Cardiopulmonary resuscitation-related injuries and homicidal blunt abdominal trauma in children

Defendants accused of inflicting fatal abdominal injuries to children occasionally raise the defense that the injuries were caused by cardiopulmonary resuscitation (CPR). The purpose of this study is to answer the question: Does closed chest CPR result in fatal blunt abdominal injuries that can be mistaken for homicidal assault? To that end, a retrospective study was conducted of all homicidal blunt abdominal injuries in children 10 years and younger from the Dade, Broward, and Palm Beach Medical Examiner's Offices from 1981 through 1997. These were compared to cases of children who died of natural causes during the same time period in Broward County who had CPR (control group 1) and to children who died of nonvehicular accidental blunt abdominal trauma (control group 2). Children with life-threatening head injuries were excluded. Medical examiner records, autopsy reports, documenting photographs, and clinical records were reviewed. The data analyzed included subject demographics, whether CPR was performed and by whom, and autopsy findings. Thirty-three child homicides with fatal abdominal injuries were reviewed. Twenty-four (73%) of the homicides received CPR. There was no difference in the nature and severity of injuries between the 24 children who received CPR and the 9 who did not. Three hundred and twenty-four cases of pediatric natural deaths were reviewed, all of which had CPR. No traumatic abdominal injuries were found in any of the children who died of natural causes. Only four children who died of natural causes had evidence of extraabdominal trauma related to CPR. No cases of nonvehicular accidental blunt abdominal trauma were identified during the 17-year period, although there were nonvehicular accidental fatalities due to extraabdominal injuries. The likelihood of CPR-related primary abdominal trauma in child homicides is very low.     

The eyes of child abuse victims: autopsy findings.

The authors studied 77 pairs of eyes removed from children who had died of suspected child abuse. Forty-seven of the cases had retinal hemorrhages. Those showing retinal hemorrhages were younger children and had fewer other stigmata of child abuse. Hemorrhages are more likely to occur in cases where the child was shaken or swung than in those with severe direct head trauma. The authors recommend that examination of the eyes be included in the autopsies of all small children who died without an obvious cause of death. Experience in both processing and reading of ocular material is necessary for reliable results.     

Fatal child abuse-maltreatment syndrome. A retrospective study in Ontario,Canada, 1990-1995

Child death due to repeated episodes of physical assault or neglect has been termed the child abuse-maltreatment syndrome (CAMS). We characterized the injuries in a series of fatally abused or maltreated child to delineate objective diagnostic criteria for the CAMS for use by clinicians and pathologists. All deaths (age <17 years) investigated by the Office of the Chief Coroner for Ontario, Canada during the time period 1990-1995 were reviewed. Cases of CAMS were defined as death due to lethal recent injury or malnutrition in the presence of significant old (healing or healed) injuries indicative of repeated episode of inflicted trauma. The nature and frequency of the various injuries was determined. The frequency of the shaken baby syndrome, and the types and frequency of ano-genital injuries were also studied. Twenty-one cases of fatal CAMS were found in the study period. Most cases had significant recent head injury with intra-cranial hemorrhage (71%). Other significant recent injuries commonly observed included blunt injuries of the skin and soft tissues (67%), blunt abdominal trauma with visceral injuries (14%), and fractures (18%). Eight cases (38%) fulfilled accepted criteria for the shaken baby syndrome. Many children with fatal head injuries had evidence of older head trauma (38% of all cases). A significant minority of cases had evidence of malnutrition due to neglect (10%) or ongoing ano-genital injuries (10%). Most cases of child homicides due to repeated episodes of abuse or maltreatment involve head trauma including shaken baby syndrome. Fractures of long bone and ribs, the classical markers of child abuse, were relatively infrequent compared with head injury. A proportion of cases had ano-genital injuries due to repeated sexual abuse or punitive maltreatment. All clinicians and pathologists must recognize the wide spectrum of injuries in child abuse to ultimate protect the victim or other children in an at-risk situation.     

Traumatic dissection of the vertebral artery in a toddler following a short fall

Spontaneous subarachnoid haemorrhage (SAH) in children is uncommon, but is sometimes seen after rupture of aneurysms, and in different disorders. Traumatic SAH is common after serious accidental head injury, but is also reported after child abuse with vigorous shaking. To avoid unnecessary accusations of innocent care givers, it is important not to misinterpret the findings as abusive head trauma in small children with SAH. In the presented case, a nearly two-year-old girl was brought to the hospital after a fall witnessed by her father. The girl was unconscious, with elevated intracranial pressure, SAH and bilateral retinal haemorrhage (RH). She was pronounced dead after 9h. Premortem angiography revealed a dissection of the right vertebral artery, and postmortem examination revealed a traumatic lesion deep in the neck, at the base of the skull. Cerebral edema, in combination with SAH and RH, is highly suggestive of abusive head trauma. However, no external lesions, no skeletal lesions, especially no long bone metaphyseal lesions, or subdural haematomas occurring at the same time as SAH, were found. There was no report of previous child abuse in the family. Based on the radiological and postmortem findings, we believe that an accidental fall caused a blunt force trauma with a subsequent dissection of the right vertebral artery. To our knowledge, accidental tear of one of the vertebral arteries, leading to SAH in a toddler, has previously not been described. Child abuse is an important exclusion diagnosis with serious legal implications.     

