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Controversy # 4
A Child Becomes Immediately Unconscious After Incurring a Subdural Hematoma
There is little controversy in the field of head injuries as to whether
it is possible for an adult to suffer an impact to the head and appear
relatively normal, until some time later when the individual collapses
and dies. The undefined period of time between impact and loss of consciousness
or death, when consciousness seems to be relatively unaffected, is referred
to as a "lucid interval." The phenomenon has been described
by several different names in different bodies of literature, but it is
generally agreed to occur. Doctors specializing in sports medicine have
coined the term "Second Impact Syndrome" to describe athletes
who incur a blow to the head and suffer little to no alteration in consciousness,
until hours or days later when the unexpectedly lapse into unconsciousness
or death (1). Pediatricians use the term "Talk and deteriorate or
Die" or TADD to describe the lucid intervals in individuals with
epidural hematomas (2). It is the very reason we keep people under 24-hour
observation when they have suffered a major head injury and why parents
are told to wake up their children periodically after such an event. Apparently
the only controversy that persists is whether the phenomena can occur
in babies with subdural hematomas. The states experts argue that lucid
intervals do not occur in children because children are somehow different
than adults. This contention is not only unsupported by any evidence or
explanation and is refuted by logic and published literature in the field
(3).
Recent studies have shown that lucid intervals are fairly common with subdural hematomas. In Plunkett's 2001 study of short falls from playground equipment, 12 of the 18 children had lucid intervals with lengths ranging from 5 minutes to 48 hours. It has also long been recognized that intracranial injuries may go undiagnosed or may be misdiagnosed as something benign only to result in complications later (4,5,6). Several studies have recently called into question our ability to time injuries based on an unproven theory that decomposition begins immediately after the SDH is formed (7,8,9).
Even the trial testimony of leading prosecution supports the existence of a lucid interval after a subdural hematoma. Prosecution witness Randall Alexander has testifies that subdural hematomas can often be mistaken for gastroenteritis or other minor childhood ailments (10) and that as many as 50% of the SBS cases have evidence of an old subdural hematoma. We know from the cases themselves that many of these children have been seen by doctors or have been cared for by parents who are physicians or nurses and his or her subdural went undetected. It is here again that we must put logic and science up against a well meaning, but implausible theory. If 50% of these cases have a previously undetected subdural hematoma, then obviously children can and do have lucid intervals after incurring a subdural hematomas.
Citations
1. Kelly, J Sports Related Recurrent Brain Injuries: Second Impact Theory 2000;46 (10) 224-227.
2. Trial Testimony,
People v. John Stevens, Pg 118.
3. Ron Usinski Shaken Baby Syndrome: Fundamental Question. British
Journal of Neurosurgery 2002; 16(3): 217-219.
4. Jenny, C,. Hymel, K.P., Ritzen, A., Reinert, S.E. and Hay, T.C. Analysis of missed cases of abusive head trauma. JAMA 1999; 281(7):621-626.
5. Greenes, D. Schultzman, S.A. Occult intracranial injury in infants. Annals of Emergency Medicine 1998; 32(6):680-686.
6. Dacey, R.G., Alves, W., Rimel, R., Winn, R., and Jane, J. Neurosurgical complications after apparently minor head injury. Neurosurgery 1986; 65:203-210.
7. Barnes, Patrick D. Ethical Issues in Imaging Nonaccidental Injury: Child Abuse Topics in Magnetic Resonance Imaging 2002 13(2) 85-94.
8. Nahelsky, M. and Dix, J. The time interval between lethal infant shaking and onset of symptoms: A review of the Shaken Baby Syndrome Literature. The American Journal of Forensic Medicine and Pathology 1995 ;16(2):154-157.
9. Snoek, W. Delayed deterioration following mild head injury in children. Brain 1984; (107) 15-36.
10. Alexander Randall, Trial Testimony in People v. Weaver Pg 33 lines 17-18.
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