Flashcards in Case 25 Deck (30)
What are key history findings with shaken baby syndrome?
Apnea, neurological depression, difficult home situation
What are key physical exam findings with shaken baby syndrome?
Hypothermic, tachycardic, bradypneic, hypertensive, abnormal neurological exam (poor suck, tense full fontanelle, intermittent crying, decreased tone, inability to fix and follow visually)
What is the differential diagnosis for a patient with shaken baby syndrome?
Meningitis, encephalitis, GERD, closed-head injury (shaken baby), cardiac arrhythmia, respiratory infection
What are the key findings from testing for shaken baby syndrome?
Subdural hematoma on CT and MRI.
What is the epidemiology of shaken baby syndrome?
-10-12 percent of all deaths among children who are victims of child abuse are due to shaken baby syndrome
-Mortality rate is 25 percent and 20-40 percent have poor outcomes due to neurological injury
What is the pathophysiology of shaken baby syndrome?
-Injuries, including close head injury (CHI) and retinal hemorrhages, are due to violent shaking or throwing (with resulting blunt trauma to the head). Bridging vessels tear when infant is shaken - or shaken and thrown - achieving an extreme rotational acceleration force to the brain and diffuse axonal injury to neurons
-Victims of shaken baby syndrome often have no other signs of physical abuse
Presentation/Signs and Symptoms of shaken baby syndrome may include:
-Difficulty to arouse
-Retinal hemorrhages (retinal hemorrhages outside the newborn period are pathognomonic for shaken baby syndrome and are found in 65-90 percent of victims)
Outcomes of shaken baby syndrome:
Increased risk for intellectual disability, developmental delays, motor delay or extreme motor deficit, difficulty with vision (including blindness) and seizures
What is apnea?
Cessation of inspiratory gas flow for 20 sec, or for a shorter period of time if accompanied by bradycardia (heart rate less than 100 bpm), cyanosis or pallor.
What is an apparent life-threatening event (ALTE)?
Not a diagnosis, but a description of an event. Caregiver usually describes apnea, color change, change in tone, and possibly choking or gagging. The observer may think the infant has died. Recovery occurs only after stimulation or resuscitation. Incidence is 0.05-1 percent in population-based studies.
What are potential causes of an ALTE?
1. Central nervous system
What are CNS causes of ALTE?
-Seizures (due to bleeding, infection, structural abnormalities, metabolic disorders, electrolyte imbalances, genetic syndromes, epilepsy)
-Breath-holding spells (pallid or cyanotic)
-Increased intracranial pressure (due to bleed, trauma, tumor, infection)
What are Cardiac causes of ALTE?
-Arrhythmia (bradycardia, long QT syndrome)
-Congenital heart disease (ductal dependent lesions, unrepaired Tetralogy of Fallot)
What are respiratory causes of ALTE?
Respiratory infections (including RSV, pertussis)
What are gastrointestinal causes of ALTE?
-GERD (may cause choking and laryngospasm)
-Swallowing abnormalities/tracheoesophageal fistula (coughing, difficulty with feeds)
What are systemic causes of ALTE?
-Infection (sepsis due to Group B strep, E. coli, or Listeria infection, among others)
-Metabolic disorders (inborn errors of metabolism)
-Intoxication (ingestions of mediations or toxins)
-Infant botulism (exposure to botulinum toxin in soil or honey)
-Environmental exposure (carbon monoxide)
Vital signs in shaken baby syndrome:
1. Tachycardia: Indicates a deterioration in CV status and may be related to sepsis or increased ICP.
2. Respiratory rate: A low respiratory rate suggests CNS depression of respiratory center rather than sepsis or a respiratory infection, which generally present with increased respiratory rate
3. Blood pressure: Elevated blood pressure indicates a response from the CV system either to pain, compensated shock, or increased ICP.
At two months of age a typically developing infant:
1. Can fix and follow easily with his eyes, smiles to voices; has a strong suck and is beginning to coo
2. Lies flexed at hips with good tone and moves all four extremities well
3. Lacks good head control when held upright and cannot roll over
4. When prone, can raise head and move it from side to side
What is on the differential diagnosis for Closed-head injury (CHI)?
Meningitis, Gastroesophageal (GE) reflux, cardiac arrhythmia, respiratory infection
Closed-head injury (CHI):
-Apnea, seizure, and altered neurological status are common in closed-head injuries
-Subdural hematomas result from trauma, either accidental or non-accidental. They can be seen in newborns, particularly after vacuum extraction deliveries. Not seen as result of cardiopulmonary resuscitation or seizures and do not occur from short falls (eg, from a height of less than 4 feet). Subdural hematomas are often found in infants who have experienced violent shaking.
-Meningitis in young infants causes increased ICP and may present with apnea
-Infants are irritable, do not eat well, vomit, and usually have fever greater than 38.2C
-Infants are inconsolable and lethargic
Gastroesophageal (GE) reflux:
-May cause emesis, gagging and aspiration pneumonia
-Seldom presents as apnea without associated symptoms
-Infants with GE reflux would have normal vital signs; may be irritable at times, but would not present with abnormal neurological findings
-Arrhythmia may cause apnea, but would not lead to persistent alteration of mental status
-A long QT syndrome or other arrhythmia may be identified on electrocardiogram
-Respiratory infection may present as apnea; other sx include tachypnea, fever, decreased feeding, and change in activity.
-Respiratory rate may be increased
-Infants may not cough or wheeze initially
Necessary to rule out a bleeding disorder
X-rays of the entire body to evaluate for old or new fractures. Involvement of a pediatric radiologist skilled in interpreting these films can be critical. Skeletal survey findings that raise suspicion for abuse include:
-Fractures or injuries that are inconsistent with reported mechanism of injury and/or the developmental stage or abilities of the child
-Multiple fractures or injuries at different stages of healing
-Fracture of the femur or tibia in a non-walking child
-Posterior rib fractures - frequently associated with shaken baby syndrome due to squeezing of the thorax by the perpetrator's hands during shaking.
-Skull fracture in an infant is also very suspicious for abuse.
CT of the head:
CT is often the first and definitive study to confirm subdural hematomas. Repeat CT should be considered if there is a concern about clinical deterioration.
MRI requires sedation and is not done until the child is stable. MRI is superior to CT for defining ischemia, visualizing shearing injuries to neurons. MRI can act as confirmation for findings identified on a head CT.
Initial emergency management of head trauma:
1. Assess circulation, airway, and breathing (CABs) before beginning resuscitation efforts. The airway should be clear and stable.
2. Assess heart rate, respiratory rate, pulse ox, and strength of pulses
3. If CABs or vital signs are abnormal, immediate intervention is required.
4. Obtain IV access
5. Obtain head CT.
6. Admit to critical care unit
7. Consult neurosurgery/neurology