Investigation of fatal traumatic head injuries.

BACKGROUND: Traumatic head injuries (THIs) are one of the major causes of death in forensic cases. The aim of this study was to investigate the characteristics of patients with fatal THIs. METHODS: In this study, a total of 311 patients with fatal THIs, who underwent postmortem examinations and/or autopsies, were retrospectively analyzed. Cases were evaluated based on sex, age group, incident origin, cause of the incident, presence of skull fracture, type of fractured bone (if any), fracture localization and pattern, presence and type of intracranial lesion (if any), and cause of death. RESULTS: Out of the patients, 242 (77.8%) were male and 69 (22.2%) were female. Accidents accounted for 235 (75.6%) of the incidents, with in-vehicle traffic accidents causing 117 (37.6%). In 221 cases (71.1%), intracranial lesions and skull fractures were observed together. The most common fractures were base fractures (171 cases) and temporal bone fractures (153 cases). The rate of intracranial hemorrhage was lower in the adult age group (69.7%) compared to the older age group (92.6%). CONCLUSION: The results obtained in this study indicate that the cause of the incident, type of fracture, presence of skull base fracture, and multiple skull fractures increase the likelihood of fatalities. The occurrence of skull fractures reduces intracranial pressure, thereby decreasing the incidence of intracranial lesions. The development and effective enforcement of road traffic safety policies and regulations will reduce the incidence of fatalities.

Bicycle-related accidents in Rome: Investigating clinical patterns, demographics, injury contexts, and health outcomes for enhanced public safety.

INTRODUCTION: This study aims to analyze the clinical characteristics, demographic features, and injury circumstances of patients admitted to the Emergency Department (ED) at Fondazione Policlinico Universitario A. Gemelli (IRCCS) in Rome, Italy, due to bicycle accidents. METHODS: Data on clinical characteristics, accident timing, injury circumstances, and helmet use were collected for ED patients involved in bicycle accidents from January 2019 to December 2022. Subsequently, Abbreviated Injury Scale codes of all diagnoses were recorded and the Injury Severity Score was calculated. RESULTS: Over the study period, 763 patients were admitted to the ED following bicycle accidents, with a 0.3 % fatality rate and a 30.4 % frequency of multitrauma. Multivariate analysis revealed that collisions with other vehicles increased trauma severity and the risk of ICU admission. Conversely, helmet use was associated with reduced severity of head trauma and a lower likelihood of ICU admission. Notably, toxicological investigations were not conducted for any ED-admitted patients. CONCLUSIONS: Although a low mortality rate and a low incidence of multi-trauma have been shown in comparison to other nations, it is necessary to adopt prevention strategies like safety devices, more cycle paths, and better infrastructures on the one hand, and stricter laws on the other. It is essential to require toxicological testing in Italy for all accidents involving this means of transport, and to make helmet use compulsory for all ages.

Abusive head trauma: The body of the iceberg - A population-based survey on prevalence and perpetrators.

BACKGROUND: Research on abusive head trauma (AHT) is usually research on clinically identified cases, while population-based studies, having the potential to identify cases of shaking that did not end with hospital admission, are missing to date. OBJECTIVE: Thus, we aimed to assess the prevalence of AHT and associated risk factors in a representative sample of the German population. PARTICIPANTS AND SETTING: We conducted a cross-sectional, observational study in Germany from July to October 2021. Using different sampling steps including a random route procedure, a probability sample of the German population was generated. The final sample consisted of 2503 persons (50.2 % female, mean age: 49.5 years). METHODS: Participants were asked about sociodemographic information in a face-to-face interview and whether they had been ever responsible for the care of an infant and whether they had ever performed potential harmful methods including shaking to calm it, intimate partner violence (IPV) and adverse childhood experiences (ACEs) using a questionnaire. RESULTS: In total, 1.4 % of women (N = 18) and 1.1 % of men (N = 13) reported to have at least once shaken an infant to calm it. Ever having used a potential harmful parenting method in calming an infant was reported by 4.9 % of women (N = 61) and 3.1 % (N = 39) of men. No gender differences were seen. A low income, living with someone under 16 in the household and victimization and perpetration of IPV and ACEs are associated with increased risks of shaking and other potential harmful methods to calm an infant. CONCLUSIONS: Our data suggest that despite better knowledge on the dangers of shaking, the percentage of women that shake infants might be higher than previously thought. Also, intimate partner violence and ACEs are key risk factor for shaking and harmful parenting behaviors in general. This has important implications for future prevention programs.

