Medical and Legal Uncertainties and Controversies in "Shaken Baby Syndrome" or Infant "Abusive Head Trauma".

Uncertainties and controversies surround "shaken baby syndrome" or infant "abusive head trauma". We explore Vinaccia v The Queen (2022) 70 VR 36; [2022] VSCA 107 and other selected cases from Australia, the United Kingdom and the United States. On expert opinion alone, a "triad" of clinical signs (severe retinal haemorrhages, subdural haematoma and encephalopathy) is dogmatically attributed diagnostically to severe deliberate shaking with or without head trauma. However, the evidence for this mechanism is of the lowest scientific level and of low to very low quality and therefore unreliable. Consequently, expert opinion should not determine legal outcomes in prosecuted cases. Expert witnesses should reveal the basis of their opinions and the uncertainties and controversies of the diagnosis. Further, the reliability of admissions of guilt while in custody should be considered cautiously. We suggest abandonment of the inherently inculpatory diagnostic terms "shaken baby syndrome" and "abusive head trauma" and their appropriate replacement with "infantile retinodural haemorrhage".

The World Brain Death Project: The More You Say It Does Not Make It True.

The World Brain Death Project clarified many aspects of the diagnosis of brain death/death by neurologic criteria. Clearer descriptions than previously published were presented concerning the etiology, prerequisites, minimum clinical criteria, apnea testing targets, and indications for ancillary testing. Nevertheless, there remained many epistemic and metaphysical assertions that were either false, ad hoc, or confused. Epistemically, the project was not successful in explaining away remaining brain functions, complex reflexes as "spinal," the risk and lack of utility of the apnea test, the ignored and often present confounders of central endocrine dysfunction and high-cervical-spinal-cord injury, the limitations of ancillary tests, or the cases of reversibility of some findings of brain death/death by neurologic criteria. Metaphysically, the World Brain Death Project variously suggested different concepts of death that were not supported with argument. Concepts offered included simply restating the criterion of brain death/death by neurologic criteria; personhood, without recognizing it is a higher-brain concept; and emergent functions of the organism as a whole, without specifying what these might be, if not biologic anti-entropic integration that actually remains after brain death/death by neurologic criteria. The World Brain Death Project only offered confused metaphysical discussion, and gave no reason why the state they described as brain death/death by neurologic criteria should be considered death itself. The main epistemic and metaphysical problems with brain death/death by neurologic criteria remain untouched by the World Brain Death Project.

New Challenges to the Legal Definition and Medical Determination of Brain Death: A Multi-jurisdictional Approach - Cases from the United States, the United Kingdom, Canada and Australia.

Legal definitions of death and its medical determination have been challenged in high-profile cases in several jurisdictions which define death as either cessation of all functions of the brain or only of the brain stem. Several patients diagnosed brain dead have recovered some vestigial brain activity. Plaintiffs, seeking to prevent withdrawal of life-sustaining treatment, have sought to prevent performance of the key test, the apnoeic-oxygenation test, because it can cause harm and as a medical procedure requires informed consent. Reform of the American Uniform Determination of Death Act, which resembles Australian legislation, has been proposed to include specification of the medical determination of death and lack of requirement of consent to conduct testing. In this article we consider cases and proposals for law reform, concluding that the Australian definition of brain death ought to be retained but that the apnoeic-oxygenation test should be abandoned in lieu of testing brain blood flow and that religious accommodation should be considered.

Parenting a child at home with hypoplastic left heart syndrome: experiences of commitment, of stress, and of love.

