Download Step Two: History - 2nd Chair Services

User Guide
Before you get started, here are some tips on how to get the most benefit for your client out of the
information provided within this packet.
Investigation
You will find a list of items to subpoena. Subpoena all of the medical records directly from the hospital.
Do not trust what the DA’s give you as what we consider Brady material in these cases, they may not (i.e.
an old subdural is inculpatory to them and exculpatory to us). We often find these records cherry picked
and it is imperative that your experts get all of the information.
Behind that you will find an investigation worksheet. This is what I use to make sure I asked all the right
questions. We sometimes recommend giving a copy to your client so that they can write down everything
they remember while the memory is still fresh.
Experts
We recommend that you hire your experts early and make sure that they would be willing to testify if
needed. There are many experts out there, but they often have specialties specific to only certain fact
patterns. Make sure that you have the right expert for your case. You should have your experts 4-6
months before trial. We recommend that it is the first thing that you do after securing ALL of your
records. We also recommend that you organize your records before sending them out to your expert.
They will often times come to you in complete disarray, but you are always better off paying us, or
someone in your office to organize them, as opposed to paying an expert at $350-$950/hour. Our office
will scan, organize and send your records in both electronic and hard copy form to your expert for 5 cents
a page. We will also provide you with electronic copies for yourself and the other experts you might use.
Sample Direct and Cross
These directs and crosses were written for a deceased child, with a chronic subdural and a short fall.
Obviously, you will need to alter them to fit the fact pattern of your case, but the general questions on the
literature should be about the same for most cases. All of the literature cited in the questions, can be
found in Part 2 of the Defender’s Packet. The articles are arranged in order of the questions and in
sections according to subject matter.
Remember that the rules of evidence allow you to question the expert about anything used in forming his
or her opinion. So, you can ask the opposing expert if they have read the article. If the answer is yes, then
read the findings into the record. If the answer is no, you have at least gotten the title in, and you have
shown the jury that the prosecution’s “experts” are not as well read as yours.
Some questions may be used interchangeably between the direct and cross. If you didn’t get the article in
on cross, you can always bring it in on direct. Any of the experts that we refer you to, will know these
articles and will have been provided with a packet similar to yours.
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Defenders Packet Part 2- The Articles
When you receive or download your defenders packet:
 Open it up to page one and open the bookmark portion on the side bar to the left of your Adobe
Acrobat reader. The articles are bookmarked for electronic projection/use in the courtroom.
 You may want to print out a copy of the entire trial binder series. It will print into a nice tidy
little trial binder with sections on the history of the debate/controversy, retinal hemorrhages,
short falls/alternate explanations for subdurals, chronic subdurals and rebleeds, and lucid
intervals/asymptomatic subdural hematomas.
 If you got your packet by email, it may be separated into different files, you can print them each
out, or combine them for use in trial, by using the insert pages command.
I generally recommend sending some articles to the prosecution’s experts 30 days in advance of trial,
using return receipt mail or email, and asking them to review them before they come to court to testify. It
is always more powerful for jurors when the opposing expert gives you the supportive literature than
when your expert does.
At prelim, you can ask them for a list of the articles that they have read:
 on the subject of shaken baby syndrome
 the last article they read
 whether they have kept up on the debate in England and Canada, etc.
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TABLE OF CONTENTS
INVESTIGATION-----------------------------------------------------------------------------------------------Investigation Worksheet -------------------------------------------------------------------------------- 8-9
Subpoenas ----------------------------------------------------------------------------------------------------History ------------------------------------------------------------------------------------------------------ 8-9
Short Form Worksheet ------------------------------------------------------------------------------- 10-14
EXPERTS --------------------------------------------------------------------------------------------------------- 15-19
Decision Tree ----------------------------------------------------------------------------------------------- 16
Litmus Test ------------------------------------------------------------------------------------------------- 16
Retention Letter ---------------------------------------------------------------------------------------- 17-19
A SHORT BIBLIOGRAPHY: Articles on Childhood Head Injury ---------------------------------- 20-27
History of the Theories on Shaken Baby Syndrome and Non-Accidental Trauma: Accident
vs. Abuse ------------------------------------------------------------------------------------------------- 21-22
Retinal Hemorrhages --------------------------------------------------------------------------------- 22-24
Prosecution Theory #1: Retinal hemorrhages are diagnostic for shaken baby syndrome.