A lucid interval in a victim of abusive head trauma with multiple parenchymal lacerations.

Abusive head trauma (AHT) is a leading cause of abusive deaths in children under age one. AHT can include intracranial hemorrhages, hypoxic ischemic injury, or parenchymal lacerations. Most infants with parenchymal lacerations present with acute neurological symptoms. There has been some published literature on lucid intervals in cases of AHT; however, there has not been a described lucid interval with parenchymal lacerations. Parenchymal lacerations typically present with acute symptomatology such as seizures, alteration in mental status, or increased fussiness/lethargy given the damage to neurons and brain structure. We present a case of a healthy 2-month-old who ultimately was diagnosed with AHT and three parenchymal lacerations and had a 2.5 hour period of normal neurological status prior to acute decompensation.

Retinal hemorrhage variation in inertial versus contact head injuries.

BACKGROUND: Abusive head trauma (AHT) is frequently accompanied by dense/extensive retinal hemorrhages to the periphery with or without retinoschisis (complex retinal hemorrhages, cRH). cRH are uncommon without AHT or major trauma. OBJECTIVE: The study objectives were to determine whether cRH are associated with inertial vs. contact mechanisms and are primary vs. secondary injuries. PARTICIPANTS AND SETTING: This retrospective study utilized a de-identified PediBIRN database of 701 children <3-years-old presenting to intensive care for head trauma. Children with motor vehicle related trauma and preexisting brain abnormalities were excluded. All had imaging showing head injury and a dedicated ophthalmology examination. METHODS: Contact injuries included craniofacial soft tissue injuries, skull fractures and epidural hematoma. Inertial injuries included acute impairment or loss of consciousness and/or bilateral and/or interhemispheric subdural hemorrhage. Abuse was defined in two ways, by 1) predetermined criteria and 2) caretaking physicians/multidisciplinary team's diagnostic consensus. RESULTS: PediBIRN subjects with cRH frequently experienced inertial injury (99.4 % (308/310, OR = 53.74 (16.91-170.77)) but infrequently isolated contact trauma (0.6 % (2/310), OR = 0.02 (0.0004-0.06)). Inertial injuries predominated over contact trauma among children with cRH sorted AHT by predetermined criteria (99.1 % (237/239), OR = 20.20 (6.09-67.01) vs 0.5 % (2/339), OR = 0.04 (0.01-0.17)). Fifty-nine percent of patients with cRH, <24 h altered consciousness, and inertial injuries lacked imaging evidence of brain hypoxia, ischemia, or swelling. CONCLUSIONS: cRH are significantly associated with inertial angular acceleration forces. They can occur without brain hypoxia, ischemia or swelling suggesting they are not secondary injuries.

Predictors of neurologic outcomes and mortality in physically abused and unintentionally injured children: a retrospective observation study.

OBJECTIVES: This study aimed to identify the predictors of neurologic outcomes and mortality in physically abused and unintentionally injured children admitted to intensive care units (ICUs). METHODS: All maltreated children were admitted to pediatric, neurosurgical, and trauma ICUs between 2001 and 2019. Clinical factors, including age, sex, season of admission, identifying settings, injury severity score, etiologies, length of stay in the ICU, neurologic outcomes, and mortality, were analyzed and compared between the physically abused and unintentionally injured groups. Neurologic assessments were conducted using the Pediatric Cerebral Performance Category scale. The study was approved by the Institutional Review Board of Chang Gung Memorial Hospital and the Ethics Committee waived the requirement for informed consent because of the anonymized nature of the data. RESULTS: A total of 2481 children were investigated; of them, there were 480 (19.3%) victims admitted to the ICUs, including 156 physically abused and 324 unintentionally injured. Age, history of prematurity, clinical outcomes, head injury, neurosurgical interventions, clinical manifestations, brain computed tomography findings, and laboratory findings significantly differed between them (all p < 0.05). Traumatic brain injury was the major etiology for admission to the ICU. The incidence of abusive head trauma was 87.1% among the physically abused group. Only 46 (29.4%) and 268 (82.7%) cases achieved favorable neurologic outcomes in the physically abused and unintentionally injured groups, respectively. Shock within 24 h, spontaneous hypothermia (body temperature, < 35 °C), and post-traumatic seizure were strongly associated with poor neurologic outcomes and mortality in both groups. CONCLUSIONS: Initial presentation with shock, spontaneous hypothermia at ICU admission, and post-traumatic seizure were associated with poor neurologic outcomes and mortality in physically abused and unintentionally injured children.

