II. Definitions

  1. Abusive Head Trauma of Infancy (previously known as Shaken Baby Syndrome)
    1. Non-accidental injury in infants with diffuse cerebral injury with cerebral edema
    2. Occurs with or without intracerebral bleeding and Retinal Hemorrhages

III. Pathophysiology

  1. High velocity, acceleration-deceleration injury of brain
  2. Predisposing factors in infants
    1. Weak neck Muscles
    2. Large head to body ratio
    3. Incomplete brain Myelination
    4. Low body mass compared with abuser

IV. Epidemiology

  1. Represents up to 50% of deaths secondary to Child Abuse

V. Symptoms

  1. Irritability
  2. Vomiting
  3. Failure to Thrive
  4. Lethargy

VI. Signs

  1. Classic Triad
    1. Cerebral edema
    2. Subdural Hematoma
    3. Retinal Hemorrhage (85% of cases as performed by pediatric ophthalmology)
  2. Other signs
    1. Acute onset Seizure (common)
    2. Altered Mental Status
    3. Typically no other findings on external exam
    4. Fontanels bulging
    5. Altered respiratory pattern
  3. Examine for other signs of related Child Abuse
    1. See Child Abuse
    2. Facial Bruising
    3. Intraoral injuries (e.g. frenulum tears)
    4. Posterior Rib Fractures

VII. Imaging

  1. CT Head
    1. Indicated for Altered Level of Consciousness or neurologic changes (otherwise, obtain MRI Brain)
    2. Intracranial Bleeding (Subdural Hemorrhage, Subarachnoid Hemorrhage, Intraparenchymal Hemorrhage)
    3. Cerebral edema
  2. MRI Brain with diffusion weighted images
    1. Consider instead of CT Head in clinically stable infant without neurologic changes
    2. Hypoxic-ischemic injury (MRI)

VIII. Diagnosis

  1. Most predictive findings of abusive Head Trauma
  2. Apnea
  3. Seizures
  4. Retinal Hemorrhage
  5. Bruising of the head or neck
  6. Rib Fractures
  7. Long bone Fractures

IX. Differential Diagnosis

  1. See Inconsolable Crying in Infants
  2. See Seizure Causes
  3. Falls from height >1.5 meters (~5 feet)
    1. Falls from lower heights are unlikely to cause severe intracranial Trauma

X. Management: Medical stabilization

  1. ABC Management
  2. Evaluate Altered Mental Status
    1. Sepsis evaluation
      1. Urine Culture, Blood Culture, CSF Culture
      2. Empiric Ampicillin and Gentamicin or Cefotaxime
      3. Include HSV coverage if <3 weeks old
    2. Metabolic evaluation
      1. Consider VBG, CBC, basic metabolic panel, ammonia, Magnesium, Phosphorus
      2. Consider urine toxicology screen
  3. Pediatric Ophthalmology Consultation
    1. Fundoscopic Exam for Retinal Hemorrhages (found in 85% of cases)

XI. Course

  1. High mortality rate (as high as 38% of cases)
  2. Surviving infants have severe brain injury

XII. Complications

  1. Death
  2. Blindness
  3. Cerebral Palsy

XIII. References

  1. Bogdanowicz and Ponce (2020) Crit Dec Emerg Med 34(5):25
  2. Vitale (2012) Minerva Pediatr 64(6):641-7 [PubMed]

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