Accidental vs. Abusive Head Trauma in Infancy: Is Revival Shaking the Missing Link?

IF 0.6 Q3 MEDICINE, GENERAL & INTERNAL
Mark J. Greenwald
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The baby appeared to have made a full neurologic recovery within days of injury.</p><p>The ophthalmologist's description, to my reading of the handwritten note reproduced in of the report, includes the following observations: “… Large macular intraretinal (? preretinal) hemorrhage both eyes across macula. Almost all intraretinal dot blot + preretinal. Nil [illegible] flame hemorrhages seen. … (A) Lack of superficial flame hemorrhages indicates insult/injury likely to be ≥ 1 week ago. (B) Need to document resolution of hemorrhages to better confirm timing of injury.” It is further noted, with an arrow pointing to the structure in question (described in text as “a retinal fold along the inferior arcade of the right eye”), “? fold ? older schisis.”</p><p>In the text, it is subsequently stated “The IRHs resolved slowly, still present 1 week later,” followed by the comment “This indicates that the RHs occurred around the time of the fall and, given the changes to the state of the infant caused by the fall, it is reasonable to attribute the RHs to the fall.” While not directly contradicted by the facts as presented, I do not believe this conclusion is warranted based on the reported findings and their evolution, particularly given the history of a possible seizure weeks and a prior fall days before the documented incident, and head images that appear to be consistent with the chronic presence of at least a portion of the extra-axial fluid collections they demonstrate. Acuteness of RH onset would in fact have been better supported by disappearance of most of them after 1 week, rather than the observed persistence [<span>2</span>]. The authors have not, in my opinion, adequately established either the very recent onset of extensive retinal hemorrhage, or the presence of a retinal fold typical of acute traumatic retinoschisis [<span>3, 4</span>].</p><p>A further concern, which relates more generally to the question of whether short falls can duplicate the clinicopathologic picture that is widely ascribed to abusive head trauma: We are given no information about what may have transpired immediately after the recorded incident. The video ends abruptly with the infant lying still on the floor. There is no indication of the immediate response of his caregivers. The mother “collected” him after an unspecified interval, finding him “floppy” and “unresponsive.” There was more than sufficient opportunity and reason to suspect the baby may have been subjected to “revival shaking” at the hands of one of the adults in whose care he remained until delivered to a hospital by his mother [<span>5</span>].</p><p>Since the earliest descriptions of shaken baby syndrome, the literature has been replete with histories of shaking done by a caregiver intent on helping a baby found unconscious or in acute distress [<span>3, 6, 7</span>]. A recent comprehensive review of confessions in presumed shaking injury cases confirmed that the second most commonly described scenario was attempted revival or relief from distress (31%, vs. incessant crying in 60%) [<span>8</span>]. Despite their pervasiveness and persistence, such narratives have, especially in more recent years, tended to be dismissed as fabricated or irrelevant [<span>9</span>]. There is, however, no sound empirical basis for this view.</p><p>All available evidence is in fact consistent with the possibility that a nearby adult can, with only good intentions, administer a succession of brisk shakes to an infant who has been momentarily incapacitated (by a blow to the head, choking, seizure, apneic episode, or other ALTE-type event), which will cause the “triad” associated with many cases of abusive head trauma: retinal hemorrhage, intracranial hemorrhage, and encephalopathy (now regarded by some as a consequence of anoxic brain damage caused by apnea secondary to less-than-extreme kinking or stretching of the lower brainstem or cervical cord/nerve roots) [<span>10, 11</span>].</p><p>Furthermore, the possibility cannot be discounted that brief shaking, in a moment of panic or confusion, may fail to be reported or even recalled (as an action distinct from inexpertly performed CPR) by the perpetrator or eyewitnesses (Caffey, in his seminal 1972 paper, described “traumatic amnesia” on the part of those involved toward such impulsive and perhaps instinctual behavior [<span>12</span>].). This could truly be the “missing link” that has long blurred the boundary between accidental and inflicted head injuries in infancy.</p><p>It would be of enormous importance if there were additional video in this case that shows a caregiver shaking the baby in an attempt at revival. Presuming such is not the case, I believe that for this or any short fall in infancy, or other apparently minor head trauma, to be conclusively identified as the cause of the AHT-linked triad (or two of its components), there must be continuous video documentation from the moment of injury until transfer to the care of EMS or other professional support, to exclude the possibility that the infant was shaken in the course of innocent but inappropriate resuscitation efforts.</p><p>The authors' contribution to the knowledge foundation of infant head trauma is welcome, but their work as presented does little to clarify the pathogenesis of ocular or cerebral hemorrhage in victims.</p><p><b>Mark J. 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引用次数: 0

Abstract

I wish to comment on the recent case report from Brook, Squier, and Mack [1], which describes an infant who was found to have bilateral subdural hemorrhage and extensive bilateral retinal hemorrhage (RH) after a short fall with occipital impact, which was captured on surveillance video. The authors attribute all of the hemorrhagic findings to the fall, which occurred less than 24 h prior to fundus examination and CT imaging. RHs were documented with a detailed description including drawings made by the examining ophthalmologist. The baby appeared to have made a full neurologic recovery within days of injury.