Head trauma analysis of laboratory reconstructed headers using 1966 Slazenger Challenge and 2018 Telstar 18 soccer balls.

Retired soccer players are presenting with early onset neurodegenerative diseases, potentially from heading the ball. It has been proposed that the older composition of soccer balls places higher strains on brain tissues. The purpose of this research was to compare the dynamic head response and brain tissue strain of laboratory reconstructed headers using replicas of the 1966 Slazenger Challenge and 2018 Telstar 18 World Cup soccer balls. Head-to-ball impacts were physically conducted in the laboratory by impacting a Hybrid III head form at three locations and four velocities using dry and wet soccer ball conditions, and computational simulation was used to measure the resulting brain tissue strain. This research showed that few significant differences were found in head dynamic response and maximum principal strain between the dry 1966 and 2018 balls during reconstructed soccer headers. Headers using the wet 1966 soccer ball resulted in higher head form responses at low-velocity headers and lower head responses as velocities increased. This study demonstrates that under dry conditions, soccer ball construction does not have a significant effect on head and brain response during headers reconstructed in the laboratory. Although ball construction didn't show a notable effect, this study revealed that heading the ball, comparable to goalkeeper kicks and punts at 22 m/s, led to maximum principal strains exceeding the 50% likelihood of injury risk threshold. This has implications for the potential risks associated with repetitive heading in soccer for current athletes.

The Structural Response of the Human Head to a Vertex Impact.

In experimental models of cervical spine trauma caused by near-vertex head-first impact, a surrogate headform may be substituted for the cadaveric head. To inform headform design and to verify that such substitution is valid, the force-deformation response of the human head with boundary conditions relevant to cervical spine head-first impact models is required. There are currently no biomechanics data that characterize the force-deformation response of the isolated head supported at the occiput and compressed at the vertex by a flat impactor. The effect of impact velocity (1, 2 or 3 m/s) on the response of human heads (N = 22) subjected to vertex impacts, while supported by a rigid occipital mount, was investigated. 1 and 2 m/s impacts elicited force-deformation responses with two linear regions, while 3 m/s impacts resulted in a single linear region and skull base ring fractures. Peak force and stiffness increased from 1 to 2 and 3 m/s. Deformation at peak force and absorbed energy increased from 1 to 2 m/s, but decreased from 2 to 3 m/s. The data reported herein enhances the limited knowledge on the human head's response to a vertex impact, which may allow for validation of surrogate head models in this loading scenario.

Abusive head trauma in infants: An observational single centre study comparing developmental and functional outcome between 18 months and 5 years.