TRUTH: Retinal hemorrhages are caused by a sudden increase in intracranial
pressure.
Short Falls ----------------------------------------------------------------------------------------------- 24-25
Prosecution Theory #2: Short falls don’t case subdural hematomas and/or retinal
hemorrhages—only shaking does.
TRUTH: Short falls can cause subdural hematomas, retinal hemorrhages, and/or
death in children. Impact from a short fall is greater than shaking.
Chronic Subdural Hematomas and Rebleeds ---------------------------------------------------- 25-26
Prosecution Theory #3: Subdural hematomas do not rebleed with lesser degrees of force.
TRUTH: subdural hematomas can rebleed spontaneously or with very minor
traumas.
Lucid Intervals/Asymptomatic SDH ------------------------------------------------------------------- 27
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Prosecution Theory #4: A child becomes immediately symptomatic after suffering a
subdural hematoma thus, if your client is the last one with the baby—he or she caused it.
TRUTH: Asymptomatic subdural hematomas are common and many prior
subdurals go undetected until they become critical at a later point. Timing is much
more difficult than determining who called 911.
Sample Voir Dire -----------------------------------------------------------------------------------------------Jury Questionnaire ……………………………………………………………………………….
Sample Direct Examination (Pathologist) -----------------------------------------------------------------Sample Cross Examination -----------------------------------------------------------------------------------Spelling List of Terms for the Court Reporter ---------------------------------------------------------------Glossary ----------------------------------------------------------------------------------------------------------Useful Medical Abbreviations -------------------------------------------------------------------------------------
***SEE ELECTRONIC FILE PART 2***
Defenders’ Packet of Articles
HISTORY OF THE DEBATE:
 Caffey (1972)a
 Caffey (1972 )b
 Caffey (1974)
 Duhaime (1987)
 Duhaime (1992)
 Uscinski (2002)
 Donohoe (1999)
RETINAL HEMORRHAGES:
 Tongue (1991)
 Jayawant (2005)
 Fung (2002)
 Duhaime (1998)
 Lantz (2005)
 Plunkett (2001)
 Goetting (1990)
 Kirschner (1985)
 Kaur (1990)
 Donohoe (2003)
 Ommaya (2002)
SHORT FALLS:
 Plunkett (2001)
 Howard (1993)
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 Ommaya (2002)
 Reiber (2001)
 Martin
 Kurinsky
CHRONIC SUBDURALS:
 Parent (1992)
 Piatt (1999)
 Sherwood (1930)
 Swift (2000)
LUCID INTERVALS/ASYMPTOMATIC SDH:
 Greenes (1998)
 Jenny (1999)
 Nahelsky and Dix (1995)
 Dacey (1986)
 Looney (2007)
 Rooks (2008)
***SEE ELECTRONIC FILE PART 3***
Appendix A: Commonwealth of Kentucky v. Davis
Appendix B: People v. Froelich
Appendix C: People v. Hiatt
Appendix D: People v. Shirley Ree Smith
Appendix E: People v. Audrey Edmunds
Motions:


Daubert/Harper/Hiatt
“Mantra”
6
Investigation
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INVESTIGATION WORKSHEET
Step One: Subpoenas
1. Subpoena any and all medical records since birth, including:
 Prenatal records (will be listed under the mother’s name)
 Birth records (under both mother’s and child’s names)
 Well-baby check-ups and all previous doctor visits
 Vaccination records
 Medical records of siblings
 Daycare records
 Paramedic records
 ER records
 CT Scans, Bone Scans, MRI’s, X-Rays, Retinal Camera Photos
 Progress and follow up records—(if the baby lived)
 Autopsy (if applicable)
Step Two: History
1. Get a timeline of the child’s recent history in the last 1-3 days.
 Was anyone else with the baby, unsupervised, for the last three days?
 Were there any short falls or impacts to the head in the last 3 days?
o If yes, did the child see the doctor?
 Did the parents call the doctor in the last 3 days?
2. Get a timeline of the child’s remote history in the last 4-10 days.
 Were there any doctor visits in the last two-three weeks?
o If yes, what was/were the reasons for the visit?
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o Did the doctor take a head circumference measurement? Height?
Weight? What percentile were these measurements in?
o Did the doctor administer a vaccine?
 Were there any short falls or impacts to the head?
3. Get a timeline of the child’s extended medical history since birth.
 Any short falls in recent history or at any time since birth?