OBJECTIVE: To evaluate the experiences of parenting a child with hypoplastic left heart syndrome after the child has been discharged home from hospital. DESIGN: A study of the parents' experiences using face-to-face interviews and psychometric measures with parents whose child had survived stage surgery. SETTING: Parents were interviewed within the home environment or within the hospital if that was their choice. SUBJECTS: A total of 29 parents (16 mothers and 13 fathers) of surviving children. Intervention A semi-structured face-to-face interview plus psychometric tests (parent demographics, Maslach Burnout Inventory, Impact on Family Scale, and the Psychological Check List - Civilian). Measurements and main results The parents' experience in supporting a child with hypoplastic left heart syndrome is one of stress, of commitment, and of love. Although parents experienced joy in their child, they were also subjected to anxiety with four parents test positive to post-traumatic stress disorder and hypervigilance while monitoring their child's condition. Parents lived with many difficulties, and demands.

Five-Year Survival of Children With Chronic Critical Illness in Australia and New Zealand.

OBJECTIVE: Outcomes for children with chronic critical illness are not defined. We examined the long-term survival of these children in Australia and New Zealand. DESIGN: All cases of PICU chronic critical illness with length of stay more than 28 days and age 16 years old or younger in Australia and New Zealand from 2000 to 2011 were studied. Five-year survival was analyzed using Kaplan-Meir estimates, and risk factors for mortality evaluated using Cox regression. SETTING: All PICUs in Australia and New Zealand. PATIENTS: Nine hundred twenty-four children with chronic critical illness. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Nine hundred twenty-four children were admitted to PICU for longer than 28 days on 1,056 occasions, accounting for 1.3% of total admissions and 23.5% of bed days. Survival was known for 883 of 924 patients (95.5%), with a median follow-up of 3.4 years. The proportion with primary cardiac diagnosis increased from 27% in 2000-2001 to 41% in 2010-2011. Survival was 81.4% (95% CI, 78.6-83.9) to PICU discharge, 70% (95% CI, 66.7-72.8) at 1 year, and 65.5% (95% CI, 62.1-68.6) at 5 years. Five-year survival was 64% (95% CI, 58.7-68.6) for children admitted in 2000-2005 and 66% (95% CI, 61.7-70) if admitted in 2006-2011 (log-rank test, p = 0.37). After adjusting for admission severity of illness using the Paediatric Index of Mortality 2 score, predictors for 5-year mortality included bone marrow transplant (hazard ratio, 3.66; 95% CI, 2.26-5.92) and single-ventricle physiology (hazard ratio, 1.98; 95% CI, 1.37-2.87). Five-year survival for single-ventricle physiology was 47.2% (95% CI, 34.3-59.1) and for bone marrow transplantation 22.8% (95% CI, 8.7-40.8). CONCLUSIONS: Two thirds of children with chronic critical illness survive for at-least 5 years, but there was no improvement between 2000 and 2011. Cardiac disease constitutes an increasing proportion of pediatric chronic critical illness. Bone marrow transplant recipients and single-ventricle physiology have the poorest outcomes.

Transplantation of the heart after circulatory death of the donor: time for a change in law?

Australia has a shortfall in donated hearts for transplantation. Hearts are usually procured from brain dead donors, but procurement from circulatory dead donors is a potential additional source. However, heart transplantation after circulatory death of the donor may not conform to the dead donor rule. An amendment in law is required to permit heart procurement for transplantation after circulatory death.

Psychosocial responses of parents to their infant's diagnosis of hypoplastic left heart syndrome.

OBJECTIVE: To evaluate the psychosocial status of mothers and fathers in response to their infant's diagnosis of hypoplastic left heart syndrome. DESIGN: A study on interviews with parents whose children had survived staged surgery. SETTING: Tertiary hospital paediatric ICU. SUBJECTS: A total of 29 parents (16 mothers and 13 fathers) of surviving children. INTERVENTION: A semi-structured face-to-face interview was conducted to explore experiences of parents in response to their infant's diagnosis, their interaction with the doctor delivering the diagnosis, their deliberation about staged surgery, and their reasons for this choice. MEASUREMENT AND MAIN RESULTS: All parents were devastated about their infant's diagnosis, and most (83%) of them said that the time of the diagnosis and the aftermath was the worst time of their lives. Parents reported helpful and unhelpful communication at this time. Although all parents in this study chose surgery for their infant, when faced with the choice, 17 of them made an immediate decision "to protect their infant's life", 8 were initially unsure when their infant was diagnosed in utero, and 4 were unsure when the infant was diagnosed after birth. Parents also experienced loss and other stressors. CONCLUSIONS: All parents of the infants diagnosed with hypoplastic left heart syndrome experienced intense loss and stressors. Physicians need to be sensitive to the needs and thinking of the parents when discussing treatment options before surgery. The nature of the relationship with the doctor at this time can support parents or be a further source of stress.

