1
|
Deliliga A, Chatzinikolaou F, Koutsoukis D, Chrysovergis I, Voultsos P. Cardiopulmonary resuscitation (CPR) complications encountered in forensic autopsy cases. BMC Emerg Med 2019; 19:23. [PMID: 30819095 PMCID: PMC6396442 DOI: 10.1186/s12873-019-0234-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 02/18/2019] [Indexed: 11/28/2022] Open
Abstract
Background Cardiopulmonary resuscitation (CPR) provides a significant increase in survival rate, even if performed by bystanders. However, bystanders may refrain from performing CPR for fear of eventual malpractice litigation. Currently lack Guidelines specifying whether a particular CPR-related complication is in all likelihood unavoidable or not. To fulfill this gap a great number of studies is required to be published in the most relevant leading academic literature. This paper aims at making a contribution to addressing such a challenge. Methods A retrospective observational study based on forensic autopsy material aiming at recording injuries resulting from the application of CPR. The severity of injuries was forensically evaluated. Results Out of 88 cases autopsied, only 26.7% had rib fractures (only 20% of which were located in the 6 lower ribs), 17.4% had sternal fractures (85.7% of which were detected in the body of the sternum and 14.3% in the manubrium). The ratio of sternal fractures to rib fractures is similar to the ratio cited in other studies reported in the literature (2:3, approximately). The number of fractures was 7.86 (4.11 on the right side and 4.75 on the left side). 16% of the cases were found to be mild, 48% were moderate, and 35% of the cases were severe. When a physician was present, a (not statistically significant) trend towards more severe complications was found. Conclusion The findings are in accordance with other similar studies reported in the literature referring to the classic external CPR. This study offers a proposal aiming at making a contribution to develop Guidelines specifying whether a particular CPR-related complication is in all likelihood unavoidable or not.
Collapse
Affiliation(s)
- Aspasia Deliliga
- Department of Forensic Medicine & Toxicology, School of Medicine, Aristotle University of Thessaloniki, (Campus), School of Medicine, 54124, Thessaloniki, Greece
| | - Fotios Chatzinikolaou
- Department of Forensic Medicine & Toxicology, School of Medicine, Aristotle University of Thessaloniki, (Campus), School of Medicine, 54124, Thessaloniki, Greece
| | - Dimitrios Koutsoukis
- Department of Forensic Medicine & Toxicology, School of Medicine, Aristotle University of Thessaloniki, (Campus), School of Medicine, 54124, Thessaloniki, Greece
| | - Ioannis Chrysovergis
- Department of Forensic Medicine & Toxicology, School of Medicine, Aristotle University of Thessaloniki, (Campus), School of Medicine, 54124, Thessaloniki, Greece
| | - Polychronis Voultsos
- Department of Forensic Medicine & Toxicology, School of Medicine, Aristotle University of Thessaloniki, (Campus), School of Medicine, 54124, Thessaloniki, Greece.
| |
Collapse
|
2
|
Krous HF, Byard RW. Controversies in pediatric forensic pathology. Forensic Sci Med Pathol 2015; 1:9-18. [PMID: 25869831 DOI: 10.1385/fsmp:1:1:009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2004] [Indexed: 11/11/2022]
Abstract
Pediatric forensic pathology is an emerging medical subspecialty that spans the area between pediatric and forensic pathology. Advances in both of these fields have increased the sophistication of diagnoses, with overlap of disorders that might present to either the pediatric or forensic pathologist, adding further layers of complexity. Not surprisingly, therefore, there are important ethical and medical controversies in pediatric forensic pathology that merit careful consideration and attention.
Collapse
Affiliation(s)
- Henry F Krous
- Children's Hospital and Health Center and University of California, San Diego, CA,
| | | |
Collapse
|
3
|
Kemp WL. A Simple, Effective, and Inexpensive Method for Backlighting Retinal Hemorrhages. Acad Forensic Pathol 2014. [DOI: 10.23907/2014.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Adequate photographic documentation of important autopsy findings, both positive and negative, is vital for serving as a record of the pathologist's examination, as well as for a tool in the courtroom, for consultations, or for educational endeavors. Examination of the eye, especially the retina, is an important part of the investigation of suspicious infant deaths; however, obtaining good photographs can be difficult due to many factors. The method described herein allows for the development of a cost-effective, technically simple, and mobile way to take outstanding photographs of the retina.
