Pediatrics · Year 3 · from Pediatrics
Case 1: Abusive Head Trauma
Patient Demographics
- Age: 4-month-old male
- Sex: Male
Chief Complaint
"He's been really fussy and not eating well."
History of Present Illness
A 4-month-old male infant is brought to the emergency department by his mother and her boyfriend because the baby has been irritable and feeding poorly for the past day. The mother reports the baby has been "different" since yesterday evening, crying more than usual and not wanting to take his bottle. She denies any trauma, fever, vomiting, diarrhea, or other symptoms. When specifically asked, the boyfriend mentions he was caring for the baby yesterday afternoon while the mother was at work, and the baby was "fine" but "cried a lot." The infant was born full-term without complications. There is no significant past medical history.
Physical Examination
- Vital Signs: Temperature 36.9C, HR 145 bpm, RR 32/min, BP 85/50 mmHg
- General: Lethargic infant, intermittently irritable, weak cry
- HEENT: Anterior fontanelle full and tense; no external head trauma visible
- Eyes: Left retinal hemorrhages noted on fundoscopic examination (dilated exam pending)
- Chest: No external bruising; lungs clear
- Cardiovascular: Tachycardic, regular rhythm
- Abdomen: Soft, non-tender
- Extremities: No swelling or deformity; no bruising
- Skin: No visible bruises or marks
- Neurologic: Lethargic, decreased tone, poor suck reflex, sunset eyes noted
Imaging and Laboratory Findings
- CT head: Bilateral subdural hematomas of varying ages (acute and subacute); mild cerebral edema
- Dilated fundoscopic examination: Extensive multilayered retinal hemorrhages bilaterally, extending to the ora serrata
- Skeletal survey: Healing posterior rib fractures (right ribs 6-8, approximately 2-3 weeks old); acute classic metaphyseal lesion of left distal tibia
- CBC: Hemoglobin 9.8 g/dL
- Coagulation studies: PT, PTT, fibrinogen, platelets - all normal
Diagnosis
Abusive head trauma (previously termed shaken baby syndrome)
Clinical Reasoning
This infant presents with the classic triad of abusive head trauma: (1) subdural hematomas of varying ages, (2) extensive multilayered retinal hemorrhages, and (3) encephalopathy (lethargy, poor feeding, irritability). The absence of external trauma is common in abusive head trauma. The skeletal survey reveals highly specific injuries: posterior rib fractures (from squeezing the chest during shaking) and a classic metaphyseal lesion (from shearing forces across the growth plate). Multiple injuries of different ages indicate repeated trauma. The normal coagulation studies exclude bleeding disorders. The history of non-specific symptoms without explanation for severe intracranial injury, combined with the boyfriend being the sole caregiver during the time symptoms began, raises significant concern.
Management
- Medical stabilization: ICU admission, neurosurgery consultation for ICP monitoring/management
- Seizure prophylaxis: Levetiracetam or phenobarbital if clinical or subclinical seizures
- Report to Child Protective Services: Mandatory; contact CPS and law enforcement immediately
- Full skeletal survey: Already completed; follow-up skeletal survey in 2 weeks to detect additional healing fractures
- Documentation: Detailed, objective documentation of all findings with photographs
- Social work involvement: Complete social assessment of the family
- Sibling evaluation: Any other children in the home should undergo medical evaluation
- Safety planning: Infant should not be discharged to the care of the suspected perpetrator
Clinical Image
Image Description: Axial CT scan of the head demonstrating bilateral subdural hematomas (mixed density suggesting different ages) characteristic of abusive head trauma in an infant.
Source: Radiopaedia URL: https://radiopaedia.org/cases/abusive-head-trauma-1 License: CC BY-NC-SA 3.0