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peds.abusive-head-trauma.v1

Abusive head trauma / non-accidental trauma in infants

pediatricsacutepediatricacuteinpatient
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NEW pediatric dossier (lane-D 2026-05-26). Manifest authored at prisma/seed/manifests/peds.abusive-head-trauma.v1.ts. All RxCUIs RxNav-verified (forward + reverse) on 2026-05-26: mannitol 6628, levetiracetam 114477, phytonadione (vitamin K1) 8308. Hypertonic saline 3% and FFP/cryoprecipitate are non_pharm composites (no single RxCUI). PMIDs verified via PubMed MCP on 2026-05-26: 19403508 Christian AAP 2009 abusive head trauma in infants and children (canonical AHT consensus); 20660545 Levin AAP 2010 eye examination in child abuse (dilated retinal exam); 26900382 Glauser AES 2016 status epilepticus (cross-reference for post-traumatic seizures). Workup IDs omitted as not in registry: abusive_head_trauma, skeletal_survey, retinal_exam — orchestrator may add later. Used safe registry workups: workup.encephalopathy, workup.pediatric_fever, workup.first_seizure. Calculator gap: Hymel PECARN-AHT clinical decision rule not in registry; used calc.gcs (resolves) for severity classification. Largely non-pharmacologic workflow per AAP — multidisciplinary team is the foundation; pharmacotherapy is supportive (hyperosmolar for ICP, levetiracetam for AED prophylaxis, vitamin K + FFP for coagulopathy). CPS reporting is mandatory per state law; encoded as non_drug_action with "per state law" notation. Sibling differentiation from peds.head-injury-mtbi.v1 (accidental TBI) and peds.status_epilepticus.v1 (post-traumatic seizures) provided.

Entry points (5)

  • history
    Caregiver-reported "minor fall" or trivial mechanism with severe intracranial injury in an infant < 3 yr (Christian AAP 2009 PMID 19403508)
    history_injury_mismatch_infant
  • symptom
    BRUE-like event in infant < 6 mo with no explanation — abusive head trauma differential (Christian AAP 2009)
    brue_unexplained_under_6mo
  • imaging
    Unexplained subdural hemorrhage or intracranial hemorrhage on CT/MRI in an infant (Christian AAP 2009)
    unexplained_subdural_or_ich_infant
  • symptom
    Retinal hemorrhages on dilated ophthalmologic exam in an infant (Levin AAP 2010 PMID 20660545)
    retinal_hemorrhages_in_infant
  • symptom
    Bruising in non-mobile infant ("those who don't cruise rarely bruise" Sugar 1999) — AHT screen mandated (Christian AAP 2009)
    bruising_in_non_mobile_infant

Required inputs (19)

  • agerequired
    demographic • used at FRAME
    Peak AHT < 6 mo; age < 3 yr is sentinel risk band; mobility status affects bruise interpretation (Christian AAP 2009)
  • weightrequired
    demographic • used at CONTEXT
    All dosing for hyperosmolar therapy, AED loading, vitamin K weight-based (AAP Red Book 2024-2027, Lexicomp Peds)
  • developmental_milestonesrequired
    demographic • used at CONTEXT
    Distinguish mobile from non-mobile infant — non-mobile bruises are red flag (Sugar 1999; Christian AAP 2009)
  • reported_mechanism_vs_injury_severityrequired
    history • used at FRAME
    History-injury mismatch is a cardinal AHT feature (Christian AAP 2009)
  • caregiver_structurerequired
    history • used at CONTEXT
    Single parent, partner-of-non-parent, unrelated male caregiver, caregiver-stress factors raise AHT prior (Christian AAP 2009)
  • prior_cps_involvementrequired
    history • used at CONTEXT
    Prior CPS involvement OR prior similar events in this infant or siblings raises AHT prior (Christian AAP 2009)
  • social_history_substance_ipv_mental_healthrequired
    history • used at CONTEXT
    Substance use, intimate partner violence, caregiver mental health, social-isolation features (Christian AAP 2009)
  • gcsrequired
    vital • used at RED_FLAGS
    Severity + airway protection threshold (PALS 2020)
  • sbprequired
    vital • used at RED_FLAGS
    Cushing's triad (HTN + bradycardia) signals ICP crisis (Christian AAP 2009)
  • hrrequired
    vital • used at RED_FLAGS
    Bradycardia in Cushing's triad
  • rrrequired
    vital • used at RED_FLAGS
    Respiratory pattern — apnea / Cheyne-Stokes signals herniation (PALS 2020)
  • head_ct_noncontrastrequired
    imaging • used at INITIAL_WORKUP
    First-line for acute hemorrhage (Christian AAP 2009)
  • mri_brain_cervical_spinerequired
    imaging • used at INITIAL_WORKUP
    Detail of subdural, parenchymal injury, axonal injury, cervical-cord injury (Christian AAP 2009)
  • skeletal_survey_complete_seriesrequired
    imaging • used at INITIAL_WORKUP
    Complete AP + lateral series at presentation; repeat at 2 weeks for occult metaphyseal lesions (Christian AAP 2009; ACR Appropriateness)
  • dilated_retinal_exam_by_ophthalmologyrequired
    imaging • used at INITIAL_WORKUP
    Indirect ophthalmoscopy through dilated pupil by ophthalmology — number / type / pattern / distribution differentiates AHT from other causes (Levin AAP 2010 PMID 20660545)
  • cbc_with_diffrequired
    lab • used at INITIAL_WORKUP
    Anemia from hemorrhage, thrombocytopenia (Christian AAP 2009)
  • coagulation_panel_pt_inr_apttrequired
    lab • used at INITIAL_WORKUP
    Rule out coagulopathy as alternative explanation (Christian AAP 2009)
  • factor_viii_ix_vwf
    lab • used at BRANCHING_WORKUP
    Hemophilia + vWD screen — alternative bleeding diathesis (Christian AAP 2009)
  • lft_for_occult_abdominal_traumarequired
    lab • used at INITIAL_WORKUP
    AST/ALT elevation flags occult abdominal trauma (Christian AAP 2009)