Collapse
Affiliation(s)
- Walter L. Kemp
- Deputy State Medical Examiner, Montana State Forensic Science Division, Missoula, MT, University of Texas Southwestern Medical Center, Dallas, TX, and Faculty Affiliate, Department of Biology, University of Montana, Missoula, MT
| |
Collapse
|
4
|
Abstract
OBJECTIVE To determine the prevalence of retinal hemorrhages in apparent life-threatening events (ALTEs) with the purpose of facilitating the differential diagnosis of the cases of nonaccidental head trauma. METHODS Prospective study on children aged 15 days to 2 years admitted to our hospital with a diagnosis of an ALTE over a period of 2 years (May 2004-May 2006). All the children underwent detailed ophthalmologic examination within 72 hours of admission. If retinal hemorrhages were detected, further investigation was undertaken to rule out systemic disorder or maltreatment. RESULTS One hundred eight children with an ALTE were examined. No patient was found to have retinal hemorrhages nor was any found to have experienced child abuse. Therefore, using the Hanley rule of 3, we can be confident to an upper limit of 95% that the chance of retinal hemorrhages occurring as a result of an ALTE alone is at the most 0.028. CONCLUSIONS Apparent life-threatening events alone are unlikely to cause retinal hemorrhages in children younger than 2 years. Therefore, if retinal hemorrhages are detected, investigation into the possibility of nonaccidental injury is essential.
Collapse
|
5
|
Goldman M, Dagan Z, Yair M, Elbaz U, Lahat E, Yair M. Severe cough and retinal hemorrhage in infants and young children. J Pediatr 2006; 148:835-6. [PMID: 16769399 DOI: 10.1016/j.jpeds.2005.12.052] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2005] [Revised: 12/05/2005] [Accepted: 12/19/2005] [Indexed: 11/30/2022]
Abstract
No retinal hemorrhages were detected in any of 100 consecutive children aged 3 months to 2 years with severe, persistent coughing (0 of 100, 95% CI: 0%- 3%). Therefore, if one finds retinal hemorrhage in infants and young children with cough, child abuse must be excluded.
Collapse
Affiliation(s)
- Michael Goldman
- Department of Pediatrics, Assaf Harofeh Medical Center, Zerifin, Israel.
| | | | | | | | | | | |
Collapse
|
6
|
Abstract
Bruising and bleeding are commonly seen in children and are usually associated with minor injury and trauma. However, in two groups of children the bruising may be more significant than expected: those with an underlying haemostatic abnormality, such as an inherited bleeding disorder, or those who have been subjected to non-accidental injury (NAI). Diagnosing inherited bleeding disorders in children is fraught with difficulty, from venous access to interpretation of results; the possibility of NAI should be borne in mind, even in those children with proven significant bleeding disorders when the severity of the injury and the history are non-compatible. We describe the investigation of the haemostatic system in children with bruising and/or bleeding with emphasis on the key haemostatic disorders that need to be excluded.
Collapse
Affiliation(s)
- Kate Khair
- Haemophilia Comprehensive Care Centre, Great Ormond St NHS Trust, London, UK.
| | | |
Collapse
|
7
|
Abstract
Intraretinal hemorrhages have been found in some abusively injured infants and children. Intraretinal hemosiderin has been proposed as an indication of previous injury. The limits of the accuracy of the proposal have not been established. Experimental central retinal vein occlusion (CRVO) was produced in 20 eyes of adult rhesus monkeys as part of ongoing research by one of the authors (SSH). The animal experiments were conducted in accordance with a research protocol approved by the Animal Care Committee, University of Iowa. CRVO produced diffuse intraretinal hemorrhages. Clinical ocular examinations assessed the onset and time course of retinal hemorrhages. Enucleation specimens were used to assess hemosiderin in the retinas. Hemosiderin was detected within 2 days of induction of retinal hemorrhages. It was detected in only 4 of 11 eyes (36%) studied more than 1 week following induction of hemorrhages. In 2 eyes, hemosiderin was found 9 and 16.8 months after development of hemorrhages. Hemosiderin can represent organization of current hemorrhage rather than evidence of prior hemorrhage. This study does not allow specifying the duration of hemorrhages with greater precision than "more than 2 days prior to death," and that, only if there is no survival interval. Failure to detect hemosiderin does not exclude prior retinal hemorrhages.
