Abusive head trauma — branching viva

Opening

Examiner: A three-month-old infant arrives in the emergency department with altered responsiveness and a seizure. The CT shows a thin inter-hemispheric subdural bleed and cerebral oedema. The father says he rolled off a low bed an hour ago. How do you frame this? ^[1]

Candidate: I would treat this as a critically brain-injured infant and as suspected abusive head trauma in parallel. I would resuscitate the airway, breathing and circulation and treat the seizures and raised intracranial pressure with neuroprotection and urgent neurosurgical and intensive-care input, while informing my consultant and the child-protection team from the first minute. The history of a short fall does not fit a thin inter-hemispheric subdural bleed with cerebral oedema, so I would arrange the full inflicted-injury workup and keep the child safe while it completes. ^[1]

Branch 1 — building the probability

Examiner: What makes you think this is inflicted rather than accidental? ^[2]

Candidate: Four things raise the probability. First, the history is developmentally implausible — a three-month-old does not reliably roll, and a short fall onto a flat surface rarely causes cerebral oedema. Second, the injury pattern of an inter-hemispheric subdural bleed with oedema is characteristic of abusive rather than accidental head trauma. Third, I would look for retinal haemorrhages, skeletal injury and cutaneous injury across the other domains. Fourth, the Maguire pooled analysis and the Piteau radiographic systematic review define the discriminating features, and the PediBIRN screen — here, suspected seizure, severe head injury and, if present, ear or torso bruising — flags likely AHT. ^{[2] [3]}