Psychosocial experiences of parents of infants with hypoplastic left heart syndrome in the PICU.

OBJECTIVE: To evaluate the psychosocial status of mothers and fathers of infants with hypoplastic left heart syndrome while in the PICU. DESIGN: A retrospective study combining interviews and psychometric testing of parents. SETTING: Tertiary hospital PICU. SUBJECTS: Twenty-nine parents (16 mothers and 13 fathers) of surviving children. INTERVENTION: A semistructured face-to-face interview was conducted to explore parental experiences, and a Structured Clinical Interview for Diagnosis-Clinical Version (posttraumatic stress disorder module) was conducted to determine the possibility of an acute stress disorder or a posttraumatic stress disorder. MEASUREMENT AND MAIN RESULTS: All parents reported multiple stresses which commenced with their infant's diagnosis and endured throughout their infant's time in PICU. The Structured Clinical Interview for Diagnosis revealed that acute stress disorder or posttraumatic stress disorder developed in 24 parents (83%). Of 18 parents whose infants were diagnosed with hypoplastic left heart syndrome in utero, eight of nine mothers (88%) and six of nine fathers (66%) had posttraumatic stress disorder. Of 11 parents whose infants were diagnosed with hypoplastic left heart syndrome postbirth, six of seven mothers had acute stress disorder and one mother had posttraumatic stress disorder, and of four fathers, two fathers had acute stress disorder and one father had posttraumatic stress disorder. The prevalence of parental stress-related disorder was not different between mothers and fathers (p = 0.85). Only five parents were free of traumatic stress-related illness. Parents also experienced losses. Many parents were marginalized from their infant's care by the environment of PICU. Fifty percent of mothers experienced difficulties with parental-infant bonding. Ten parents (34%) began the process of adaptation to their infant's hypoplastic left heart syndrome and were assisted by the support and sensitivity of staff or had discovered other resources. CONCLUSIONS: All parents of surviving infants with hypoplastic left heart syndrome in PICU, irrespective of timing of diagnosis, experienced numerous stresses and losses, and the majority exhibited clinical levels of traumatic stress. Receiving the diagnosis itself is very traumatic and is compounded by the environment of the PICU which alienates parents from their infants and interferes with parent-infant bonding. Parental adaptation to this situation can be assisted by staff.

Basic and advanced paediatric cardiopulmonary resuscitation - guidelines of the Australian and New Zealand Resuscitation Councils 2010.

Guidelines for basic and advanced paediatric cardiopulmonary resuscitation (CPR) have been revised by Australian and New Zealand Resuscitation Councils. Changes encourage CPR out-of-hospital and aim to improve the quality of CPR in-hospital. Features of basic CPR include: omission of abdominal thrusts for foreign body airway obstruction; commencement with chest compression followed by ventilation in a ratio of 30:2 or compression-only CPR if the rescuer is unwilling/unable to give expired-air breathing when the victim is 'unresponsive and not breathing normally'. Use of automated external defibrillators is encouraged. Features of advanced CPR include: prevention of cardiac arrest by rapid response systems; restriction of pulse palpation to 10 s to diagnosis cardiac arrest; affirmation of 15:2 compression-ventilation ratio for children and for infants other than newly born; initial bag-mask ventilation before tracheal intubation; a single direct current shock of 4 J/kg for ventricular fibrillation (VF) and pulseless ventricular tachycardia followed by immediate resumption of CPR for 2 min without analysis of cardiac rhythm and avoidance of unnecessary interruption of continuous external cardiac compressions. Monitoring of exhaled carbon dioxide is recommended to detect non-tracheal intubation, assess quality of CPR, and to help match ventilation to reduced cardiac output. The intraosseous route is recommended if immediate intravenous access is impossible. Amiodarone is strongly favoured over lignocaine for refractory VF and adrenaline over atropine for severe bradycardia, asystole and pulseless electrical activity. Family presence at resuscitation is encouraged. Therapeutic hypothermia is acceptable after resuscitation to improve neurological outcome. Extracorporeal circulatory support for in-hospital cardiac arrest may be used in equipped centres.

