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Assessing Changes in Synaptic Plasticity Using an Awake Closed-Head Injury Model of Mild Traumatic Brain Injury
Published on: January 20, 2023
Initial neurologic presentation in young children sustaining inflicted and unintentional fatal head injuries
Kristy B Arbogast1, Susan S Margulies, Cindy W Christian
1Division of Emergency Medicine, Department of Pediatrics, University of Pennsylvania, Philadelphia, USA. arbogast@email.chop.edu
Insights
Fatal pediatric head injuries show varied presentation. Young children (<24 months) with inflicted injuries are more likely to appear lucid (GCS >12) or have moderate impairment (GCS >7) before death, unlike those from motor vehicle crashes.
Area of Science:
- Pediatric Traumatology
- Neurology
- Forensic Medicine
Background:
- Determining the clinical course of fatal pediatric brain injuries is crucial for legal proceedings, particularly in suspected child abuse cases.
- Understanding whether these injuries cause immediate deterioration or allow for a lucid interval is key to perpetrator identification.
Purpose of the Study:
- To investigate the patterns of neurological presentation upon hospital admission in infants and toddlers who succumb to inflicted versus unintentional head injuries.
- To compare Glasgow Coma Scale (GCS) scores across different injury mechanisms and age groups in fatally injured children.
Main Methods:
- Analysis of data from the Pennsylvania Trauma Outcomes Study (1986-2002) for children under 48 months with fatal head injuries.
- Inclusion criteria specified external-causes-of-injury codes for inflicted injury, falls, and motor vehicle crashes (MVCs), with recorded admission Glasgow Coma Scale (GCS).
- Comparison of GCS scores across injury mechanisms (inflicted, falls, MVCs) and age strata (0-11, 12-23, 24-35, 36-47 months).
Main Results:
- Out of 314 children, 37% had inflicted injuries, 13% falls, and 49% MVCs.
- At admission, 6.8% had a GCS >7, and 1.9% were lucid (GCS >12).
- Children with inflicted injuries were 3 times more likely to present with GCS >7 than those in MVCs (OR: 3.6). This effect was amplified in children <24 months, who were over 10 times more likely to have GCS >7 (OR: 9.36) and overrepresented among lucid patients (5 of 6).
Conclusions:
- Neurologic presentation in fatal pediatric head injuries is dependent on age and injury mechanism.
- Young children (<24 months) with inflicted head trauma are significantly more likely to present with moderate (GCS >7) or lucid (GCS >12) neurological status compared to those with MVCs.
- The observed differences may stem from challenges in assessing consciousness in younger children or distinct biomechanical factors in inflicted trauma.
Background:
It remains unclear if fatal brain injuries in young children are characterized by immediate rapid deterioration or can present after an initial period of lucidity. This issue has legal implications in child abuse, for which understanding the clinical course affects perpetrator identification.
Objective:
To determine patterns of neurologic presentation on hospital admission in infants and toddlers who die of inflicted and unintentional injury.
Design/Methods:
Data on children <48 months of age who sustained a fatal head injury from 1986-2002 were extracted from the Pennsylvania Trauma Outcomes Study. Only those with external-causes-of-injury codes for inflicted injury, falls, and motor vehicle crashes (MVCs) with a recorded Glasgow Coma Scale (GCS) on admission were included. The GCS was compared across mechanisms and age groups (0-11, 12-23, 24-35, and 36-47 months).
Results:
Of the 314 fatally injured children, 37% sustained inflicted injury, 13% sustained a fall, and 49% sustained an MVC. At admission, 6.8% of all children had a GCS score of >7, and 1.9% presented with a GCS score of >12 (lucid). The incidence of admission a GCS score of >7 varied by mechanism. Overall, children with inflicted injury were 3 times more likely to present with a GCS score of >7 than those injured in MVCs (odds ratio [OR]: 3.6; 95% confidence interval [CI]: 1.2-10.3), but incidence of a GCS score of >7 did not differ between inflicted injuries and falls. Similarly, when considering only those children >or=24 months old, a GCS score of >7 did not differ by mechanism. In contrast, in those <24 months old, children who died as a result of inflicted injury were >10 times more likely to have a GCS score of >7 than those who died as a result of a MVC (OR: 9.36; 95% CI: 1.3-80.9).
Conclusions:
The data suggest an age- and mechanism-dependent presentation of neurologic status in children with fatal head injury. Although infrequent, young victims of fatal head trauma may present as lucid (GCS score: >12) before death. Furthermore, children <48 months old sustaining inflicted injury are 3 times more likely to be assessed with a moderate GCS score (>7) than those in MVCs. This effect is amplified in the youngest children (<24 months old): those with inflicted injury were 10 times more likely to present with moderate GCS scores than those in MVCs. In addition, this youngest age group seems to be overrepresented in those who present as lucid (GCS score: >12 [5 of 6]). It is unclear whether these differences are the result of inadequate tests to evaluate consciousness in younger children or differences in biomechanical mechanisms of inflicted trauma.
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