This handout is for abusive head trauma / non-accidental trauma in infants. Your care team identified this based on: caregiver-reported "minor fall" or trivial mechanism with severe intracranial injury in an infant < 3 yr (christian aap 2009 pmid 19403508).
Other reasons your team may use this plan: brue-like event in infant < 6 mo with no explanation — abusive head trauma differential (christian aap 2009); unexplained subdural hemorrhage or intracranial hemorrhage on ct/mri in an infant (christian aap 2009); retinal hemorrhages on dilated ophthalmologic exam in an infant (levin aap 2010 pmid 20660545).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| PICU admission + neurosurgery consultation + multidisciplinary team | Mandatory for all suspected AHT — PICU + neurosurgery + child-abuse pediatrics + social work + ophthalmology + CPS notification per state law | — | — | Christian AAP 2009 PMID 19403508 — multidisciplinary team is the foundation; non-pharmacologic and mandatory |
| complete skeletal survey AP + lateral series + repeat at 2 weeks | Complete AP + lateral series at presentation per ACR Appropriateness; repeat at 2 weeks (occult metaphyseal lesions become visible) | — | — | Christian AAP 2009 — repeat skeletal survey detects occult / healing fractures not visible at presentation |
| dilated retinal exam by ophthalmology (indirect ophthalmoscopy) | Within 24-72 h of presentation by ophthalmology (NOT bedside fundoscopy); document number, type, pattern, distribution (Levin AAP 2010 PMID 20660545) | — | — | Levin AAP 2010 PMID 20660545 — pattern of retinal hemorrhages differentiates AHT from other causes; bedside fundoscopy inadequate |
| CPS notification per state law + law enforcement notification | Mandatory reporting per state law (all 50 states + DC mandate physician reporting of suspected child abuse) | — | — | Christian AAP 2009 — mandatory reporting protects child + initiates investigation; reasonable suspicion is the threshold, not proof |
| neuroprotective ICU care (HOB 30°, normothermia, normocarbia 35-40 mmHg, target CPP, minimal handling) | HOB 30°, normothermia (avoid hyperthermia, target T 36.5-37.5°C), normocarbia (PaCO2 35-40), target CPP age-appropriate, minimal handling protocol | — | — | PALS 2020 + ICS pediatric severe TBI consensus — neuroprotective bundle reduces secondary brain injury |
| mannitol | 0.25-1 g/kg IV q4-6h PRN for ICP crisis | IV | PRN q4-6h | ICS pediatric severe TBI consensus — hyperosmolar therapy first-line for ICP crisis; check serum osm + Na before each dose (avoid >320 mOsm; AAP Red Book 2024-2027, Lexicomp Peds) |
| hypertonic saline 3% NaCl | 3-5 mL/kg IV bolus over 10-15 min for ICP crisis; may follow with continuous infusion 0.1-1 mL/kg/h titrated to serum Na 145-155 mEq/L | IV | bolus + infusion | ICS pediatric severe TBI consensus — preferred over mannitol when hypovolemic or hypotensive; weight-based dosing (Lexicomp Peds; AAP Red Book 2024-2027) — listed as non_pharm because 3% NaCl is a compounded concentration not a single RxCUI |
| levetiracetam | 20-40 mg/kg IV loading dose over 15 min, then 30-60 mg/kg/day divided BID for 7-day post-traumatic seizure prophylaxis | IV/PO | BID after load | ICS pediatric severe TBI consensus — AED prophylaxis for severe TBI reduces 7-day post-traumatic seizure incidence; levetiracetam preferred over phenytoin (no cardiac monitoring, no enzyme interactions); AVOID valproate < 2 yr (hepatotoxicity) (AAP Red Book 2024-2027, Lexicomp Peds) |
| phytonadione (vitamin K1) | 0.3 mg/kg IV/IM/SC slow IV (max 10 mg single dose); for vitamin-K deficiency reversal in suspected hemorrhagic disease of newborn DDx | IV/IM/SC | single dose, may repeat per INR | Reverses vitamin-K-dependent coagulopathy that mimics AHT (hemorrhagic disease of newborn); use slow IV due to anaphylactoid risk (AAP Red Book 2024-2027, Lexicomp Peds) |
| fresh frozen plasma + cryoprecipitate | FFP 10-15 mL/kg IV for INR > 1.5; cryoprecipitate 1 unit/5-10 kg for fibrinogen < 100 | IV | per coagulopathy + bleeding | AAP transfusion guidance — blood-product reversal for active bleeding + coagulopathy |
Plan: Abusive head trauma — neuroprotective supportive care + ICP rescue + seizure prophylaxis (Christian AAP 2009)
Call 911 or go to the nearest emergency room right away if you have:
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)
Guideline: Christian AAP 2009 PMID 19403508 (abusive head trauma in infants and children) + Levin AAP 2010 PMID 20660545 (eye examination in child abuse) + AES 2016 Glauser PMID 26900382 (status epilepticus cross-reference) + ICS pediatric severe TBI consensus + PALS 2020