Coagulopathy in pediatric abusive head trauma

Objectives. Coagulopathy is a potential complication of head trauma that may be attributable to parenchymal brain damage. The objectives of this study were to assess the frequency of coagulation defects in pediatric abusive head trauma and to analyze their relationship to parenchymal brain damage. Methods. We reviewed the records of 265 pediatric patients hospitalized for head trauma. One hundred forty-seven patients met study inclusion criteria: (1) radiologic evidence of head trauma, (2) multidisciplinary validation that head trauma had been inflicted, and (3) coagulation screening performed within 2 days of presentation. Using nonparametric analysis, initial coagulation test results were compared between study patients without parenchymal brain damage and those with parenchymal brain damage. Results. Mild prothrombin time (PT) prolongations (median 13.1) occurred in 54% of study patients with parenchymal brain damage and only 20% of study patients without parenchymal brain damage. Among pediatric abusive head trauma patients with parenchymal brain damage who died, 94% displayed PT prolongations (median 16.3) and 63% manifested evidence of activated coagulation. Conclusions. PT prolongation and activated coagulation are common complications of pediatric abusive head trauma. In the presence of parenchymal brain damage, it is highly unlikely that these coagulation abnormalities reflect a preexisting hemorrhagic diathesis. These conclusions have diagnostic, prognostic, and legal significance.