Collapse
Affiliation(s)
- M G F Gilliland
- Department of Pathology and Laboratory Medicine, Brody School of Medicine at East Carolina University, Greenville, NC 27858, USA.
| | | | | |
Collapse
|
8
|
Forbes BJ, Christian CW, Judkins AR, Kryston K. Inflicted childhood neurotrauma (shaken baby syndrome): ophthalmic findings. J Pediatr Ophthalmol Strabismus 2004; 41:80-8; quiz 105-6. [PMID: 15089062 DOI: 10.3928/0191-3913-20040301-07] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Inflicted childhood neurotrauma (shaken baby syndrome) is the term used for violent, nonaccidental, repetitive, unrestrained acceleration-deceleration head and neck movements, with or without blunt head trauma, combined with a unique, age-related biomechanical sensitivity in children typically younger than 3 years. This syndrome is typically characterized by a combination of fractures, intracranial hemorrhages, and intraocular hemorrhages. Retinal hemorrhage is the most common ophthalmic finding, and usually occurs at all levels of the retina. In recent years, increasing pressure has been placed on ophthalmologists to render diagnostic interpretations of the retinal findings in children suspected to be victims, which may have great forensic implications in criminal proceedings. New research has increased our understanding of the pathophysiology of retinal hemorrhages, the importance of specifically characterizing the types, patterns, and extent of these retinal hemorrhages, and the differential diagnosis.
Collapse
Affiliation(s)
- Brian J Forbes
- Department of Ophthalmology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | |
Collapse
|
9
|
Mierisch RF, Frasier LD, Braddock SR, Giangiacomo J, Berkenbosch JW. Retinal hemorrhages in an 8-year-old child: an uncommon presentation of abusive injury. Pediatr Emerg Care 2004; 20:118-120. [PMID: 14758311 DOI: 10.1097/01.pec.0000113883.10140.c2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Retinal hemorrhages in pediatric patients have been best described as a component of shaken baby syndrome (SBS), which has been described almost exclusively in the infant/toddler population. We describe the occurrence of retinal hemorrhages in the setting of abusive injury in an older child. METHODS Case report. RESULTS An 8-year-old boy was transferred to our institution with coma and respiratory arrest. Evaluation demonstrated intracranial hemorrhage, cerebral edema, and severe bilateral retinal hemorrhages. The patient subsequently died of intractable intracranial hypertension. Police investigation confirmed that the injuries were caused by severe abusive injury, including shaking. CONCLUSIONS This case emphasizes that the diagnosis of SBS is not limited to babies and that the possibility of abusive shaking injury should also be considered in older children presenting with intracranial pathology and retinal hemorrhages.
Collapse
Affiliation(s)
- Raymond F Mierisch
- *Department of Child Health, University of Missouri-Columbia, Columbia, MO; †Department of Pediatrics, University of Utah, Salt Lake City, UT; ‡Division of Medical Genetics, University of Missouri-Columbia, Columbia, MO; §Department of Ophthalmology, University of Missouri-Columbia, Columbia, MO; ∥Division of Pediatric Critical Care/Pediatric Anesthesiology, University of Missouri-Columbia, Columbia, MO
| | | | | | | | | |
Collapse
|
10
|
Ransom GH, Mann FA, Vavilala MS, Haruff R, Rivara FP. Cerebral infarct in head injury: relationship to child abuse. CHILD ABUSE & NEGLECT 2003; 27:381-392. [PMID: 12686323 DOI: 10.1016/s0145-2134(03)00025-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
BACKGROUND To determine whether CT-detected cerebral infarct in young children is associated more often with abuse or unintentional head injury. METHODS Retrospective case-control study of injured children under age 6 who had abnormal initial head CT scans and who were admitted to the only Level I pediatric trauma center in Washington State for closed head injury (CHI) from January 1, 1992 to December 31, 1998. RESULTS Fifteen children developed cerebral infarct after CHI during the 7 year period. These cases were compared to 53 controls (those who did not develop infarct). After adjusting for the presence of SDH and for severity of injury, patients with infarcts were six times more likely to have been abused than patients without infarcts (OR 6.1; 95% CI, 1.02-36.0). CONCLUSIONS Cerebral infarct after CHI appears to result more frequently from abuse than unintentional injury in young children.