 Has the child shown any of the following symptoms now or at any time since
birth:
o Lethargy?
o Vomiting? (projectile)
o Change in eating patterns? (Off food for little ones)
o Inconsolable crying or unusual sounding cries? (cat cries for babies)
o Positional discomfort? (For babies: Parents describe this as being extra
needy, wanting to be held more than usual, preferring to be seated in a
swing or carrier, upright, etc.)
o Seizures? (Parents describe them as arching or looking cold/rigid.)
o Developmental delay? (for toddlers)
o Clumsiness? (for toddlers)
o Irregular gait? (for toddlers)
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Decision Tree
Much of the success in these cases comes from choosing the right expert for your particular
fact pattern.
If the baby lives, you may want to consult with a:
◦ Pediatric Radiologist – To read CT scans, MRI’s, X-rays and bone scans.
◦ Pediatrician – Difficult to find objective experts in this area.
◦ Neurologist – If you want to discuss treatment post injury.
◦ ER Physician – If you want to discuss hospital procedures and findings.
◦ Ophthalmologist – If you want to discuss the various causes of retinal
hemorrhages.
If the baby dies, you may need a/an:
◦ Pathologist- Generally a medical examiner. Looks at the injuries, explains the
origin of the injuries, and the cause of death.
◦ Forensic Neuropathologist- Checks the timing and dating of injuries, screens for
other disorders of the brain.
◦ Ophthalmologist- if you want to discuss the various causes of retinal
hemorrhages.
Not every defense expert is right for every case. For instance:
◦ If your case involved a short fall or impact of some kind to the head, you may
need a short fall expert or a biomechanician.
◦ If your case involves a coagulation disorder or anemia, you may want to consult
with a pediatrician, a hematologist or an osteopath.
◦ If your case involves a rebleeding subdural, you may want a neurosurgeon, a
neurologist, radiologist, neuropathologist or an ER doctor.
Litmus Test for Finding a New Expert
Question #1: Ask them if they believe that retinal hemorrhages are generally an indicator of nonaccidental trauma. If the answer is yes, move on to another expert.
Question #2: Ask them if they believe that short falls can kill children or cause subdural hematomas and
retinal hemorrhages. If they say no, and you have a short fall case, move on to another expert.
Question #3: Ask them if they believe subdural hematomas can be asymptomatic. If they say no, and you
have an asymptomatic/lucid interval case, move on to another expert.
Question #4: Ask them if they believe that subdural hematomas can rebleed with little to no force at a
later date. If they say no, and you have a rebleed case, move on to another expert.
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Attorney and Attorney
Attorney at Law
Attorney
Attorney
Address Line 1
City, State Zip Code
[email protected]
Telephone (000) 555.5555
Fax 555.5555
MONTH DAY, YEAR
Dr.
Address
City, State ZIP
Confidential Communication Protected by Attorney-Client &
Work Product Privileges Re: People v. John Doe
Dear Dr.
,
Thank you for agreeing to be my consultant in this case. I am putting the terms of
our contract in writing to make clear the nature of our relationship and our mutual
responsibilities.
The fee agreement between us is that I shall pay you $_____ an hour for your
consultative services provided me. This financial arrangement forms the basis for the
contract for your expert services. Enclosed is a check for $___________ as an initial
payment of your fee.
The California Courts advise attorneys that they are required to put in writing to
their experts information about the nature of the confidentiality requirements. What
follows may seem obvious to you, but I am obligated to detail the boundaries of the
relationship established by our contract.
My obligation to you is to pay your fees, give you direction as to my needs in the
case, and provide you with the relevant information needed to give me your expert
advice. Your duties include providing your expert advice to me in confidence which
means a thorough and accurate appraisal of the issues you evaluate. Also,
1. All information about this case from the moment I first speak to you is completely
confidential. That is, unless you become a witness in this case (and unless I inform
you differently, you are not one), you are my consultant and work within the privacy
of the attorney-client privilege and my personal work product privilege. These
privileges are statutory mandates under California Evidence Code section 952 and
Penal Code section 1054.6, which state that your work for me is private, confidential
and cannot be discovered by anyone. This privilege covers all oral discussions and
written communications between us. Also, any and all written work product you
produce in this case will be the property of this office.
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2. If by chance, counsel or investigators from the other side of this lawsuit contact you
for help with the case, you cannot oblige them. This would put you in a conflict of
interest and would breach our contract and privileged relationship. Should the
opponent contact you about this case, your only response is, "Sorry, I cannot help
you." You cannot state that the reason you are not helping is because you are
working for me as that is revealing a confidence.
