Non-Accidental Trauma: A Case of Seizing and Limp Infant in the PICU

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists.I'm Pradip Kamat coming to you from Children’s Healthcare of Atlanta/Emory University School of Medicine and I'm Rahul Damania from Cleveland Clinic Children’s Hospital. We are two Pediatric ICU physicians passionate about all things MED-ED in the PICU. PICU Doc on Call focuses on interesting PICU cases & management in the acute care pediatric setting so let’s get into our episode.Here's the case of a 12-week-old girl old who is limp and seizing presented by Rahul.Chief Complaint: A 12-week-old previously healthy female infant was found limp in her crib and developed generalized tonic-clonic seizures on the way to the hospital.History of Present Illness: The mother returned from work on a Saturday to find her daughter unresponsive in her crib. The infant had been left in the care of her mother's boyfriend, who stated that the daughter had been sleeping all day and had a small spit up. As the patient continued to have low appetite throughout the day and continued to be unresponsive in her crib, mother called EMS to bring her to the emergency department. En route, the patient had tonic movement that did not resolve with intranasal benzodiazepines.ED Course: The infant presents to the ED being masked. Upon arrival at the ED, the infant was in respiratory distress, with a heart rate of 190 beats per minute, respiratory rate of 50 breaths per minute, and oxygen saturation of 85% with bagging. She was intubated for seizure control upon arrival at the ED. Physical examination in the ED revealed bruising on the right neck region but was otherwise unremarkable. A non-contrast head CT showed no acute intracranial abnormalities. The initial diagnostic workup revealed normal CBC, mildly elevated hepatic enzymes, and pancreatic enzymes which were within normal limits. The blood gas showed metabolic acidemia with PCO2 in the 60s.Admission to PICU: Upon admission to the PICU, neurosurgery and trauma teams were consulted. A skeletal survey and ophthalmology consult for a fundoscopic examination were ordered, as there were concerns of non-accidental trauma. Further investigation is underway to determine the cause of the infant's condition.To summarize key elements from this case, this patient has:Patient left with mother's boyfriendInfant found limp and had seizures requiring intubationNeck bruiseAll of these bring up a concern for Non-Accidental Trauma (NAT) the topic of our discussion.Let's start with a short multiple-choice question:Which imaging modality is the most appropriate for establishing a diagnosis of abusive head trauma (AHT) in a 12-week-old infant with an open fontanelle on the exam?A. CT scan of the brain without contrast B. MRI of the brain without contrast C. Skull X-ray D. Doppler ultrasound of the headRahul, the correct answer is A. Though ultrasound may be less invasive, the penumbra effect in cranial ultrasound makes it hard to visualize the parts of the brain located just under the convexity of the skull such as a subdural hematoma. Regardless of the small radiation risk, noncontrast head CT is the method of first choice in imaging traumatic brain injury for both fractures and intracranial pathology. CT scan has a short scan time and is widely available. Non-contrast-enhanced CT has a high sensitivity for detecting acute hemorrhage and midline shift.Thanks for that detailed explanation, I agree CT scan is a valuable diagnostic tool that provides detailed recon images for understanding the mechanism of fractures.What about the role of MRI in diagnosing abusive head trauma?MRI has lower sensitivity for acute hemorrhage compared to a CT scan and takes longer to acquire images, which may require anesthesia to provide immobility. However, a systematic review by Kemp and colleagues published in 2009 (Clin Radiol. 2009;64:473–483) reported that MRI performed following an abnormal CT scan in children with abusive head trauma revealed new information in at least 25% of cases, such as cranial shearing, ischemia, infarction, parenchymal hemorrhages, and cerebral contusions. It's important to note that the role of MRI in cases where the initial CT scan is normal is unclear. Additionally, MRI is more accurate in evaluating time points in certain lesions, making it a valuable tool in the diagnosis and management of abusive head trauma in pediatric patients.💡 In summary, a CT scan is the preferred imaging modality for assessing traumatic brain injury in cases of suspected abusive head trauma, while cranial ultrasonography may be useful in some cases. It's important to remember that interpretation of imaging in cases of suspected AHT requires complete clinical information.Alright, Pradip, very interesting that our initial CT scan did not show any signs of bleeding, once the patient became more stable in the PICU, what did the skeletal survey show?The skeletal survey showed multiple fractures of varying ages, including multiple rib fractures, and an unhealed clavicle fracture. The team closely monitored the infant's condition and initiated treatment as necessary.Rahul, can you give us a brief introduction to non-accidental trauma in the pediatric ICU?Child abuse, also known as battered child syndrome, can take multiple forms such as physical abuse, sexual abuse, neglect, psychological maltreatment, general neglect, and medical neglect. Today, we'll focus on physical abuse that intensivists may encounter in their practice.In the Pediatric Intensive Care Unit (PICU), the team is more likely to see cases of abusive head trauma, abdominal trauma, burns, complex fractures, and rib fractures, which may be identified when a chest radiograph is obtained after intubation. These are serious and often life-threatening conditions that require a multidisciplinary team approach and specialized care.💡 To summarize, physical abuse in children, particularly infants, can present with nonspecific symptoms and signs, such as vomiting or apnea. This highlights the importance of considering the possibility of abusive head trauma in such cases.Please also remember that the term, abusive head trauma replaced "shaken baby syndrome," and it's a serious and often life-threatening condition that requires prompt recognition and intervention. Therefore, it's essential for us as intensivists to be familiar with the various forms of physical abuse, including abusive head trauma, and work closely with other specialists to ensure that the patient receives the best possible care.Pradip, let’s dive deep into abusive head trauma, do you mind talking about the spectrum of symptoms we can see?Abusive head trauma is the most common presentation of child abuse in the PICU: As seen in our case presentation infants may present with apnea, altered mental status, loss of consciousness, limpness, vomiting, seizure, poor feeding, or have subtle signs like swelling of the scalp.In a third of abusive head trauma cases, the infant was seen by another physician in the preceding 2-3 weeks. The diagnosis requires a high level of suspicion especially in an infant with fractures, ecchymosis, and failure to gain weight. AHT is the leading cause of fatal injuries in children.📖 AHT is responsible for 53% of all severe TBI cases in infants.What is the pathophysiology of injury in abusive head trauma?The pathophysiology of abusive head trauma in infants is complex and multifactorial. The skull of a neonate is soft and malleable, which allows forces applied to the skull to propagate directly to the brain tissue. Additionally, the higher water content and lack of myelination make the brain more susceptible to shearing forces, which occur with shaking. Infants have a larger head in...