BACKGROUND: Abusive head trauma (AHT) is a major cause of traumatic brain injury in infancy. This exploratory study compared standardized developmental assessment versus functional outcome assessment between 18 months and 5 years of age following AHT in infancy. METHODS: Observational cross-sectional study after surviving AHT in infancy. Seventeen children between 18 months and 5 years of age underwent clinical examination, developmental assessment using the Schedule of Growing Skills II (SGS II) and functional assessment using the Glasgow Outcome Scale-Extended Pediatric Revision (GOS-E Peds). Additional clinical information was extracted from medical records. RESULTS: Age at assessment ranged from 19 to 53 months (median 26 months). Most (n = 14) were delayed in at least 1 domain, even without neurological or visual impairment or visible cortical injury on neuroimaging, including 8 children with favourable GOS-E Peds scores. The most affected domain was hearing and language. Delay in the manipulative domain (n = 6) was associated with visual and/or neurological impairment and greater severity of delay across multiple domains. Eleven (64.7 %) had GOS-E Peds scores indicating good recovery, with positive correlation between GOS-Peds scores and number of domains delayed (r = 0.805, p < 0.05). CONCLUSION: The SGS-II detects behavioural and cognitive deficits not picked up by the GOS-E Peds. Combining both tools for assessment of AHT survivors under 5 years of age provides a comprehensive profile which addresses multiple domains of development and function, facilitating targeted intervention. Detection of developmental problems in the majority of survivors makes AHT prevention a public health priority.

Adolescent alcohol and cannabis use as risk factors for head trauma in the Northern Finland Birth Cohort study 1986.

BACKGROUND: The aim of this study was to assess the associations between cannabis use and frequency of alcohol intoxication in adolescence with the risk of traumatic brain injury and craniofacial fractures in early adulthood. Hypothesis was that using alcohol and cannabis in adolescence could increase the risk for head traumas. METHODS: Data from the Northern Finland Birth Cohort 1986 (n = 9432 individuals) were used to investigate the prospective association between the self-reported frequency of alcohol intoxication (n = 6472) and cannabis use (n = 6586) in mid-adolescence and register-based, head trauma diagnoses by ages 32-33 years. To test the robustness of these associations, the statistical models were adjusted for a range of other confounders such as illicit drug use, previous head trauma and self-reported mental health problems. RESULTS: In multivariate analyses, cannabis use was statistically significantly associated with a greater risk of traumatic brain injury among females [hazard ratio (HR) 1.9, 95% confidence interval (CI) 1.1-3.2, P = 0.024). Frequent alcohol intoxication was a statistically significant independent risk factor for both traumatic brain injury (HR 2.6, 95% CI 1.7-3.9, P < 0.001) and craniofacial fractures (HR 2.7, 95% CI 1.6-4.8, P < 0.001) among males. CONCLUSIONS: Cannabis use in adolescence appears to associate independently with elevated risk for traumatic brain injury among females, and frequent alcohol intoxication in adolescence seems to associate with elevated risk of both traumatic brain injury and craniofacial fractures among males.

ICD-10 codes for surveillance of non-fatal abusive head trauma in Aotearoa New Zealand: a retrospective cohort study.

OBJECTIVES: To assess the validity of an International Classification of Diseases (ICD) code based definition of non-fatal head trauma caused by child abuse (abusive head trauma) for population surveillance in New Zealand. DESIGN: A retrospective cohort study of hospital inpatient records. SETTING: A tertiary children's hospital in Auckland, New Zealand. PARTICIPANTS: 1731 children less than 5 years of age who were discharged after a non-fatal head trauma event over a 10-year period from 1 January 2010 to 31 December 2019. OUTCOME MEASURES: The outcome of assessment by the hospital's multidisciplinary child protection team (CPT) was compared with the outcome of ICD, Tenth Revision (ICD-10) discharge coding for non-fatal abusive head trauma (AHT). The ICD-10 code definition of AHT was derived from an ICD, Ninth Revision, Clinical Modification definition developed by the Centers for Disease Control, Atlanta, Georgia, which requires both a clinical diagnosis code and a cause-of-injury code. RESULTS: There were 1755 head trauma events with 117 determined as AHT by the CPT. The ICD-10 code definition had a sensitivity of 66.7% (95% CI 57.4 to 75.1) and specificity of 99.8% (95% CI 99.5 to 100). There were only three false positives but 39 false negatives, with 18 of the false negatives coded with X59 (exposure to unspecified factor). CONCLUSIONS: The ICD-10 code broad definition of AHT is a reasonable epidemiological tool for passive surveillance of AHT in New Zealand but it underestimates the incidence. Its performance could be improved by clear documentation of child protection conclusions in clinical notes, clarifying coding practice and removing the exclusion criteria from the definition.