3. If the opponent contacts you with the express purpose of finding out if you are
working, or have worked for me, on this case, that is sanctionable misconduct on their
part. It is serious misconduct for a legal adversary to exploit privileged
communications of the other side. It can be a basis for that attorney's disqualification
from the case and other sanctions. If you are contacted about the case and the
situation appears to you ambiguous, do not rely on the expressions of others to say
that it is permissible for you to talk. Call me first. You can always call the person
back.
Of course, if you are publicly declared a witness for the case, the opponent may call
you and you may chose to talk to them if you wish. You have no obligation to do so.
If you elect to talk to them, please let me know as I would like to be there.
4. Your obligation of confidentiality is not time-limited. It does not conclude upon the
resolution of the case in court. Thus, unless expressly authorized by me (i.e., by
designating you as a witness in the case), you cannot ever reveal the contents of your
consultation with me.
5. Sometimes a case is very interesting and you might wish to discuss it at conferences
with your colleagues. Do not do it. Even discussing the facts without names could
give away the identity of the case to a lawyer or expert working for the opposition.
6. Should you deem it necessary to consult with other experts on this case outside your
office, please contact me beforehand. If we agree on it, you should be careful to first
make sure they are not working on the case for the other side so as to avoid the
problems noted in paragraph three above. If they are to be made privy to the facts of
the case and our communications, they must also agree to consult within the same
terms and conditions of confidentiality as you. Thus, if you are going to consult with
others, it is best if I first establish these ground rules with them.
7. You have the responsibility to insure that employees and other staff members in your
office are aware that the confidentiality obligations stated in this contract apply to
them as well.
8. All written communications between us should be labeled at the top of the document
as I have done with this letter to you.
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Please sign this contract and return it to me in the enclosed stamped, self-addressed
envelope. I have enclosed a copy for your files. You come highly recommended, and I look
forward to working with you on this matter.
Yours truly,
Attorney
DATE: _____________ I have read the above foregoing fee contract and agree to be bound by
the terms contained therein.
______________________________
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Bibliography
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A Short Bibliography of Must Read Articles on Childhood Head Injury
What follows is a short bibliography of the articles for litigators. There are literally hundreds of articles
written on the subject, but these are some of the essentials.
History of the Theories on Shaken Baby Syndrome and Non-accidental
Trauma: Accident vs. Abuse
Barnes Patrick D. Ethical Issues in Imaging Nonaccidental Injury: Child Abuse Topics in
Magnetic Resonance Imaging 2002. 13(2): 85-94.
Well respected Pediatric Radiologist, Patrick Barnes, questions the effectiveness of
dating and timing subdural hematomas by CT and MRIs. The author calls into question some of
the historical assumptions surrounding the theory of Shaken Baby Syndrome and dispels some of
the radiological myths. He concludes that subdural hematomas and retinal hemorrhages come
from rotational decelerational injuries, both accidental and nonaccidental, and that current
radiological findings alone cannot tell you the nature or mechanism of injury. The article
mentions coagulopathies, metabolic disorders and vaccines as conditions that could contribute to
or be misdiagnosed as Shaken Baby Syndrome. Barnes says that MRI (T1 and T2 SE) is the most
effective way to identify and date injuries and that CTs are often inadequate to determine the
nature or age of fluid collections on the brain, particularly in the presence of an anemia or
coagulopathy. The author also spells out the job of an expert witness and the windows for dating
subdural hematomas with an MRI.
Caffey J. On the Theory and Practice of Shaking Infants. American Journal of Diseases in
Childhood 1972; 124:161-9.
This is the original article discussing what is now called Shaken Baby Syndrome. Caffey
says the constellation of injuries found in "shaken-whiplash syndrome" is generally found
in conjunction with fractures of the long bones and/or bilateral symmetrical fractures of the arms
and legs. Caffey discusses fractures of the bones and joints from whiplash injuries. The article
cites cases of whiplash injury from a father swinging an infant over his head. Caffey says injuries
can be caused by coughing, overly vigorous burping, "riding the horse," tossing the baby up in
the air, rough roads and flipping a toddler head over heels to his or her feet. Caffey says that CPR
can also lead to an increase in venous pressure that causes these types of injuries.