Collapse
Affiliation(s)
- Galen H Ransom
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | | | | | | |
Collapse
|
11
|
Abstract
BACKGROUND In the published reports of the developed society, subdural hematoma and/or retinal hemorrhages, in the absence of documented history of major trauma, should be considered diagnostic of child abuse. Many people used the above criteria for diagnosis, but subsequently found that retinal hemorrhages were more common in non-accidental injuries (NAI). To what extent is the proposed pathognomonic association between unexplained subdural hematoma/retinal hemorrhages and child abuse a self-fulfilling prophecy? METHODS Clinical details of nine children under 2 years with unexplained subdural hematoma admitted to Prince of Wales Hospital between 1995 and 1998 were reviewed. RESULTS Four had no other physical signs of injury, five had retinal hemorrhages and one had multiple bruises over the body. Following multidisciplinary case conferences for seven children, a diagnosis of NAI was concluded in four cases, but in no case could the abuser be definitely identified. Clinical outcome was poor with seven children showing either profound disability (n = 5) or evidence of developmental delay (n = 2). CONCLUSION In this series, NAI were not established in three of the seven cases. Did we underdiagnose child abuse in these cases? Despite a magnitude of opinion to the contrary, the issue of whether "trivial" head injury can cause subdural hemorrhages and/or retinal hemorrhages is yet unresolved. Clearly much more information on this very sensitive and serious issue is required and these data should be collected with an open mind.
Collapse
Affiliation(s)
- Eva Lai Wah Fung
- Department of Paediatrics, Faculty of Medicine, 6/F Clinical Science Building, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.
| | | | | | | |
Collapse
|
12
|
Affiliation(s)
- F M Nadel
- Division of Emergency Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | | |
Collapse
|
13
|
Abstract
Retinal hemorrhages are the most common fundus finding in the shaken baby syndrome. They vary in type and location; no particular type is pathognomonic for the condition. Retinal hemorrhages are not needed to make a diagnosis of shaken baby syndrome. However, in a child under age 3 years, the presence of extensive bilateral retinal hemorrhages raises a very strong possibility of abuse, which must be investigated. The other possible causes for hemorrhages in this age child can be investigated and eliminated. The diagnosis of abuse should be made by someone particularly trained in this area, who can put together the entire picture of inadequate or changing history, fractures of various ages, particularly rib fractures, subdural hematoma of the brain, and retinal hemorrhages. Photographs of retinal hemorrhages are very helpful to child advocacy experts who take these cases to court.
Collapse
Affiliation(s)
- J D Kivlin
- Department of Ophthalmology, Medical College of Wisconsin, Milwaukee, Wisconsin 53226-4812, USA.
| |
Collapse
|
14
|
Krugman SD, Zorc JJ, Walker AR. Hyponatremic seizures in infancy: association with retinal hemorrhages and physical child abuse? Pediatr Emerg Care 2000; 16:432-4. [PMID: 11138891 DOI: 10.1097/00006565-200012000-00016] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We present two cases of infants with hyponatremic seizures who had an unexpected finding of retinal hemorrhages. A review of the literature found no prior association between hyponatremic seizures and retinal hemorrhages. The retinal hemorrhages found in the first patient were a result of shaken baby syndrome (SBS) and associated with long bone fractures and a subdural hematoma. The second patient had retinal hemorrhages and cerebral edema, presumed to be a result of SBS. We suggest that children who become hyponatremic owing to neglect, lack of education, or intentional water poisoning may be at risk for other forms of child abuse. Additional research needs to be done to further elucidate the relationship between hyponatremic seizures and child abuse.
Collapse
Affiliation(s)
- S D Krugman
- Department of Pediatrics, Franklin Square Hospital Center, Baltimore, Maryland 21237, USA
| | | | | |
Collapse
|
15
|
Affiliation(s)
- D Taylor
- Eye Department, Great Ormond Street Hospital, London, UK
| |
Collapse
|
16
|
Abstract
The classic ophthalmologic finding in nonaccidental traumatic injury is bilateral widespread retinal hemorrhage with or without intracranial hemorrhage. We present 3 cases of unilateral retinal hemorrhage associated with ipsilateral intracranial bleeds to extend the many different presentations of nonaccidental trauma.
Collapse
Affiliation(s)
- J C Paviglianiti
- Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | |
Collapse
|
17
|
Abstract
Child abuse has been documented in various forms since the beginning of recorded history. This article reviews the legal aspects of reporting child abuse, the epidemiology of child abuse, various physical manifestations of child abuse, and effective treatment procedures. It is only with the appropriate interventions that physicians can begin to make an impact on the future of abused children.
