In a recent study, Initial Neurologic Presentation in Young Children Sustaining Inflicted and Unintentional Fatal Head Injuries, Drs. Arbogast, Margulies, and Christian examine the possibility that a child could sustain a fatal head injury and still present as lucid to hospital clinicians prior to death1. They concluded that, while infrequent, young victims of fatal head injuries may present as lucid before death. Even when there is a period of lucidity, children generally exhibit other clinical symptoms of head trauma such as vomiting, irritability, or issues with alertness.
The researchers looked at cases involving 314 children under the age of four who sustained fatal head injuries. The data were taken from the Pennsylvania Trauma Outcomes Study, a statewide registry that collects data from all 26 accredited trauma centers throughout Pennsylvania. The authors only utilized data related to falls, motor vehicles crashes, and inflicted injury. Of the 314 children studied, 13% sustained falls, 49% were involved in motor vehicle crashes, and 37% sustained an inflicted injury.
The Glasgow Coma Scale (GCS) was used to determine the children’s lucidity. A GCS score of 3-7 indicated poor neurological status; a GCS score of 8-12 indicated moderate neurological status; a GCS score of 13-15 indicated a good or lucid neurological status.
The GCS scores were reviewed by mechanism of injury and age. Children with inflicted head injuries were three times more likely than those in a motor vehicle crash to have a GCS score greater than 7. Children who were younger than 24 months and died due to inflicted injury were ten times more likely than those who die from motor vehicle crashes to have a GCS score greater than 7. The incidence of a GCS score greater than 7 did not differ between inflicted injuries and injuries sustained in a fall. For children who were 24 months or older, a GCS score of greater than 7 did not differ by mechanism.
Only six children (1.9%) had good/lucid neurological status, a GCS score greater than 12, when admitted to the trauma center. Children younger than 24 months represented 5 of the 6 children who presented as lucid. The researchers suggest that this overrepresentation may have occurred because the GCS scale is based on motor and verbal skills which may not be as developed in younger children. There have been attempts to create a GCS scale that is an appropriate measure for infants and toddlers, but none have been widely accepted by clinicians.
The researchers recognize that the determination of how severe head injuries present themselves is very important in the investigation of child abuse. According to this study, homicide is a leading cause of death in infants with the majority of such deaths involving inflicted traumatic brain injury.
1 PEDIATRICS, Vol. 116 No. 1, July 2005 180-184