Caffey J. The parent-infant traumatic stress syndrome: (Caffey-Kempe Syndrome),
(Battered Baby Syndrome). Amer J Radiol 1972; 114:218-29.
The article was published later the same year altering Caffey's theory of SBS. This article
looked at 12 cases of "SBS" from other articles. Caffey uses anecdotal data from a nurse who
confessed to shaking several children in her care. Some of those children showed Caffey's signs
of Shaken Baby Syndrome; some did not. The author goes through the literature on SBS and
reviews babies used in other studies to prove his point. This study defines SBS triad as: 1) Retinal
hemorrhage 2) Subdural hemorrhage, and 3) Lack of external signs of abuse. Some of the cases
Caffey discusses show lucid intervals. Caffey cites that 14% of newborns show signs of retinal
hemorrhage.
Caffey J. The whiplash shaken infant syndrome: manual shaking by the extremities with
whiplash-induced intracranial and intraocular bleedings, linked with residual permanent
brain damage and mental retardation. Pediat 1974; 54:396-403.
In this article, Caffey comes up with yet another rendition of his theory. The author posits
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that it is the whiplashing of the head onto the thorax that causes traction-stretching stresses and
causes SBS. Now Caffey believes Shaken Whiplash Syndrome is characterized by: 1) Bilateral
SDH, 2) Bilateral RH and 3) external signs of trauma to the head and neck.
American Academy of Pediatrics. American Academy of Pediatrics: Shaken Baby
Syndrome: Rotational Cranial Injuries - Technical Report. Pediatrics 2001; 108(1)
This is the prosecutor's tutorial on "Shaken Baby Syndrome" (SBS). It gives a brief
description of the current dogma surrounding childhood head injuries. The article also gives a list
of symptoms/signs to look for in a purported case of "shaken baby syndrome" or nonaccidental
head trauma. Also included are some legal citations and tips for prosecutors on how to try these
cases.
Donohoe M. Shaken Baby Syndrome and Nonaccidental Injuries: A Review. 1999.
This is an excellent article reviewing the medical theories around the "Shaken Baby
Syndrome." The author takes a thorough look at the five axioms of controversy in SBS cases and
the lack of literature and scientific data on the subject. This is a good tutorial on Shaken Baby
Syndrome and the evolution of the theory over the years. It is a must read for defense attorneys.
Duhaime A.C, Gennarelli T, Tibualt L.E, Bruce D.A, Margulies S.S, and Wiser R. The
Shaken Baby Syndrome: A clinical, pathological, and biomechanical study. Journal of
Neurosurgery 1987; 66:409-15.
The authors used a biomechanical model with the parameters of an infant's head and an
accelerometer placed in the model to study shaking vs. impact injuries. The study determined that
angular decelerations for shaking were less than that for impact by a factor of 50. The authors
found that shaking alone, of an otherwise normal infant, could not cause the degree of injuries
generally associated with shaken baby syndrome.
Duhaime AC, Christian CW, Rorke LB, Zimmerman RA. Nonaccidental head injury in
infants: The "shaken-baby syndrome". New Engl J Med 1998; 338:1822-9.
The authors discuss translational vs. rotational forces with regards to nonaccidental head
trauma. They analyze the significance of retinal hemorrhages and subdural hematomas and the
degree of force needed to inflict the injuries seen in SBS cases. The authors looked at the timing
of head injuries through radiological studies and autopsies.
Usinski Ron. Shaken Baby Syndrome: Fundamental Question. British Journal of
Neurosurgery 2002;16(3): 217-219.
The author reviews a history of the "Shaken Baby Syndrome" and highlights the fact that
the theory is greatly disputed by medical and biomechanical evidence. The author does a quick
tutorial in Newtonian physics and shows that the G Forces required to cause a subdural hematoma
cannot be caused by human shaking alone; impact is necessary. The author indicates that prior to
1972, retinal hemorrhages were used in diagnosing increased intracranial pressure or head injury;
now, it is said to be diagnostic of SBS. The author says that there is little dispute that chronic
subdurals rebleed in adults during membrane formation and argues that there is no data to suggest
that children's brains react any different than adult brains.
Retinal Hemorrhages
Myth: Retinal hemorrhages are diagnostic for shaken baby syndrome.
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Truth: Retinal hemorrhages are caused by a sudden increase in intracranial pressure.
Goetting MG, Sowa B. Retinal hemorrhage after cardiopulmonary resuscitation in
children: an etiologic reevaluation. Pediatrics 85:585-588, 1990.