Suicide by intracerebellar ballpoint pen

Self-inflicted eye injuries among psychiatric patients are relatively common. Transorbital penetrating traumas are more rare but if undiagnosed may cause lethal intracranial lesions. We report a fatal case of a 25-year-old schizophrenic man who introduced a plastic ballpoint pen through his right orbit up to the cerebellum. The computed tomography findings were misinterpreted as a penetrating track from a bullet. The patient died 4 days after the trauma, and the causative object was identified only at autopsy. When no precise information about an apparently trivial ocular trauma is available, clinicians and investigators must adequately consider, especially in psychiatric patients, the possibility of an intracranial penetrating lesion.     

Commotio cordis as a result of a fight: report of a case considered to be imprudent homicide

The report describes a fatal outcome in a 5-year-old male who died after drinking a fatal dose of ethanol at the party held by his parents. Urine and blood alcohol level of the deceased was 0.4 and 0.5 g/dL, what might explain the sudden death of the child. In addition, the analysis of the boy's hair demonstrated the presence of ethyl glucuronide (EtG), a marker of alcohol consumption; hair EtG concentration levels indicated that the boy might have occasionally imbibed alcohol prior to death. Pathological lesions of the liver observed in histopathology did not contradict such a hypothesis.     

Mechanical airway obstruction caused by accidental aspiration of part of a ballpoint pen

The authors present three cases of death in children aged 4, 9, and 10 years, respectively, that were first thought to be caused by herbal or other poisonings but at autopsy were found to be caused by airway obstruction from aspiration of ballpoint pen parts. Aspiration of a foreign body is a leading cause of accidental death in children, but the circumstances in these cases were unique. In the first case, a 4-year-old child died shortly after a visit to a traditional healer. The child's mother blamed him for the death and fatally assaulted him. The second case was a 9-year-old who died at school. Case 3 was a 10-year-old who collapsed while playing with a ballpoint pen in her mouth. In the latter two cases, the relatives alleged poisoning. At autopsy, there was no evidence of trauma, disease, or poisoning in all three cases. Ballpoint pen parts were present in the larynx, carina, and left main bronchus, respectively. Features of "asphyxial" death were present, and included subconjunctival hemorrhages, subendocardial hemorrhages, and congestion of the face and internal organs. These deaths are preventable by education of children, parents, and teachers. Ballpoint pen manufacturers should also modify the design of these pens to improve their safety.     

Fatal traffic injuries among children and adolescents in three cities (capital Budapest, Vilnius, and Tallinn)

Motor vehicle accidental injuries are a frequent cause of death among young children and adolescents. The goal of this study was to compare patterns of injury between three capitals (Budapest, Vilnius, and Tallinn). Information on 190 fatal traffic accidents (69 pedestrians, 14 bicyclists, and 107 motor vehicle occupants) between 2002 and 2006 was collected from databases of medico-legal autopsies. The role of victims in accidents, the location of injuries, cause of death, survival period, and blood alcohol levels were evaluated. One-hundred and forty-one (74%) victims had a passive role in traffic as pedestrians, passengers in cars, or public transport. In victims who died at the scene, the rate of head injury was higher than in cases who received medical treatment (odds ratio = 2.58, CI = 1.2-5.55, p = 0.0127). These results underline the importance of postmortem studies to examine the pathomechanism of fatal traffic accidental injuries and to provide information for the prevention of road traffic accidents against children and adolescents.     

Are Peripapillary Intrascleral Hemorrhages Pathognomonic for Abusive Head Trauma?*

Abstract: The American Academy of Pediatrics’ Committee on Child Abuse and Neglect, Section on Ophthalmology, acknowledges that searching for retinal hemorrhages (RHs) in infants only in cases of suspected of abuse creates selection bias. However, they also recommend that postmortem eye removal might not be indicated “in children who have clearly died from witnessed severe accidental head trauma or otherwise readily diagnosed systemic medical conditions.” Although infrequently described in the child abuse literature, peripapillary intrascleral hemorrhages (bleeding in the sclera at the optic nerve insertion)—putatively from severe repetitive acceleration/deceleration forces with or without blunt head trauma—have been considered essentially pathognomonic for abusive head trauma (shaken baby syndrome). We present two neonates who sustained accidental, severe in utero head injuries and had associated extensive RHs and optic nerve sheath hemorrhages with peripapillary intrascleral hemorrhages detected at autopsy. Neither neonate had a documented clinical fundal examination in the intensive care unit.     

