A discussion of closed head injuries as a presentation for domestic violence

1. CLOSED HEAD TRAUMA
IN DOMESTIC VIOLENCE
Frank W Meissner, M.D.
Emergency Physician
19 June 1998

2. Learning Objectives
●Basic understanding
○ Head anatomy as it relates to trauma
●Overall understanding
○Types of head injury and significance
●Understanding of relationships
○Domestic violence to head trauma
●Understand importance
○Universal screening

3. Head Injuries
●Major cause of death & disability
○Approximately 50% of trauma patients
●Mortality rate from severe head injury
○Approximately 35%
●Domestic violence significant risk factor
○Head trauma and associated injuries

4. Severe Head Injury
●Mortality rate from severe head injury
○Approximately 35%
●Functional recovery in only 40-50%
○Patients with severe head injury
●Severity of injury & recovery
○Primary and secondary brain injury

5. Anatomy
●Skull - rigid & inflexible for protection
●Brain - 80% of intracranial volume
●Cerebrospinal fluid
○Cushions & buffers brain & spinal cord
●Facial bones
●Eyes & ears

8. Types of Closed Head Trauma
●Concussions
●Cerebral Contusions
●Skull Fractures
●Intracerebral hemorrhage

9. Concussion
●Immediate & transient post traumatic
impairment of neurologic function
●Symptoms resolve
○No residual damage
●“Dazed”
●“Star struck”

10. Concussions - Grading
●Mild
●Moderate
●Severe
●Management decisions
○Based on severity level

11. Mild Concussion
●Symptoms
○No loss of
consciousness
○Momentary confusion
○Mild dizziness
○Headache
●Resolution
○Normally QUICK
recovery
○Watch closely

12. Moderate Concussion
●Symptoms
○Momentary LOC
○Amnesia
○Confusion
○Severe dizziness
○Blurred/dble vision
○Loss of coordination
○Nausea
○Tinnitus
●Resolution
○Symptoms subside in
30-60 minutes
○Disappear d’s - week
○Observed 24 hours
for changing
symptoms

13. Severe Concussion
●Symptoms
○LOC > 1 minute
○Prolonged amnesia
○Severe confusion
○Loss of balance or
coordination
○Severely altered
vision
○Nausea
●Resolution
○Days
○Some symptoms
linger for weeks
○Refer to Neurologist
○Watch for 48 hours
○Checked periodically
over several weeks

14. Cerebral Contusions
●Direct or contrecoup injury
●Results in swelling
●Signs and symptoms of concussion
○BUT, more severe

15. Skull Fractures
●Requires great force
●Seriousness related to underlying injury
●Closed
○CSF barrier maintained
●Open
○CSF leak/exposed brain

16. Intracerebral Hemorrhage
●3% patients WITH concussions
○Have intracranial hemorrhage
●Subdural
●Epidural
●Subarachnoid

17. Types of Brain Injury
●Primary
○Instantaneous onset
○At time of injury
●Secondary
○Due to tissue hypoxia
■ low oxygen level
○Potentially treatable

18. Associated Medical Problems
●Other injuries to the head
●Fluid and electrolyte abnormalities
●Respiratory complications
●Gastro-intestinal bleeding
●Cardiovascular changes

19. Outcome
●Damage & sequelae occur
○Over a continuum
●Most patients recover
○Normal after mild injury
●High rate after all but mildest injuries
○Temporary inattention
○Memory
○Other subtle deficits

20. Outcomes
●Post-concussive syndrome
●Formal testing (neuropsychological)
○Deficits that are not important
■Daily functioning

21. Head Trauma in DV - Overview
●Face/head most frequent site injured
○Studies vary: 60-95% domestic violence
■Head/neck/facial injuries
○10-25% battered women
■Injuries with LOC

22. Overview - Continued
●25-30% of victims
○Choking or strangulation
●In one study
○Abuse by a man
○3rd most common cause
■Maxillofacial trauma in women
○Fracture of mandible
■Most common injury