Collapse
Affiliation(s)
- A M Jain
- Department of Emergency Medicine, George Washington University, Washington, DC, USA
| |
Collapse
|
18
|
|
19
|
Affiliation(s)
- E E Conway
- Department of Pediatrics, Beth Israel Medical Center/North Division, New York, New York, USA
| |
Collapse
|
20
|
Odom A, Christ E, Kerr N, Byrd K, Cochran J, Barr F, Bugnitz M, Ring JC, Storgion S, Walling R, Stidham G, Quasney MW. Prevalence of retinal hemorrhages in pediatric patients after in-hospital cardiopulmonary resuscitation: a prospective study. Pediatrics 1997; 99:E3. [PMID: 9164799 DOI: 10.1542/peds.99.6.e3] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Child abuse occurs in 1% of children in the United States every year; 10% of the traumatic injuries suffered by children under 5 years old are nonaccidental, and 5% to 20% of these nonaccidental injuries are lethal. Rapid characterization of the injury as nonaccidental is of considerable benefit to child protection workers and police investigators seeking to safeguard the child care environment and apprehend and prosecute those who have committed the crime of child abuse. Physically abused children present with a variety of well-described injuries that are usually easily identifiable. In some cases, however, particularly those involving children with the shaken baby syndrome, obvious signs of physical injury may not exist. Although external signs of such an injury are infrequent, the rapid acceleration-deceleration forces involved often cause subdural hematomas and retinal hemorrhages, hallmarks of the syndrome. Frequently, retinal hemorrhages may be the only presenting sign that child abuse has occurred. Complicating the interpretation of the finding of retinal hemorrhages is the belief by some physicians that retinal hemorrhages may be the result of chest compressions given during resuscitative efforts. The objective of this study is to determine the prevalence of retinal hemorrhages after inpatient cardiopulmonary resuscitation (CPR) in pediatric patients hospitalized for nontraumatic illnesses in an intensive care unit. DESIGN Prospective clinical study. SETTING Pediatric intensive care unit. PATIENTS Forty-three pediatric patients receiving at least 1 minute of chest compressions as inpatients and surviving long enough for a retinal examination. Patients were excluded if they were admitted with evidence of trauma, documented retinal hemorrhages before the arrest, suspicion of child abuse, or diagnosis of near-drowning or seizures. All of the precipitating events leading to cardiopulmonary arrest occurred in our intensive care unit, eliminating the possibility of physical abuse as an etiology. INTERVENTIONS None. MEASUREMENTS Examination of the retina was performed by one of two pediatric ophthalmologists within 96 hours of CPR. The chart was reviewed for pertinent demographic information; the platelet count, prothrombin time, and partial thromboplastin time proximate to the CPR were recorded if they had been determined. RESULTS A total of 43 pediatric patients hospitalized with nontraumatic illnesses survived 45 episodes of inpatient CPR. The mean age was 23 months (range, 1 month to 15.8 years), and 84% of the patients were under 2 years old. The majority of the patients (44%) were admitted to the intensive care unit after surgery for congenital heart disease, and another 21% were admitted for respiratory failure. The mean duration of chest compressions was 16.4 minutes +/- 17 minutes with 58% lasting between 1 and 10 minutes. Five patients had chest compressions lasting >40 minutes, and two patients had open chest cardiac massage. All patients survived their resuscitative efforts. Ninety-three percent of patients had an elevated prothrombin time and/or partial thromboplastin time while 49% were thrombocytopenic. Sixty-two percent of the patients had low platelet counts and an elevated prothrombin time and/or partial thromboplastin time. Small punctate retinal hemorrhages were found in only one patient. CONCLUSIONS Retinal hemorrhages are rarely found after chest compressions in pediatric patients with nontraumatic illnesses, and those retinal hemorrhages that are found appear to be different from the hemorrhages found in the shaken baby syndrome. Despite the small number of patients in this prospective study, we believe that these data support the idea that chest compressions do not result in retinal hemorrhages in children with a normal coagulation profile and platelet count. A larger number of patients should be evaluated in a prospective multi-institutional study to achieve statistical significance
Collapse
Affiliation(s)
- A Odom
- Divisions of Critical Care, Le Bonheur Children's Medical Center, University of Tennessee, Memphis, TN 38103, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Abstract
AIMS To evaluate the incidence of retinal haemorrhages after convulsions in children. PATIENTS AND METHODS All children who required hospital admission after an episode of convulsions were included in the study. Complete neurological and ocular examinations, including ophthalmoscopy, were undertaken within 48 hours of hospital admission. RESULTS Thirty three children were examined according to the protocol and their seizures were classified by a paediatric neurologist. Despite the fact that some of the children also vomited or underwent cardiopulmonary resuscitation, none of the 33 children developed retinal haemorrhages. CONCLUSIONS Convulsions rarely (if ever) give rise to retinal haemorrhages. The finding of retinal haemorrhages should stimulate a detailed assessment to exclude non-accidental injury, whatever the nature of the associated or antecedent events.
Collapse
|