12-phase flow (12)

  1. 1FRAME
    Confirm AHT differential: history-injury mismatch, multiple injuries different ages, retinal hemorrhages, subdural hematoma without explanation, fractures inconsistent with mechanism (Christian AAP 2009 PMID 19403508)
    inputs: age, reported_mechanism_vs_injury_severity
    advance: AHT considered in differential + multidisciplinary team alerted
  2. 2ENTRY
    Caregiver-reported minor fall with severe injury, BRUE < 6 mo, unexplained ICH on imaging, retinal hemorrhages, bruising in non-mobile infant (Christian AAP 2009)
    inputs: age
    advance: Entry trigger captured + AHT workup initiated
  3. 3CONTEXT
    Age (esp < 3 yr), birth history, developmental milestones, caregiver structure, prior CPS, prior similar events, social-history red flags (substance use, IPV, mental health) (Christian AAP 2009)
    inputs: weight, developmental_milestones, caregiver_structure, prior_cps_involvement, social_history_substance_ipv_mental_health
    advance: Context complete + social work consulted
  4. 4RED_FLAGS
    Coma (GCS ≤ 8), seizure, focal neuro deficit, bulging fontanelle, Cushing's triad (HTN + bradycardia + irregular respiration), retinal hemorrhages, bruising in non-mobile infant, multiple fractures different ages, posturing (Christian AAP 2009)
    inputs: gcs, sbp, hr, rr
    advance: Life-threatening features identified + ABC addressed + neurosurgery consulted
  5. 5INITIAL_WORKUP
    Head CT non-contrast (acute hemorrhage); MRI brain + cervical spine (parenchymal injury, axonal injury, subdural detail, spinal cord injury); dilated ophthalmologic exam by ophthalmology (Levin AAP 2010 PMID 20660545); complete skeletal survey AP + lateral; CBC + coags + factor VIII/IX/vWF; LFTs (occult abdominal trauma) (Christian AAP 2009)
    inputs: head_ct_noncontrast, mri_brain_cervical_spine, dilated_retinal_exam_by_ophthalmology, skeletal_survey_complete_series, cbc_with_diff, coagulation_panel_pt_inr_aptt, lft_for_occult_abdominal_trauma
    actions: workup.encephalopathy, workup.pediatric_fever, panel.cbc, panel.coag, panel.lft
    advance: Baseline workup complete + child-abuse pediatrics consulted
  6. 6BRANCHING_WORKUP
    Repeat skeletal survey at 2 weeks (occult metaphyseal lesions); bone scan if equivocal; abdominal CT if LFT elevation; metabolic workup for IEM mimics (organic acid, ammonia, lactate, plasma amino acids); genetics consult if osteogenesis imperfecta suspected (Christian AAP 2009)
    inputs: factor_viii_ix_vwf
    advance: Differential narrowed; alternative explanations excluded
  7. 7DIFFERENTIAL
    AHT vs accidental (mechanism correlates with history); birth-related subdural (resolves by 4 wk typically); hemorrhagic disease of newborn (vitamin K deficiency); glutaric aciduria type 1; osteogenesis imperfecta; benign external hydrocephalus; coagulopathy; accidental scalp injury (Christian AAP 2009)
    advance: Differential narrowed + multidisciplinary review documented
  8. 8RISK_STRATIFICATION
    Hymel/PECARN-AHT clinical decision rule — 4-feature screen: respiratory compromise, bruising of torso/ear/neck, scalp swelling, age < 24 mo with serious head injury or altered MS (Hymel PECARN-AHT validation literature)
    inputs: gcs, age
    advance: Risk tier documented + multidisciplinary plan in place
  9. 9TREATMENT
    Non-pharm primary: PICU + neurosurgery for evacuable hemorrhage + intubation for airway protection if GCS ≤ 8 + social work + CPS + law enforcement + multidisciplinary team. Pharm supportive: mannitol or hypertonic saline for ICP crisis, levetiracetam for seizure prophylaxis, FFP + vitamin K for coagulopathy reversal (Christian AAP 2009; PALS 2020)
    inputs: weight
    advance: Treatment plan documented + CPS notified + ophthalmology + child-abuse pediatrics + neurosurgery engaged
  10. 10DISPOSITION
    PICU mandatory for severe (GCS ≤ 8, ICP crisis, post-op); ward observation with monitoring + safety planning for moderate; CPS placement decision before discharge — DO NOT discharge to suspected perpetrator (Christian AAP 2009)
    advance: Disposition + level of care set + safety plan in place
  11. 11MONITORING
    ICP, neuro q1 h, seizure precautions, cEEG if intubated or sedated, daily neuro exam, social work follow-up, repeat skeletal survey at 2 weeks (Christian AAP 2009; AES 2016)
    advance: Monitoring orders documented
  12. 12FOLLOWUP
    Pediatric neurology + neurosurgery + ophthalmology (Levin AAP 2010) + developmental pediatrics + early intervention + mental health for sibling cohort + CPS / foster placement coordination + court testimony preparation (Christian AAP 2009)
    advance: Follow-up + early intervention + CPS placement documented