cheeks are pretty soft and squishy and we wouldn't expect bruises there. Any injury around the eyes. Subconjunctival hemorrhage, so any red spots in the white part of the eye or patterned bruising. If it looks like a loop mark or a belt, it probably is from a belt and that's concerning. The recommended workup for any child or non-ambulatory infant with a concerning injury is a full physical exam, so we want to make sure we're getting these babies undressed and look at all of their skin, look in their mouth, look for those oral injuries, look at their ears, photo document any cutaneous findings, so we want to take pictures of any skin injury or any injuries we're seeing. We want neuroimaging on all children less than six months of age, and that's because our neuro exam on these infants just isn't great. They can't do a lot, so if they're unable to do things, it's hard to catch, so we just have a low threshold for getting neuroimaging on kids under six months. Between six and 12 months, I still have a pretty low threshold, and if there's any kind of head or neck injury, so oral injury, bruising to the ear, bruising to the cheek, if there's any kind of altered mental status, seizure activity, we're going to get head imaging. Skeletal survey, again, is a series of about 24 x-rays of each area of the body, including apian lateral views and oblique views of the ribs for any fractures, screening labs for abdominal trauma, ASC, ALT, lipase, and we do the screening labs for abdominal trauma up to age five, skeletal surveys up to age two, psychosocial assessment, so having a social worker, if you have that available to you, meet with the family to talk about what stressors they may have, who's caring for the child, how we can help support the family, and then if we do identify injuries that are concerning for non-accidental trauma, make sure we see all contact children, so any other child or sibling that's living in the same environment needs to be assessed for concerning injuries as well. Then we do the hematologic evaluation, like we talked about, CBC, COAGs, factor levels, platelet function analysis. At our institution, any child with abusive head injury or suspected abusive head injury does get a full hematology consult. We also get MRI of the brain and cervical spine, like I mentioned. We do head CT first and then MRI. We consider doing the whole spine in cases where we think there may be additional injury further down the spine, and we do, as a child abuse team, we do a full child abuse pediatrics consult with a very detailed history of present illness, past medical history and family history to help understand if there's anything on that differential diagnosis that I talked about that we need to think about before diagnosing abusive head trauma. These are many, many references. I know that has been a lot, and I am happy to answer any questions. We're obviously not live. There's my email address and my daughter, who is a tiger, and hopefully will bring a smile to your face after this long presentation. Thank you so much for listening. Please feel free to reach out any time with questions.

abusive head trauma

infants

recognizing abuse

epidemiology

risk factors

anatomy of infants

imaging modalities

dating hemorrhages

differential diagnosis

intracranial injuries

sentinel injuries

prevention strategies