The ophthalmologist's description, to my reading of the handwritten note reproduced in of the report, includes the following observations: “… Large macular intraretinal (? preretinal) hemorrhage both eyes across macula. Almost all intraretinal dot blot + preretinal. Nil [illegible] flame hemorrhages seen. … (A) Lack of superficial flame hemorrhages indicates insult/injury likely to be ≥ 1 week ago. (B) Need to document resolution of hemorrhages to better confirm timing of injury.” It is further noted, with an arrow pointing to the structure in question (described in text as “a retinal fold along the inferior arcade of the right eye”), “? fold ? older schisis.”

In the text, it is subsequently stated “The IRHs resolved slowly, still present 1 week later,” followed by the comment “This indicates that the RHs occurred around the time of the fall and, given the changes to the state of the infant caused by the fall, it is reasonable to attribute the RHs to the fall.” While not directly contradicted by the facts as presented, I do not believe this conclusion is warranted based on the reported findings and their evolution, particularly given the history of a possible seizure weeks and a prior fall days before the documented incident, and head images that appear to be consistent with the chronic presence of at least a portion of the extra-axial fluid collections they demonstrate. Acuteness of RH onset would in fact have been better supported by disappearance of most of them after 1 week, rather than the observed persistence [2]. The authors have not, in my opinion, adequately established either the very recent onset of extensive retinal hemorrhage, or the presence of a retinal fold typical of acute traumatic retinoschisis [3, 4].

A further concern, which relates more generally to the question of whether short falls can duplicate the clinicopathologic picture that is widely ascribed to abusive head trauma: We are given no information about what may have transpired immediately after the recorded incident. The video ends abruptly with the infant lying still on the floor. There is no indication of the immediate response of his caregivers. The mother “collected” him after an unspecified interval, finding him “floppy” and “unresponsive.” There was more than sufficient opportunity and reason to suspect the baby may have been subjected to “revival shaking” at the hands of one of the adults in whose care he remained until delivered to a hospital by his mother [5].

Since the earliest descriptions of shaken baby syndrome, the literature has been replete with histories of shaking done by a caregiver intent on helping a baby found unconscious or in acute distress [3, 6, 7]. A recent comprehensive review of confessions in presumed shaking injury cases confirmed that the second most commonly described scenario was attempted revival or relief from distress (31%, vs. incessant crying in 60%) [8]. Despite their pervasiveness and persistence, such narratives have, especially in more recent years, tended to be dismissed as fabricated or irrelevant [9]. There is, however, no sound empirical basis for this view.

All available evidence is in fact consistent with the possibility that a nearby adult can, with only good intentions, administer a succession of brisk shakes to an infant who has been momentarily incapacitated (by a blow to the head, choking, seizure, apneic episode, or other ALTE-type event), which will cause the “triad” associated with many cases of abusive head trauma: retinal hemorrhage, intracranial hemorrhage, and encephalopathy (now regarded by some as a consequence of anoxic brain damage caused by apnea secondary to less-than-extreme kinking or stretching of the lower brainstem or cervical cord/nerve roots) [10, 11].

Furthermore, the possibility cannot be discounted that brief shaking, in a moment of panic or confusion, may fail to be reported or even recalled (as an action distinct from inexpertly performed CPR) by the perpetrator or eyewitnesses (Caffey, in his seminal 1972 paper, described “traumatic amnesia” on the part of those involved toward such impulsive and perhaps instinctual behavior [12].). This could truly be the “missing link” that has long blurred the boundary between accidental and inflicted head injuries in infancy.

It would be of enormous importance if there were additional video in this case that shows a caregiver shaking the baby in an attempt at revival. Presuming such is not the case, I believe that for this or any short fall in infancy, or other apparently minor head trauma, to be conclusively identified as the cause of the AHT-linked triad (or two of its components), there must be continuous video documentation from the moment of injury until transfer to the care of EMS or other professional support, to exclude the possibility that the infant was shaken in the course of innocent but inappropriate resuscitation efforts.

The authors' contribution to the knowledge foundation of infant head trauma is welcome, but their work as presented does little to clarify the pathogenesis of ocular or cerebral hemorrhage in victims.

Mark J. Greenwald: conceptualization, writing – original draft, writing – review and editing.