23. Sites of Injury
●face
●extremities
●skull
●eyes
●upper torso
●lower torso
●neck
●50-70%
●50%
●50%
●45%
●45%
●20%
●6%

24. Physical Indicators DV in Head Trauma
●Unexplained fracture
○Nose
○Face
○Skull
●Face/neck contusions
●Unexplained bruises/welts
○Face/mouth/lips
●Dental injuries
●Ear injuries
●Eye injuries

25. Facial & Neck Contusions
●Most common findings in acute cases
●Usually bilateral
●If unilateral, usually L- side
●Often various stages of healing

26. Facial Trauma
●In one study:
○Approx 8% of facial injuries in treated
women
○Due to violence by man
■67% husband or boyfriend
○70% assault hands/fists
○Most common injury
■Fracture of the mandible

27. Eye Injuries
●Specific eye injuries
○Contusions & lacerations
○Hemorrhages
○Rupture of the globe
○Corneal & retinal injuries
●Orbital fracture
○DV is a frequent cause of orbital fracture

28. Ear Injuries
●Ruptured Tympanic Membrane
○Uncommon injury
○High predictive value of DV
●Hearing Loss

29. Case Study #1
●30 y/o woman
●Past history of migraine HA’s & mild htn
●2 week history
○Mod severe L - sided HA’s
○Centered behind L - eye & over L - forehead &
scalp
○Occasional sensation of heat with pain in this
region

30. ●Mild drooping of the left upper eyelid
●Hx of being treated in ED several
months earlier L - eye trauma
○After being hit with a fist
○No apparent sequelae
●She denies additional or more recent
trauma or chiropractic manipulation
Case Study #1

31. Diagnosis
●Extensive evaluation
●MRI diagnosed
○Left carotid artery dissection
○Blood leaking into arterial wall after tear

32. Discussion
●Mechanism: traumatic Vs. spontaneous
●Risk of stroke
●Lag time of hours to weeks
○Dissection & onset of symptoms
●Difficulty getting history from victims
○Abused women fail to volunteer information

33. Addendum
●The patient later acknowledged
●Boyfriend had tried to strangle her
●Week preceding onset symptoms
●As well as 4 months prior
●He was also cause of eye trauma

34. Take Home Point
Necessity
for Universal
Screening

35. Case Study #2
●76 y/o woman admitted to a hospital
●Unconscious after being found at home
●Multiple injuries
○Rib fractures
○Multiple bruises & abrasions to head
●L- sided weakness

36. ●Past medical history of probable stroke
●Several years of worsening dementia
○Memory loss and confusion
●Hx/o years of husband being violent
●Often seen with cuts and bruises
Case Study #2

37. ●She died in hospital after 10 months
●Autopsy
○“cauliflower ears”
○Old rib fractures
○Brain changes
■Dementia pugilistica
■“punch drunk syndrome”
Case Study #2

38. Discussion
●Relationship between traumatic head injury &
degenerative dementia
●Associations between single traumatic head injury &
subsequent Alzheimer dementia have been reported
●Long-time survivors of head injury are at increased
risk of degenerative dementia

39. Take Home Point
Necessity
for Universal
Screening

40. What it all Means
●Studies confirm that there are specific
injury types that are more common in
battered women than in women injured
by other causes
●Statistics support the use of universal
screening in all injured women

41. Interesting Notes
●Data in male batterers suggests
relationship between
○Child abuse & head injury
○Alcohol abuse & head injury
●? biological etiologies in marital
aggression/domestic violence
●Implications - prevention and treatment

42. Interesting Notes
●Face to Face Program
○The American Academy of Facial Plastic
and Reconstructive Surgery
○Offers reconstructive surgery
○No cost to victims of DV
●1-800-842-4546

43. Conclusion
●Domestic Violence significant risk factor for head
trauma & associated injuries
●Head Trauma significant risk factor for morbidity &
mortality
●Universal Screening all injured women