Retinal Hemorrhage, Orbital Fracture Linked to Higher Mortality From Abusive Head Trauma

Fasika A. Woreta, MD

Citing a lack of previous research, a recent study examined the incidence and characteristics of abusive head trauma (AHT) presenting to the emergency department (ED), as well as the association with presenting ophthalmic and non-ophthalmic clinical signs.

Study author Fasika A. Woreta, MD, MPH, Wilmer Eye Institute, Johns Hopkins School of Medicine and colleagues found the incidence of AHT decreased by about two-thirds in the study period, while mortality rates remained consistent.

“Despite the decreasing prevalence of AHT, the number of patients with AHT who died stayed relatively stable throughout the entire study period, with no statistical difference between 2006 and 2018,” investigators wrote.

The Study

The retrospective, longitudinal cross-sectional study was conducted in 2021. Data was obtained from the Nationwide Emergency Department Sample (NEDS) to identify all visits with a primary diagnosis of AHT from January 2006 - December 2018 for patients ≤5 years.

In analyses, descriptive statistics were calculated for patient demographic characteristics, hospital characteristics, and ED charges. Then, incidence was calculated using US Census data of population estimates of children ≤5 years. Income quartiles were additionally measured (Quartile 1, $1 - $45,999; Quartile 2, $48,000 - $58,999; Quartile 3, $59,000 - $78,999; Quartile 4, $79,000 and above).

Further, descriptive statistics were calculated for ophthalmologic findings, including retinal hemorrhage, retinal detachment, orbital fracture, and orbital hemorrhage, followed by neurologic findings, musculoskeletal findings, procedures, and disposition from the ED.

Both univariable and multivariable logistic regression models were used to assess demographic characteristics and clinical variables associated with mortality (P <.05).

Findings

An estimated 12,287 cases of ED visits in the US for patients ≤5 years with a primary diagnosis of AHT was found between 2006 - 2018. Data show the estimated number of AHT cases decreased by 672 (95% CI, 403 - 940, P <.001) from 2006 - 2018.

Each year, the incidence decreased by 6.7% (incidence rate ratio, 0.93; 95% CI, 0.93 - 0.94, P <.001) from 5.4 cases (95% CI, 4.1 - 6.6) in 2006 to 2.1 cases (95% CI, 1.7 - 2.4) cases in 2018, per 100,000 population.

The majority of patients (n = 7046, 57.3%) were younger than 1 year, male (n = 7268, 59.2%), and had Medicaid insurance (n = 8585, 70.0%). Most patients were in the first/second income quartile (n = 8252, 68.6%).

Investigators observed the most commonly documented ophthalmologic findings was retinal hemorrhage (n = 2685, 21.8%). Others observed included retinal detachment (n = 18, 0.1%), vitreous hemorrhage (n = 87, 0.7%), papilledema (n = 73, 0.6%), optic nerve sheath hemorrhage (n=17, 0.1%), and orbital fracture (n = 15, 0.1%).

Demographic characteristics associated with increased mortality included age ≥1 year (OR, 2.45; 95% CI, 1.50 - 3.99, P <.001), first or second income quartile (OR, 1.78; 95% CI, 1.08 - 2.91, P = .02), and residency in the midwestern US (OR, 2.04; 95% CI, 1.04 - 4.00, P = .04).

Additionally, patients were more likely to die at a level 1 trauma center (OR, 2.69; 95% CI, 1.07 - 6.75, P = .04).

Clinical findings associated with increased mortality included orbital fracture (OR, 15.38; 95% CI, 2.41 - 98.18, P = .004), cerebral edema (OR, 8.49; 95% CI, 5.57 - 12.93, P <.001), intracranial hemorrhage (OR, 4.27; 95% CI, 1.71 - 10.67, P = .002), retinal hemorrhage (OR, 2.17; 95% CI, 1.40 - 3.38, P <.001), and subdural hemorrhage (OR, 2.05; 95% CI, 1.05 - 3.98, P = .04).

Takeaways

“Although other ophthalmologic findings may be important for diagnosis and overall visual outcomes, these findings suggest clinicians should pay special attention to retinal hemorrhages and orbital fractures in a child already diagnosed with AHT, as they are readily assessable and indicative of survival,” investigators noted.

The study, “A National Analysis of Ophthalmic Features and Mortality in Abusive Head Trauma,” was published in JAMA Ophthalmology.