External and internal biphasic direct current shock doses for pediatric ventricular fibrillation and pulseless ventricular tachycardia.

OBJECTIVE: To determine energy dose and number of biphasic direct current shocks for pediatric ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT). DESIGN: Observation of preshock and postshock rhythms, energy doses, and number of shocks. SETTING: Pediatric hospital. PATIENTS: Shockable ventricular dysrhythmias. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Forty-eight patients with VF or pulseless VT received external shock at 1.7 ± 0.8 (mean ± SD) J/kg. Return of spontaneous circulation (ROSC) occurred in 23 (48%) patients with 2.0 ± 1.0 J/kg, but 25 (52%) patients remained in VF after 1.5 ± 0.7 J/kg (p = .05). In 24 non-responding patients, additional 1-8 shocks (final dose, 2.8 ± 1.2 J/kg) achieved ROSC in 14 (58%) with 2.6 ± 1.1 J/kg but not in 10 (42%) with 3.2 ± 1.2 J/kg (not significant). Overall, 37 (77%) patients achieved ROSC with 2.2 ± 1.1 J/kg (range, 0.5-5.0 J/kg). Eight patients without ROSC recovered with cardiopulmonary bypass and internal direct current shock. At 13 subsequent episodes of VF or VT among eight patients, five achieved ROSC and survived. In combined first and subsequent resuscitative episodes, doses in the range of 2.5 to < 3 J/kg achieved most cases of ROSC. Survival for > 1 yr was seen in 28 (78%) of 36 patients with VF and seven (58%) of 11 patients with VT, with 35 (73%) overall. Lack of ROSC was associated with multiple shocks (p = .003). Repeated shocks with adhesive pads had significantly less impedance (p < .001). Pads in an anteroposterior position achieved highest ROSC rate. Internal shock for another 48 patients with VF or VT achieved ROSC in 28 (58%) patients with 0.7 ± 0.4 J/kg but not in 20 patients with 0.4 ± 0.3 J/kg (p = .01). Nineteen of the nonresponders who received additional internal 1-9 shocks at 0.6 ± 0.5 J/kg and one patient given extracorporeal membrane oxygenation all recovered, yielding 100% ROSC, but 1-yr survival tallied 43 (90%) patients. CONCLUSIONS: The initial biphasic direct current external shock dose of 2 J/kg for VF or pulseless VT is inadequate. Appropriate doses for initial and subsequent shocks seem to be in the range of 3-5 J/kg. Multiple shocks do not favor ROSC. The dose for internal shock is 0.6-0.7 J/kg.

Withdrawal of life-support in paediatric intensive care--a study of time intervals between discussion, decision and death.

