Factors which raise the index of
suspicion for NAT/child abuse include:
- retinal hemorrhage
- bilateral chronic subdural hematomas in a child < 2 yrs of age
- skull fractures that are multiple or those that associated with intracranial injury
- significant neurological injury with minimal signs of external trauma
- multiple injuries of different ages in multiple locations
Skull fracture in children :
- the parietal bone was the most common site of fracture in both groups (≈ 90%)
- depression of skull fractures was frequently missed clinically due to overlying hematoma
- clinical features in patients with skull fractures did not reliably differentiate child abuse from trauma (retinal hemorrhages (RH) were seen in 1 child abuse and 1 accidental trauma patient: note that RH is more common in “shaken child” syndrome which is not commonly associated with skull fractures)
- 3 characteristics more frequently seen after child abuse than after other trauma:
a) multiple fractures
b) bilateral fractures
c) fractures that cross sutures
Differential diagnosis of etiologies of retinal hemorrhage:
- child abuse (including “shaken baby syndrome,” see above)
- benign subdural effusion in infants
- acute high altitude sickness
- acute increase in ICP: e.g., with a severe seizure (may be similar to Purtscher’s retinopathy—see below)
- Purtscher’s retinopathy: loss of vision following major trauma (chest crush injuries, airbag deployment…), pancreatitis, childbirth or renal failure, among others. Posterior pole ischemia with cotton-wool exudates and hemorrhages around the optic disc due to microemboli of possibly fat, air, fibrin clots, complement-mediated aggregates, or platelet clumps. No known treatment
Prevalent of NAT / child abuse :
At least 10% of children < 10 yrs of age that are brought to E/R with alleged accidents are victims of NAT.
The incidence of accidental head trauma of significant consequence below age 3 is low, whereas this is the age group in which battering (abuse) is highest
What is is the most common cause of death or
disability in childhood ?
TBI
WHat are the mechanisms of TBI in children ?
The main mechanisms of paediatric TBI are dependent on age.
* In those under 2 years, non- accidental head injuries (NAI) and ground
level falls are the most common.
* From 2 to 4 years, falls predominate.
* Between age 4 and teenage years, falls or road traffic collisions
(RTC) are the most common.
* In teenagers, RTCs are the main cause of TBI.
What is the epidemiology of spine fractures in children ?
- Paediatric spine fractures account for a minority (1– 3%) of all
paediatric fractures. - Around 60% are cervical spine injuries, and while only 3% of these will present with neurologic deficits, spinalcord injury (SCI) in children remains a catastrophic event.
- In children under the age of 8 years, as many as 87% of injuries
occur at C3 or above. - Injuries below C3 are more common in older children with an adult pattern of injury.
- With regards to age the commonest types of fracture in the very young are C1 ring and C2 (Hangman) fractures, while odontoid fractures are evenly distributed across all ages. Lumbar fractures occur in the older age group.
Anatomical and physiological differences unique to the paediatric
population ?
- disproportionately large size of the head
- weak neck musculature in neonates and infants which places
them at an increased risk from rotational and acceleration/ deceleration
injuries. - greater elasticity of bone
- wide subarachnoid spaces,
- high water content in the brain
- viscoelastic properties which increase the likelihood of a diffuse axonal
injury.
How does ICP vary with age ?
Intracranial pressure (ICP) varies with age.
In infants and young children, the normal ICP is under 10 mmHg.
In the older child and adult, the normal ICP is 15 mmHg.
How does CBF vary with age ?
Cerebral blood flow (CBF) also shows age- related variation:
* in infants it is 40 ml/ 100 g/ min,
* children 75– 110 ml/ 100 g/ min
* adolescents, like adults 50 ml/ 100 g/ min.
In children, propofol has been associated with :
metabolic acidosis and high lipid levels.
–> Moins utilisé que chez l’adulte
What is the mechanism of growing skull fractures ?
In addition to the skull fracture, the underlying adherent dura and arachnoid are torn and widen over time due to the cerebral pulsations and growing brain, resulting in herniation of the cerebrum through the dural and arachnoid tear.
In paediatric patients with a severe TBI , which drug is used to minimize the incidence of early post- traumatic seizures ?
Phenytoin is more commonly used in paediatric patients with a
severe TBI than in adult patients to minimize the incidence of early
post- traumatic seizures. Antiepileptic medication is usually given
for a 1- week course. Early seizures are much more common in
young children and become less prevalent in older children. Early
seizures in children are poorer predictors of post- traumatic epilepsy
than in adults.
What is the epidemiology of growing skull fractures ?
Half of children affected are under 1 year old and 90% are under
3 years old.
How should children be monitored for growing skull fractures ?
Children with a linear fracture aged less than 3 should be assessed
clinically 6 weeks postinjury to look for growing fractures.