Comparisons of characteristics and outcome between abusive head trauma and non-abusive head trauma in a pediatric intensive care unit.

BACKGROUND: Abusive head trauma (AHT) is the leading cause of death in infants with traumatic brain injury (TBI). Early recognition of AHT is important for improving outcomes, but it can be challenging due to its similar presentations with non-abusive head trauma (nAHT). This study aims to compare clinical presentations and outcomes between infants with AHT and nAHT, and to identify the risk factors for poor outcomes of AHT. METHODS: We retrospectively analyzed infants of TBI in our pediatric intensive care unit from January 2014 to December 2020. Clinical manifestations and outcomes were compared between patients with AHT and nAHT. Risk factors for poor outcomes in AHT patients were also analyzed. RESULTS: 60 patients were enrolled for this analysis, including 18 of AHT (30%) and 42 of nAHT (70%). Compared with those with nAHT, patients with AHT were more likely to have conscious change, seizures, limb weakness, and respiratory failure, but with a fewer incidence of skull fractures. Additionally, clinical outcomes of AHT patients were worse, with more cases undergoing neurosurgery, higher Pediatric Overall Performance Category score at discharge, and more anti-epileptic drug (AED) use after discharge. For AHT patients, conscious change is an independent risk factor for a composite poor outcome of mortality, ventilator dependence, or AED use (OR = 21.9, P = 0.04) CONCLUSION: AHT has a worse outcome than nAHT. Conscious change, seizures and limb weaknesses but not skull fractures are more common in AHT. Conscious change is both an early reminder of AHT and a risk factor for its poor outcomes.

Assessment of child safety on bicycles in baby carriers - The importance of evaluating both head and neck injuries.

INTRODUCTION: The paper addresses an important accident type that involves children in bicycle seats - the bicycle fall over. It is a significant and common accident type and many parents have been reported to experience this type of "close call." The fall over occurs at low velocities and even while a bicycle is standing still, and may result from a split-second lack of attention on behalf of the accompanying adult (e.g. while loading groceries, i.e. while not being exposed to traffic per se). Moreover, irrespective of the low velocities involved, the trauma that may result to the head of the child is considerable and may be life-threatening, as shown in the study. METHOD: The paper presents two methods to address this accident scenario in a quantitative way: in-situ accelerometer-based measurement and numerical modeling approaches. It is shown that the methods produce consistent results under the prerequisites of the study. They are therefore promising methods to be used in the study of this type of accident. RESULTS: The importanance of the protective role of a child helmet is without discussion in everyday traffic.However, this study draws attention to one particular effect observed in this accident type: that the geometry of the helmet may at times expose the child's head to considerably larger forces, by having contact with the ground. The study also highlights the importance of neck bending injuries during bicycle fall over, which are often neglected in the safety assessment - not only for children in bicycle seats. The study concludes that considering only head acceleration may lead to biased conclusions about using helmets as protective devices.

Effectiveness of Wearable Protection Equipment for Seated Pedestrians.

This study used finite element models to investigate the efficacy of seated pedestrian protection equipment in vehicle impacts. The selected safety equipment, a lap belt, an airbag vest, and a bicycle helmet, were chosen to mitigate the underlying biomechanical causes of seated pedestrian injuries reported in the literature. The impact conditions were based on the three most dangerous impact scenarios from a previous seated pedestrian impact study. Serious injury (AIS 3+) risks were compared with and without protective equipment. A 50th percentile male occupant model and two generic vehicle models, the family car (FCR) and sports utility vehicle (SUV), were used to simulate vehicle collisions. Three impact conditions were run with every combination of protective equipment (n = 24). The helmet reduced head and brain injury risks from the vehicle-head and ground-head contacts. The airbag reduced the head injury risk in the FCR vehicle-head contact but increased the brain injury risks in the SUV impacts from increased whiplash. The lap belt increased head injury risks for both the FCR and the SUV impacts because it created a stronger FCR vehicle-head contact and SUV ground-head contact. When the belt and airbag were used together the head injury risks dramatically decreased because the pedestrian body impacted the ground arm or leg first and slowly rolled onto the ground which resulted in softer ground-head contacts and in two instances, no ground-head contact. Only the helmet proved effective in all impact conditions. Future testing must be completed before recommending the belt or airbag for seated pedestrians.

