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Restricting the time of injury in fatal inflicted head injuries
K Y Willman1, D E Bank, M Senac
1Center for Child Protection, Children's Hospital and Health Center, San Diego, CA, USA.
Insights
Fatal pediatric head injuries typically show severe symptoms immediately. A reported lucid interval in fatal head trauma, unless an epidural hematoma, suggests inflicted injury and aids investigations of child abuse.
Area of Science:
- Pediatric Traumatology
- Forensic Pathology
- Neurology
Background:
- Understanding the clinical course of fatal pediatric head injuries is crucial for accurate injury time estimation.
- This is particularly important in cases of suspected nonaccidental trauma where histories may be unclear.
Observation:
- A retrospective review of 95 fatal pediatric head injury cases was conducted.
- Cases with a Glasgow Coma Scale (GCS) of 14-15 or reported lucid intervals were specifically analyzed.
- Brain swelling was detectable on CT scans as early as 1 hour and 17 minutes post-injury.
Findings:
- Only one case with a true lucid interval (epidural hematoma) was identified.
- Fatal head injuries, excluding epidural hematomas, rarely present with a lucid interval.
- Brain swelling on CT scans was not a reliable indicator for restricting the time of injury.
Implications:
- A purported lucid interval in fatal head injury cases without epidural hematoma likely indicates inflicted injury.
- This finding aids in the investigation of child abuse and trauma.
- The time of injury can be more accurately determined by establishing the last period of wellness.
Objective:
To determine the normal clinical progression of fatal head injuries in children. Such information can then be used to estimate the time of injury in cases with obscure histories and will thus aid investigations of nonaccidental trauma.
Method:
A retrospective chart review design was used. One hundred and thirty eight accidental fatalities involving head injury were identified and 95 of these were used as the study group. Details of the cases were reviewed and cases in which a child either had a Glasgow Coma Scale (GCS) of 14-15 or was described as having a "lucid interval" or as being "conscious" were further studied.
Results:
One "lucid interval" case was identified. This case involved an epidural hematoma. Three other cases that partially met the criteria for a lucid interval were also identified; one of these cases did not meet the criteria for inclusion in the study group. Review of head CTs revealed that brain swelling could be detected as early as 1 hour and 17 minutes post injury.
Conclusions:
The children studied were in obvious serious medical condition from the time of injury until death. If a history purports a lucid interval in a fatal head injury case that does not involve an epidural hematoma, that history is likely false and the injury is likely inflicted. The time of most fatal head injury events can be restricted to the time period after the last confirmed period of wellness for the child. In addition, the presence of brain swelling on a head CT scan is not helpful in restricting the time of injury.