Post-mortem radiological examination in infants:: Evidence of child abuse?

We examined the value of post-mortem radiological examination of infants who were brought in for medico–legal autopsy. Twenty children between the age of 1 month and 15 months died under the picture of SIDS. No radiological or other signs of previous child abuse were seen in our autopsy material. A fatal case of child abuse with several metaphyseal fractures is reported. Some fractures were not visible on gross examination, but could be demonstrated by radiography and histology. In our material no association between SIDS and child abuse was found. In suspected cases of child abuse, particularly rib fractures and metaphyseal fractures should be sought. We recommend that post-mortem radiography is performed in such cases. If fractures are demonstrated, they should be verified by histologic examination.     

Postshelter adjustment of children from violent families

Few studies have examined the adjustment of battered women and their children after exiting domestic violence shelters. Participants were 62 women who had endured severe partner abuse, completed a shelter program with their children, and resided in the community for at least 6 months. Field interviews concerned mothers' and children's abuse histories and included measures of maternal depression, maternal trauma, and child behavior problems. Nearly all women had lived violence free since shelter exit. Child internalizing behaviors were associated with direct abuse, maternal depression, and shelter program. Externalizing behaviors were related to maternal depression and shelter program. Neither severity of interparental violence nor maternal trauma symptoms was related to child behavior problems. Mothers' family of-origin abuse predicted current satisfaction with child functioning, beyond the effects of maternal depression and child behavioral problems. Findings suggest a need for postshelter therapeutic services and further research addressing the adjustment of such families.     

Parent–Child Discordance and Child Trauma Symptomatology Throughout Therapy: Correlates and Treatment Response

Children and their caregivers often disagree when reporting on child behavioural and emotional difficulties. But how does parent–child discordance relate to outcomes, particularly among children undergoing trauma therapy? This study examined parent–child discordance in relation to children’s trauma symptoms and therapy outcomes. Participants included 96 trauma-exposed children and their caregivers, who received Trauma-Focused Cognitive Behavioural Therapy. Discordance was calculated using absolute difference scores between child- and parent- reported psychological symptoms. Parent–child discordance, calculated at pre-therapy, post-therapy, and at a six-month follow-up, predicted the severity of children’s posttraumatic stress, dissociation, and internalizing and externalizing difficulties at each respective time-point. Pre-therapy discordance predicted improvements in externalizing behaviours after therapy and at follow-up. Improvements in discordance predicted improvements in trauma-specific symptoms over the course of treatment and at follow-up. The findings underscore how changes in parent–child discordance are related to child trauma symptoms and treatment response. Clinical implications and future directions are discussed.     

Survival time and acting capability after fatal injury by sharp weapons

Autopsy reports from 109 victims of fatal injury from sharp weapons were investigated with regard to type and number of lesions, blood loss, degree of alcohol intoxication, survival time and acting capability after the injury. Of the 13 who died immediately, nine had penetrating lesions of the heart. This group also had the highest number of lesions. Sixty-four victims survived for some time. The survival time increased with decreasing number of lesions. The greatest blood loss and the highest blood alcohol concentrations were found in those who survived between 0.5 h and 1 h. Twenty-four victims were able to make physical efforts after the injury and the movements varied from a few steps to the running of several hundred meters. Decisive factors for decrease in survival time and acting capability are penetrating lesions to the heart and the great vessels, and multiplicity of injuries.     

Intergenerational Associations Between Trauma and Dissociation

The purpose of this study was to investigate intergenerational relationships between trauma and dissociation. Short and long term consequences of betrayal trauma (i.e., trauma perpetrated by someone with whom the victim is very close) on dissociation were examined in a sample of 67 mother–child dyads using group comparison and regression strategies. Experiences of high betrayal trauma were found to be related to higher levels of dissociation in both children and mothers. Furthermore, mothers who experienced high betrayal trauma in childhood and were subsequently interpersonally revictimized in adulthood were shown to have higher levels of dissociation than non-revictimized mothers. Maternal revictimization status was associated with child interpersonal trauma history. These results suggest that dissociation from a history of childhood betrayal trauma may involve a persistent unawareness of future threats to both self and children.     

Does advancing age modify the presentation of disease?

A group of patients who had died of either cardiac tamponade due to ruptured myocardial infarct, perforated peptic ulcer, or diverticulitis with perforation were studied to determine the effect that age has on the presentation of these three potentially fatal diseases. With advanced age, a decrease in the number of patients who had symptoms typical for the disease that was ultimately the cause of death was found. We also noted a number of patients who did not experience any symptoms, and some patients who experienced symptoms that were not typical of their disease. In many instances, the disparity between disease severity and symptoms had resulted in the disease not being diagnosed either because the patient did not seek medical advice or because the doctor was unable to make the appropriate diagnosis from the patient's symptoms.     