Exercise Resistance Band induced injuries during Covid 19 Pandemic Lockdown Training.

The COVID-19 (coronavirus disease 2019) pandemic forces athletes to perform their workout at home with alternative training methods. Exercise resistance bands, often used for this purpose, can cause damage when they recoil or tear. Potentially resulting injuries include bruises, head injuries, lacerations, facial fractures and eye injuries. The following article presents two case reports including accident mechanism, injuries, diagnostic evaluation and treatment.The first patient presented with an open depressed skull fracture caused by a recoiling exercise resistance band, while the second patient sustained a complex ocular trauma caused by a tearing exercise resistance band when performing supported chin-ups.

Injury Pattern and Outcomes Following All-Terrain Vehicle Accidents in Kentucky Children: A Retrospective Study.

PURPOSE: All-terrain vehicles (ATVs) pose a significant risk for morbidity and mortality amongst children. We hypothesize that current vague legislation regarding helmet use impacts injury patterns and outcomes in pediatric ATV accidents. METHODS: The institutional trauma registry was queried for pediatric patients involved in ATV accidents from 2006 to 2019. Patient demographics and helmet wearing status were identified in addition to patient outcomes, such as injury pattern, injury severity score, mortality, length of stay, and discharge disposition. These elements were analyzed for statistical significance. RESULTS: 720 patients presented during the study period, which were predominantly male (71%, n = 511) and less than 16 years old (76%, n = 543). Most patients were not wearing a helmet (82%, n = 589) at time of injury. Notably, there were 7 fatalities. A lack of helmet use is positively associated with head injury (42% vs 23%, P < .01), intracranial hemorrhage (15% vs 7%, P = .03), and associated with lower Glasgow Coma Scale (13.9 vs 14.4, P < .01). Children 16 years and older were least likely to wear a helmet and most likely to incur injuries. Patients over 16 years had longer lengths of stay, higher mortality, and higher need for rehabilitation. CONCLUSION: Not wearing a helmet is directly correlated with injury severity and concerning rates of head injury. Children 16 years and older are at greatest risk for injury, but younger children are still at risk. Stricter state laws regarding helmet use are necessary to reduce pediatric ATV-related injury burden. LEVEL OF EVIDENCE: level III retrospective comparative study.

Head injuries caused by contact with teeth during sports and exercise activities in Japanese schools during the period 2012-2018.

BACKGROUND/AIM: During sports activities, teeth-related contact can cause injury to both ally and opponent players, which can lead to potential infections and aesthetic problems. However, the extent of such injuries remains unclear. This study aimed to clarify the frequency and situation of head injuries caused by teeth (HICBT) occurring under the supervision of schools in Japan. MATERIAL AND METHODS: HICBT records were extracted from the Japan Sport Council data on head injuries occurring reported during the 7-year period from 2012 to 2018 under the supervision of schools in Japan. RESULTS: Of the total 463,527 head injury cases during the study period, 4495 cases (approximately 1%) were HICBT. Of the HICBT cases, 3650 (81.20%) were related to sports and athletic activity. Such injuries were reported to occur most often during basketball with a rate of 57.07% and 50.43%; soccer/futsal was the next most common sport with a rate of 13.38% and 24.01% in junior high school and high school students. Tag games were responsible for a similar number of HICBT cases at 22.73% and 39.03% in kindergartens and elementary school students. CONCLUSIONS: A total of 4495 cases of HICBT were identified, accounting for about 1% of all head injuries under the supervision of schools in Japan during the study period. This result reminds us that our teeth could be the weapon against the players during sports events. HICBTs occurring during basketball and soccer/futsal, in which mouthguards are not mandatory, were conspicuous among junior and senior high school students. Active use of mouthguards in various sports will protect players as well as their teammates and opponents. Sports dentists should encourage the revision of rules, such as mandating the use of mouthguards, in popular sports with a high incidence of HICBT, such as basketball and soccer/futsal.