BACKGROUND: Scant information exists about the time-course of events during withdrawal of life-sustaining treatment. We investigated the time required for end-of-life decisions, subsequent withdrawal of life-sustaining treatment and the time to death. METHODS: Prospective, observational study in the ICU of a tertiary paediatric hospital. RESULTS: Data on 38 cases of withdrawal of life-sustaining treatment were recorded over a 12-month period (75% of PICU deaths). The time from the first discussion between medical staff and parents of the subject of withdrawal of life-sustaining treatment to parents and medical staff making the decision varied widely from immediate to 457 hours (19 days) with a median time of 67.8 hours (2.8 days). Large variations were subsequently also observed from the time of decision to actual commencement of the process ranging from 30 minutes to 47.3 hrs (2 days) with a median requirement of 4.7 hours. Death was apparent to staff at a median time of 10 minutes following withdrawal of life support varying from immediate to a maximum of 6.4 hours. Twenty-one per cent of children died more than 1 hour after withdrawal of treatment. Medical confirmation of death occurred at 0 to 35 minutes thereafter with the physician having left the bedside during withdrawal in 18 cases (48%) to attend other patients or to allow privacy for the family. CONCLUSIONS: Wide case-by-case variation in timeframes occurs at every step of the process of withdrawal of life-sustaining treatment until death. This knowledge may facilitate medical management, clinical leadership, guidance of parents and inform organ procurement after cardiac death.

Symptoms and signs differentiating croup and epiglottitis.

AIM: To determine differentiating symptoms and signs of epiglottitis and laryngotracheobronchitis (croup). METHODS: Contemporaneous interview of parents and clinical examination of children with acute upper airway obstruction presenting to the intensive care unit of a paediatric hospital. RESULTS: Two hundred and three children were examined over a 40-month period. One hundred and two had croup, of whom 49 had the diagnosis confirmed at intubation and another six by direct laryngeal inspection without intubation. One hundred and one had epiglottitis of whom 95 were diagnosed by direct inspection of the larynx at intubation, five by a lateral X-ray of the neck and one on direct inspection without intubation. One child with epiglottitis died. Although both illnesses presented with stridor, the additional presence of drooling had a high sensitivity (0.79, 95% CI 0.70-0.86) and specificity (0.94, 95% CI 0.88-0.97) for epiglottitis while coughing had a high sensitivity (1.00, 95% CI 0.96-1.00) and high specificity (0.98, 95% CI 0.93-0.99) for croup. Coughing predicted croup but drooling predicted epiglottitis. Additional reliable signs of epiglottitis were a preference to sit, refusal to swallow and dysphagia. Thirty-seven percent of children with epiglottitis and 16% with croup were treated as having another respiratory illness at least once before definitive diagnosis. CONCLUSIONS: Epiglottitis and croup are often confused because they share symptoms and signs including stridor. However, differentiation in early illness is possible by additional observation of coughing and absence of drooling in croup and by the additional observation of drooling with absence of coughing in epiglottitis.

A critique of the apneic oxygenation test for the diagnosis of "brain death".

OBJECTIVE: To determine the reliability and safety of the apneic oxygenation test to diagnose brain death for the purpose of organ donation. DATE SOURCES: Published scientific literature in Medline database, organ donation guidelines and neurophysiological principles described in medical textbooks. STUDY SELECTION: Articles on brain death, apnea testing, and radionuclide scintigraphy. DATA EXTRACTION AND SYNTHESIS: Hypercarbia with a target Paco2 of 60 mm Hg (8.0 kPa) must be reached before apnea is deemed consistent with brain death in some clinical guidelines, whereas a level of 50 mm Hg (6.7 kPa) is required in another. However, the sensitivity and specificity of the test are doubtful because some patients have commenced spontaneous respiration >60 mm Hg (8.0 kPa) and high levels of Paco2 may cause CO2 narcosis. Furthermore, the test may be harmful if the brain stem is responsive because hypercarbia may also cause intracranial hypertension and contribute to brain damage. Although guidelines for organ donation recommend the test as an essential component of brain death diagnosis, it is often not performed or performed inadequately. Wide variation in conduct of the test has prompted calls for standardization. CONCLUSIONS: : The apneic oxygenation test is unreliable in the diagnosis of brain death. It is scientifically flawed and hypothesized to cause brain death. In lieu of this test, a reliable test of brain perfusion should be mandatory, whereas the apneic oxygenation test, if performed at all, should be restricted to demonstration of apnea after brain perfusion has been shown to be absent.

