Clinical and laboratory observation

Retinal hemorrhage after cardiopulmonary resuscitation or child abuse

Few deaths receive a more extensive investigation than the untimely deaths of infants and children. A scene reenactment is an integral part of many pediatric investigations and may be as valuable, or sometimes more valuable, than the autopsy itself. Knowledge of the decedent’s medical history and any significant family history can contribute to an understanding of pediatric deaths. The investigation of infant and child deaths usually requires a more wide-ranging approach than that of adult deaths. As such, there are variations in the autopsy procedures and additional special studies. A detailed approach to the pediatric autopsy is included. Pediatric trauma, including child abuse (head and abdominal injuries) and the investigation of whether a baby was stillborn or live born are discussed. Neglect and death certification (sudden unexpected infant death, sudden infant death syndrome, sudden unexplained death in childhood, and sudden unexpected death in pediatrics) are also explored.

Hypoxia and cardiopulmonary resuscitation (CPR) have been proposed as causes of retinal hemorrhage (RH) in children evaluated for abusive head trauma (AHT). We sought to determine the prevalence and characteristics of RH in children who underwent CPR after cardiac arrest.

This was a prospective, single-center, consecutive observational study of 38 children (<18 years of age). Indirect ophthalmoscopic examination was completed by an ophthalmologist within 48 hours of CPR. Extensive medical records data were collected to assess for potential confounding factors. Outcomes included the presence and pattern of RH.

Of the 38 children, 20 had in-hospital arrest; 18 had out-of-hospital arrest. The median duration of CPR was 10 minutes. Seven children had RH, of whom 6 had an RH pattern consistent with coexistent medical conditions: 4 AHT diagnosable with nonocular findings, including subdural and subarachnoid hemorrhage, rib fractures, abdominal injury (RH pattern: diffuse, numerous, intraretinal and/or multilayered RH); 1 septic shock (RH pattern: 1-2 posterior pole RH); 1 ruptured arteriovenous malformation (RH pattern: 4-8 peripapillary RH). The seventh child had unwitnessed cardiac arrest due to nonfatal drowning and a single superficial intraretinal peripapillary hemorrhage.

CPR for cardiac arrest is rarely associated with RH, which, absent coexisting conditions causing retinal hemorrhage, are intraretinal, few in number, and located in the posterior pole. In children who have undergone CPR, when RH are multilayered, or are more than a few in number, or extend outside the posterior pole, another etiology for the RH should be sought.

Nonaccidental head injury in children (NAHI), most often due to abusive head trauma (AHT), is not uncommon and carries a high risk of mortality and morbidity. Intracranial lesions encountered are mainly subdural hematomas. Despite heterogeneous clinical presentation, symptoms are related to brain edema with intracranial hypertension and/or seizures that should prompt early diagnosis and treatment.

Two main differential diagnoses are glutaric aciduria type 1 and Menkes disease, two inborn errors of metabolism that require specific diagnostic procedures and treatment.

The aim of emergency treatment is to control seizures, prevent seizure recurrence, and decrease intracranial pressure. Because NAHI/AHT carries a worse prognosis than accidental head traumatism – with specific risk factors such as initial clinical status, age, aspect of initial CT scan, associated retinal hemorrhage, seizure recurrence – these children need close clinical, neurological, and radiological monitoring in neurointensive care units.

It is therefore important to identify the nonaccidental origin of the injury at the earliest opportunity so that the appropriate intervention, including social evaluation and reporting suspected cases to judicial authorities, can be made to protect the child from further harm.