Two of every twenty children given CPR showed retinal hemorrhages with no history of
trauma or abuse. The cases and mechanism of hemorrhages is discussed.
Greenwald MJ, Weiss A, Oestlerle CS, Friendly DS. Traumatic retinoschisis in battered
babies. Ophth 1986; 93:618-25.
Retinal hemorrhages are found in cases with a sudden increase in cranial pressure. This
article cites cases of retinal hemorrhages from CPR, swinging the child by the feet and vaginal
delivery. The authors say fundus hemorrhages are found in battered babies. Necrosis of the inner
layer of blood is said to be responsible for "late" RH. The authors document one case of RH with
no SDH but elevated ICP. They theorize that mechanical forces involved in the shaking (lens
shifting in vitreous humor) cause retinal hemorrhages; the forces applied to the eyes in shaking
make the lens move back and forth within the ocular fluids. Force translates through the lens,
vitreous gel and retina to create tugging on the retina and tearing of the blood vessels in the
subdural space of the retina, (referred to as vitreous traction of the retina). Editorial comment by
Torch says it's not retinoschisis; it is retinal hemorrhage secondary to increased venous pressure
changes. Other processes related to increased ICP include: central retinal vein occlusion, high
altitude retinopathy and subarachnoid hemorrhages secondary to aneurysm.
Gutman, F. Evaluation of a Patient with Central Vein Occlusion. American Academy of
Ophthalmology 1983; 90(5) 481-3.
This article says central retinal vein occlusion can cause retinal hemorrhages. The author
documents all the reasons for central retinal vein occlusion and says blood-clotting disorders,
alterations in viscosity of blood and abnormalities in the vein wall can cause increased
intracranial pressure which then results in retinal hemorrhages.
Kaur B, & Taylor D. Current Topic: Retinal Hemorrhages. Arch. Dis. Child 1990; 65:136972.
This article describes the different types of retinal hemorrhages and their causes. The
authors say that neonatal retinal hemorrhages are generally "dot-blot" or flame shaped and
located at the posterior or periphery. This article indicates that 1/3 of babies born with occipital
presentation have retinal hemorrhages. This incidence is increased with prolonged labor or
obstetric procedures, and decreased with c-sections and breech presentations. Retinal
hemorrhages are also more common in mothers with toxemia. With subarachnoid bleeding, there
may be an increase in intracranial pressure, optic nerve sheath hemorrhage and an increase in the
pressure within the optic nerve sheath because of raised central retinal venous pressure. Retinal
hemorrhages occur 20-32% of the time with SAH: they occur simultaneously or within a few
days. Streak and pre-retinal hemorrhages occur mainly around the optic disc. Pre-retinal
hemorrhages may leak into the vitreous (Terson's Syndrome). Retinal and pre-retinal
hemorrhages are consistently seen in infants with SDH. Superficial retinal hemorrhages can occur
from sneezing, crying, or squeezing of the chest (valsalva's hemorrhagic retinopathy).
Hemorrhages into all layers of the retina may be more common in nonaccidental trauma. This
article also cites vomiting, epileptic seizures, crying, chest compressions and coughing spells as
causes of retinal hemorrhages.
Kirschner R H, and Stein R J. The Mistaken Diagnosis of Child Abuse. American Journal of
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Diseases in Childhood 1985; 139:873-5.
The article reports a case of retinal hemorrhages after vigorous chest compressions on a
3-month-old infant. The article looks at differentiating diagnosis of abuse from coagulopathies,
CPR, TCP, SIDS, meningitis, etc. The authors say mistaken diagnosis often occurs when a child
dies with no explanation for his/her injuries and those injuries are consequently cited as indicators
of abuse. The authors list other disease processes that mimic abuse.
Lantz, P E; Sinal, S H; Stanton, C A; Weaver, R G Jr. Perimacular retinal folds from
childhood head trauma. British Medical Journal 2004; 328(27)
This is an evidence-based case report. It gives an account of a child who presented with
extensive head injuries caused by a television falling on his head. The child deteriorated and died
within 18 hours. Because the child had retinal hemorrhaging and retinal folds, CPS removed the
other child from the home. Lantz et al. explain that "An evidence based analysis of indexed
medical publications on shaken baby syndrome from 1966-1998 uncovered a weak scientific
evidence base." Lantz et al. conclude in saying that "Until good evidence is available, we urge
caution in interpreting eye findings out of context."