Pressure-created communication between lumens of a multilumen venous catheter.

OBJECTIVE: To describe the inadvertent creation of a connection between lumens of a multilumen catheter by use of an in-line intravenous hand pressure pump. DESIGN: Case report. SETTING: Operating theater. PATIENT: All lumens of a 4F triple lumen catheter were verified patent by irrigation with saline before insertion into an internal jugular vein of an 18-mo-old child undergoing cardiac surgery. During surgery, the flushing of saline into one lumen of the catheter by means of an in-line hand pressure pump caused registration of >300 mm Hg pressure recorded from another lumen. The connections to these two lumens were then reversed. Repeated flushing also caused registration of pressure >300 mm Hg. On removal of the catheter at the end of surgery, flushing of one lumen caused fluid to emerge from the wrong exit hole as the appropriate exit hole was blocked with blood clot. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Pressure measurement in intravenous catheter lumens. Greater than 300 mm Hg was recorded during flushing with an inline hand pressure pump. CONCLUSIONS: High pressure created by use of an in-line intravenous hand pressure pump may cause creation of a communication between lumens of multilumen catheters.

Two cases of idiopathic infantile arterial calcification.

We present the clinical course and management of two infants with idiopathic infantile arterial calcification. Both had coronary artery involvement and presented with ischaemic cardiac failure. Neither responded well to conventional therapy with inotropic agents, glyceryl trinitrate, diuretic and mechanical ventilation, nor to short-term biphosphonates. One was treated with levosimendan and extracorporeal membrane oxygenation to no avail.

A home respiratory support programme for children by parents and layperson carers.

AIM: To describe a respiratory support programme for children at home by parents and layperson carers. METHODS: Analysis of records of children with long-term mechanical respiratory support at home. RESULTS: From 1979 to 2008 the programme managed 168 children (median age 7 years, range 3 weeks-19 years) with obstructive sleep apnoea (55, 32%), neuromuscular conditions (42, 25%), tracheo-bronchomalacia (23, 14%), kyphoscoliosis-cerebral palsy (20, 12%), acquired central hypoventilation (8, 5%), congenital central hypoventilation (7, 4%), chronic lung disease or pulmonary hypoplasia (8, 5%), traumatic quadriplegia (3, 2%) and tumour-related quadriplegia (2, 1%). One hundred and sixty-one (96%) were discharged: 73 (46%) remain in the programme; 27 (16%) transferred to adult services, 25 (15%) recovered and 36 (23%) died. Principal modes of therapy were mask continuous positive airway pressure (CPAP) 35%, mask bilevel positive airway pressure 30%, tracheostomy CPAP 20%, tracheostomy mechanical ventilation 8%, phrenic nerve pacing 3%, negative pressure chamber ventilation 2% and nasal tube CPAP 2%. Two unexpected deaths occurred at home: one from accidental tracheostomy decannulation and another unrelated to respiratory support. Average time in the programme was 3.3 years. Parents of 69 children were provided with trained carers. Successful discharge resulted from early recognition of potential to discharge, parental training, recruitment and training of carers, purchase of equipment and secure funding. Seven children were not discharged, two of whom died in the hospital and five are subject to discharge planning. CONCLUSION: Respiratory support of children at home by trained parents and layperson carers is safe and efficient. All modes of respiratory support may be used.

Australian snake antivenom dosing: What is scientific and safe?

Because the median dose of one vial 'clears the blood of circulating venom', the authors of the Australian Snakebite Project recommend restriction of antivenom to one vial for all envenomated victims. This is neither scientific nor safe. Methodological flaws in the case series include limited detection of venom toxins and misinterpretation of data. The recommendation fails to consider larger doses of venom than that neutralised by one vial of antivenom. Although one vial may be adequate for minor envenomation, the initial dose should be two vials with more on a clinical basis.