Abusive head trauma — formative SAQs

SAQ 1 (10 marks)

A four-month-old boy is brought to the emergency department by his mother, who says he "rolled off the bed" onto a carpeted floor about an hour ago. He has been irritable and vomiting, and is now limp and grunting. On examination his GCS is 11, his anterior fontanelle is full, and he has two small bruises on his left ear and trunk. A non-contrast CT head shows a thin inter-hemispheric subdural haemorrhage and diffuse cerebral oedema. There is no history of seizures, no bleeding disorder, and no prior medical history. ^{[1] [4]}

1. Give your immediate resuscitation and safeguarding actions, and the further investigations you would arrange. (4) ^[1]
2. State the features of this presentation that increase the probability of abusive head trauma, naming the relevant evidence. (3) ^{[3] [4]}
3. Describe how you would manage the siblings and household contacts, and what you would tell the family. (3) ^[5]

Model answer — SAQ 1

(1) Resuscitation and safeguarding (4). Resuscitate the brain: protect the airway, breathing and circulation; treat seizures and raised intracranial pressure with neuroprotection, head positioning and urgent neurosurgical and intensive-care input, guarding against hypoxia, hypotension and hypoglycaemia. Run safeguarding from minute zero: inform the consultant and the child-protection team, do not discharge the child or allow him to return to the care of a suspected perpetrator, preserve clothing and evidence, and make the mandatory report. Arrange MRI brain within days to map and date the injury, a full skeletal survey to protocol with a repeat at about eleven to fourteen days, dilated ophthalmology with imaging, and a laboratory occult-injury screen (coagulation, full blood count, vitamin-K history, liver and pancreatic markers, urinalysis, and infection and toxicology screens). Document every finding and every history account contemporaneously. ^{[1] [2]}

(2) Features raising the probability (3). The developmentally implausible history — a four-month-old cannot reliably roll, and a short fall onto carpet does not cause a thin inter-hemispheric subdural bleed with cerebral oedema; the encephalopathy out of proportion to the offered mechanism; the bruising on the ear and trunk in a non-mobile infant (TEN-4); and the injury pattern of inter-hemispheric subdural haemorrhage with oedema. The Maguire pooled analysis and the Piteau radiographic systematic review define the discriminating features, and the PediBIRN screen (here, suspected encephalopathy, severe head injury and ear/torso bruising) flags likely AHT. ^{[3] [4]}

(3) Contacts and family (3). Screen siblings and household contacts for occult injury through the child-protection team — history, examination, and imaging as age-appropriate — because the Lindberg study showed a real prevalence of abusive injuries in contacts of physically abused children. Treat the family with respect and without accusation, explaining that the role of the team is to investigate and protect, keep the child safe, and complete a careful, documented assessment; do not disclose conclusions before the multidisciplinary case conference. ^[5]