Tongue Andrea. The Ophthalmologists' Role in Diagnosing Child Abuse. Ophthalmology
1991; 98(7): 1009-10.
The author indicates that retinal hemorrhages predominantly occur in children with
central nervous system injuries. She says that although it is possible that certain types of
hemorrhages are signs of Shaken Baby Syndrome, there is no evidence to date that establishes
that any type of retinal hemorrhage was pathognomonic for nonaccidental trauma. Tongue
recognizes that retinal hemorrhages are found in scenarios that do not include child abuse. They
are seen in newborns, in infants after cataract surgery, in infants undergoing extra corporeal
membrane oxygenation therapy, in infants with subdural or subarachnoid hemorrhages secondary
to accidental trauma, and with bleeding byforasias and hemoglobinopathies. The author says
nonaccidental trauma associated with retinal hemorrhage is most often found in children under
the age of two, but there is no research out there to back up the pathology. The author says there
is no proof that retinal folds are indicative of vitreous traction mechanisms or child abuse.
Short Falls
Myth: Short Falls don’t cause subdural hematomas--only shaking does.
Truth: Short falls can cause subdural hematomas, retinal hemorrhages or death in children.
Impact from a short fall has greater force than the force of shaking.
Plunkett. Fatal pediatric head injuries caused by short distance falls. American Journal of
Forensic Medicine and Pathology 2001; 22:1-12.
This study analyzed the Consumer Product Safety Commission's database on playground
equipment falls between January 1988 and June 1999. Thirteen children had subdural
hematomas, and twelve had lucid intervals ranging from five minutes to forty-eight hours. Four of
the six children that had funduscope examinations had retinal hemorrhages. The study proves that
short falls can kill children and retinal hemorrhages are not diagnostic of abuse. The study also
calls into question our ability to time injuries and contradicts the theory that decomposition
begins immediately after the SDH is formed.
Plunkett J. Biomechanical analysis of a fatal pediatric head injury caused by a shortdistance fall. National Association of Medical Examiners 2000.
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Abstract presented to the National Association of Medical Examiners on the death of a
twenty-three-month old infant after a fall from the standing height of twenty-eight inches. The
case documents a lucid interval and a gradual decline with vomiting and stupor. The incident was
captured on video and has been used as documentation of a short fall death on a previously
healthy toddler. (Accompanying the article are emails and listserve correspondences regarding the
article.)
Howard M, Bell B.A, and Uttley D. The pathophysiology of infant subdural hematomas.
British Journal of Neurosurgery 1993; 7: 355-6.
The authors did a retrospective review of 28 babies with SDH over a 20-year period (>18
months; N=18 boys and 10 girls). The study sample included 17 white, 10 nonwhite babies and 1
mixed race baby. Non-Caucasians with a head injury were more likely to have SDH than whites
(67% v. 21%). Short falls (including high chairs) were often the cause of injury. 11 infants went
unconscious immediately following the traumatic head injury, and 10 infants were observed
having breathing difficulties. Babies were observed to experience vomiting (50%) and irritability
(25%). Seizures were more common in non-whites (90%) than whites (41%). This article
discusses 3 infants with chronic SDH that were not thought to be abused. All three had minor
impact more than a week prior to their hospital admission. One other case presented with a CSDH
and questionable circumstances. There was an absence of impact site in 29% of Caucasians and
80% of non-whites. 11/20 of the infants that had funduscope examinations had retinal
hemorrhages: 9 were normal, 6 (33%) of white infants had evidence of extra cranial injuries; none
of the non-whites had those signs. This is a great article for cases involving babies of color.
Reiber G. Fatal falls in childhood. The American Journal of Forensic Medicine and
Pathology 2001; 14(3):201-7.
This article documents 3 cases of deaths from corroborated/witnessed short falls (10-20
feet). The author states that all three children had SDH and fractures. 2 of 3 children had lucid
intervals and all 3 children died after a delayed period following the fall. 2 of 3 children showed
periorbital echymosis. One child suffered a SDH and severe brain swelling from a 6-foot fall onto
a carpeted floor. 1 child fell 2-3 feet from a rocking chair.
Chronic SDH and Rebleeds
Parent A.D. Pediatric chronic subdural hematoma: a retrospective comparative analysis.
Pediatric Neurosurgery 1992; 18:266-71.