婴儿期意外与虐待性头部创伤:复苏是否撼动了缺失的环节?
我想对Brook, Squier和Mack b[1]最近的病例报告发表评论,该报告描述了一名婴儿在短暂跌倒后发现双侧硬膜下出血和广泛的双侧视网膜出血(RH),并伴有枕部撞击,这是监控视频拍摄的。作者将所有出血发现归因于跌倒,发生在眼底检查和CT成像前不到24小时。RHs记录有详细的描述,包括检查眼科医生绘制的图纸。这名婴儿似乎在受伤后几天内就完全恢复了神经系统。在我阅读报告中复制的手写笔记时,眼科医生的描述包括以下观察结果:“……视网膜内大面积黄斑(?视网膜前)双眼黄斑处出血。几乎全部为视网膜内斑点斑点+视网膜前斑点。无[听不清]火焰出血。(A)缺乏表面火焰性出血表明可能在≥1周前受到侮辱/伤害。(B)需要记录出血的消退,以更好地确定损伤的时间。进一步指出,用箭头指向有问题的结构(在文本中描述为“沿着右眼下拱廊的视网膜褶皱”),“?折叠?老schisis。”在文本中,随后声明“RHs缓慢消退,一周后仍然存在”,然后评论“这表明RHs发生在跌倒前后,并且考虑到跌倒导致婴儿状态的变化,将RHs归因于跌倒是合理的。”虽然与所提出的事实没有直接矛盾,但我不相信根据所报告的发现及其演变,特别是考虑到在记录的事件发生前几周可能发生癫痫发作的历史和先前的跌倒天数,以及头部图像似乎与至少部分轴外积液的长期存在相一致。事实上,大多数RH在1周后消失,而不是观察到的持续性bb0,更能支持RH发作的急性性。在我看来,作者没有充分确定最近出现的大面积视网膜出血,也没有充分确定急性创伤性视网膜裂的典型视网膜褶皱的存在[3,4]。另一个更普遍的问题是,短跌落是否可以复制被广泛认为是虐待性头部创伤的临床病理图像:我们没有得到关于记录事件后可能立即发生的信息。视频突然结束,婴儿一动不动地躺在地板上。没有迹象表明他的看护人立即做出了反应。过了一段时间后,母亲“接住”了他,发现他“软绵绵的”,“没有反应”。有充分的机会和理由怀疑,婴儿可能受到其中一名成年人的“复活摇晃”,他一直由这名成年人照顾,直到他的母亲将他送到医院。自从最早对摇晃婴儿综合症的描述以来,文献中一直充斥着看护人为了帮助发现无意识或处于急性痛苦中的婴儿而进行摇晃的历史[3,6,7]。最近一项对被推测为摇晃伤案例的供词的综合研究证实,第二常见的描述场景是试图复活或从痛苦中解脱出来(31%,而持续哭泣的比例为60%)。尽管这些故事无处不在、经久不衰,但尤其是近年来,它们往往被视为捏造或无关紧要的废话而不予理会。然而,这种观点没有可靠的经验基础。事实上,所有现有的证据都表明,附近的成年人可以出于良好的意图,对暂时丧失行为能力的婴儿(头部受到打击、窒息、癫痫发作、呼吸暂停发作或其他alt -type事件)进行连续的快速摇晃,这将导致与许多虐待性头部创伤病例相关的“三联症”:视网膜出血、颅内出血和脑病(现在一些人认为这是由呼吸暂停引起的缺氧脑损伤的结果,继发于脑干下部或颈髓/神经根的轻度扭结或拉伸)[10,11]。此外,不能忽视的可能性是,在恐慌或困惑的时刻,短暂的摇晃可能不会被肇事者或目击者报告,甚至回忆不起来(作为一种不同于不熟练实施的心肺复苏术的行为)(卡菲,在他1972年的开创性论文中,描述了那些涉及这种冲动和本能行为的人的“创伤性健忘症”)。这可能真的是“缺失的一环”,长期以来,它模糊了婴儿时期意外和人为头部受伤之间的界限。 如果在这个案例中有额外的视频显示看护人摇晃婴儿试图使其苏醒,那将是非常重要的。假设情况并非如此,我认为,对于这种情况或任何婴儿短暂跌倒,或其他明显轻微的头部创伤,要最终确定为与aht相关的三联症(或其两个组成部分)的原因,必须有从受伤时刻到转移到EMS或其他专业支持的连续视频记录,以排除婴儿在无辜但不适当的复苏努力过程中被摇晃的可能性。作者对婴儿头部创伤的知识基础的贡献是受欢迎的,但是他们的工作并没有阐明受害者的眼或脑出血的发病机制。马克·j·格林沃尔德:构思,写作-原稿,写作-审查和编辑。
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来源期刊
Clinical Case Reports
Clinical Case Reports MEDICINE, GENERAL & INTERNAL-
自引率
14.30%
发文量
1268
审稿时长
13 weeks
期刊介绍: Clinical Case Reports is different from other case report journals. Our aim is to directly improve global health and increase clinical understanding using case reports to convey important best practice information. We welcome case reports from all areas of Medicine, Nursing, Dentistry, and Veterinary Science and may include: -Any clinical case or procedure which illustrates an important best practice teaching message -Any clinical case or procedure which illustrates the appropriate use of an important clinical guideline or systematic review. As well as: -The management of novel or very uncommon diseases -A common disease presenting in an uncommon way -An uncommon disease masquerading as something more common -Cases which expand understanding of disease pathogenesis -Cases where the teaching point is based on an error -Cases which allow us to re-think established medical lore -Unreported adverse effects of interventions (drug, procedural, or other).
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