The Killer Bed

History and Physical

A 6-month-old, ex-full-term baby girl reportedly fell off her bed from a height of 2 feet. The parents went to the emergency department because of her irritability and poor feeding. Neurological examination showed some bruising in the dorsal thorax. Fundoscopy showed retinal hemorrhages.

Diagnostic Workup

Head CT showed bilateral mixed-density subdural hematomas at the vertex ( Fig. 68.1 ). Skeletal survey showed a left radial fracture.

Two head C T scan images side-by-side with arrows on the left extraaxial margins and arrowheads on the tilted midline fissures. — Fig. 68.1

Clinical Differential Diagnoses

Retinal hemorrhages can be seen in AHT but also in 40% of vaginally delivered newborns (resolving within 1 month), coagulopathies, sepsis, osteogenesis imperfecta, glutaric aciduria type 1, and Menkes disease.

Imaging Differential Diagnoses

Subdural hematomas can be seen in association with AHT, traumatic deliveries, coagulopathies, vasculopathies, vascular malformations, and infections.

Final Diagnosis

Abusive head trauma (AHT).

Discussion

Child abuse unfortunately remains common throughout the world. In 2021, there were 588,229 reported cases of child abuse in the United States, with the most common form of maltreatment being neglect. In the first year of life, the incidence of AHT is estimated to be approximately 35 cases per 100,000 infants. Approximately 65% of children experience significant neurological disabilities, and between 5% and 35% of infants die of their injuries.

Clinical Red Flags

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Delayed clinical presentation, with symptoms and findings that are inconsistent and/or out of proportion with reported mechanism.
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Increased ICP.
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Withdrawal from friends or usual activities, changes in behavior (e.g., aggression, anger, hostility, or hyperactivity), changes in school performance, depression, anxiety or unusual fears, sudden loss of self-confidence, sleep problems and nightmares.

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