Fatal pediatric head injuries caused by short-distance falls.

Physicians disagree on several issues regarding head injury in infants and children, including the potential lethality of a short-distance fall, a lucid interval in an ultimately fatal head injury, and the specificity of retinal hemorrhage for inflicted trauma. There is scant objective evidence to resolve these questions, and more information is needed. The objective of this study was to determine whether there are witnessed or investigated fatal short-distance falls that were concluded to be accidental. The author reviewed the January 1, 1988 through June 30, 1999 United States Consumer Product Safety Commission database for head injury associated with the use of playground equipment. The author obtained and reviewed the primary source data (hospital and emergency medical services' records, law enforcement reports, and coroner or medical examiner records) for all fatalities involving a fall. The results revealed 18 fall-related head injury fatalities in the database. The youngest child was 12 months old, the oldest 13 years. The falls were from 0.6 to 3 meters (2-10 feet). A noncaretaker witnessed 12 of the 18, and 12 had a lucid interval. Four of the six children in whom funduscopic examination was documented in the medical record had bilateral retinal hemorrhage. The author concludes that an infant or child may suffer a fatal head injury from a fall of less than 3 meters (10 feet). The injury may be associated with a lucid interval and bilateral retinal hemorrhage.     

Contradictory interests: Work,parents, and offspring in early modern Holland

The consistory notes of the Dutch Reformed Church (1573–1700) reveal conflicts over work between parents and children during the early modern period. Two issues that caused particular tension were the labor experience of future sons-in-law and the division of household tasks. Parents' concerns about the financial position of their future son-in-law were sincere and realistic. Skills definitely bettered the new family's chances to survive financially. Children were not expected to take care of their destitute parents nor were parents obliged to support their poverty-stricken married children. Power struggles between children and stepparents also resulted in conflicts over work. After a widowed parent remarried, children and stepparents had to redefine their roles in the new situation. The child who had assumed responsibilities when a parent died resisted a stepparent who took over those tasks. Although the cases presented may not represent everyday interactions between parents and children, they do provide insights into how work caused problems between parents and older children.     

Contradictory interests: Work, parents, and offspring in early modern Holland

The consistory notes of the Dutch Reformed Church (1573–1700) reveal conflicts over work between parents and children during the early modern period. Two issues that caused particular tension were the labor experience of future sons-in-law and the division of household tasks. Parents' concerns about the financial position of their future son-in-law were sincere and realistic. Skills definitely bettered the new family's chances to survive financially. Children were not expected to take care of their destitute parents nor were parents obliged to support their poverty-stricken married children. Power struggles between children and stepparents also resulted in conflicts over work. After a widowed parent remarried, children and stepparents had to redefine their roles in the new situation. The child who had assumed responsibilities when a parent died resisted a stepparent who took over those tasks. Although the cases presented may not represent everyday interactions between parents and children, they do provide insights into how work caused problems between parents and older children.     

Violence,Guns, and Suicide in New Orleans: Results from a Qualitative Study of Recent Suicide Decedents

Many Americans own guns to protect themselves against other people, but there is evidence that both victimization and gun access increase suicide risk. We conducted qualitative interviews with informants of 17 suicide cases in New Orleans of the 60 who died between January 2015 and April 2016 to understand the relationship between past trauma, gun access and storage, and suicide. Nine cases had experienced a past trauma, including three who had recently had a family member killed by homicide. Eight died via firearm; of those, seven owned the guns they used to take their lives and stored them locked (but loaded) at home or in their cars. Preventing community violence and addressing its sequelae may be important for reducing suicides. A multi‐pronged strategy consisting of policies, education, and marketing will likely be needed to address the risk of suicide conferred by gun access.     

Cardiac Ventricular Laceration Due to Child Abuse: Abusive Ventricular Laceration

Traumatic cardiac ventricular ruptures in children are rare. Only a single case of left ventricular rupture due to child abuse has been reported. We report a child who sustained a fatal left ventricular apical rupture. It appeared to have resulted from hydrostatic forces resulting from abusive blunt thoracic injury. That he was being abused was previously missed when he was presented to the emergency department with facial pyoderma. It was not noted that he also had lip and oral mucosal injury, sites not affected by staph toxins. As a result, his underlying, abusive and secondarily infected, facial flow type scald burn was not appreciated. Within a week thereafter his fatal injury occurred, accompanied by extensive and obvious associated abusive injuries. Postmortem high‐detail whole body computed tomography scanning aided the autopsy. Although rare, ventricular rupture from abusive blunt thoracic injury can occur.