The author reviewed the literature on chronic subdural hematomas. Study looked at 28
children less than 18 months old, over two decades. Most of the children in the data set were less
than 4 months old. Males were overly represented in both the first (78%) and second (60%)
decade of study. Kids in both samples tended to present with macrocephaly, lethargy, failure to
feed, apnea and seizures. Some children in the more recent sample, presented with headaches
only, or no symptoms at all. Fractures were rarely seen with subdural hematomas in either
sample. Mortality rates in the 1970s study were around 50%, whereas in the 1980s they were
closer to 10%; Seizures increased from 40% to 46%, but psychomotor retardation reduced from
33% to 28%. The authors attributed 40% of subdurals in infants to child abuse. Birth traumas and
rebleeds comprised a small percentage of the subdural bleeds. Parent discusses the evolution of a
SDH and the tendency of those with them to develop hydrocephalus over time. The author also
discusses ischemia secondary to chronic subdural hematoma because of impaired cerebral blood
flow. The study found that craniotomies were rare as a course of treatment in modern times but
were very popular in the 1980s. He cites the increased tendency in infants to bleed or to develop
new subdurals after a membranectomy or craniotomy. Modern courses of treatment generally
19
involve subdural taps or subdural peritoneal shunts. The author indicates that the histopathology
of CSDH in children is the same as that in adults in that they tend to wax and wane and rebleed.
He says that capillary fragility was the major cause of repeated hemorrhage in CSDH.
Piatt J. A pitfall in the Diagnosis of Child Abuse: External Hydrocephalus, Subdural
Hematoma & Retinal Hemorrhages. Neurosurgical Focus 1999; 7(4)(4):1-9.
The author describes a child who developed SDH and retinal hemorrhage from external
hydrocephalus (previously referred to as benign subdural effusions of infancy). Author discusses
how conditions such as external hydrocephalus, internal hydrocephalus, an arachnoid cyst or a
chronic subdural hematoma, can cause subdural hematomas from minor head injuries. The author
says that development of a subdural hematoma after minor head trauma in an infant with
craniocerebral disproportion might be the occasion for unjustified accusations of abuse. The
existence of retinal hemorrhages in this case adds to the literature supporting the argument that
retinal hemorrhages are caused by a sudden increase in ICP rather than abuse. Great article for
rebleeds, hydrocephalus, retinal hemorrhages, etc.
Sherwood D. Chronic subdural hematoma in infants. Am J Dis Child 1930; 39:980.
This is a remarkable article that clearly shows that infants do get chronic subdurals that
do "rebleed"…quotes articles from 1890s and early 1900s about chronic subdural patients WITH
retinal hemorrhages. The issue of abuse is raised.
Swift, Dale M. Chronic Subdural Hematomas in Children. Journal of Chronic Subdural
Hematomas 2000; July 11(3).
The author reviews the data on intracranial fluid collections. He says there are three ways
to generate subdural fluid collections. 1) recurrent bleeding of the chronic subdural hematoma in
the subdural space; 2) an opening in the subarachnoid allows the CSF to enter the subdural space.
(This can occur after shunt placement in hydrocephalic or macrocephalic babies. The CSF then
mixes with blood and results in a thin xanthochromic fluid, sometimes called subdural
hygromas), and 3) response to an infection or process. Subdural empyemas can result from sinitis
or otitis media, into the epidural space, and then into the subdural space. Purulent subdural
collections are sometimes seen after bacterial meningitis, especially those due to hemophilia
influenza. Bacterial cultures may or may not show organisms because the patient is usually
started on antibiotics before the tests are completed. Fluid can also accumulate around the brain
after destructive disease processes such as hypoxia. These rarely cause symptoms. The most
common cause of subdural hematomas is trauma, but underlying tissue may predispose a baby to
subdural bleeding with minor trauma. The author says that frequently the symptoms go unnoticed
and without medical attention. Causes can be accidental or nonaccidental, and nonaccidental is
the most common cause for children less than two years of age. The author says coagulopathy can
underlie subdural bleeding or abnormalities in intracranial structure. The author indicates that the
degree of trauma needed to produce injury in children with fluid collections in their brain is less
than the normal infant population, and that childbirth can cause chronic subdural hematomas. The
author indicates that the age of the infants is correlated with the presentation of subdural
hematomas. Infants can present acutely with apnea or seizures, or more protracted, with a history
of lethargy, vomiting, and a failure to feed. Older children present usually within two weeks after
trauma with symptoms of headaches and advanced intracranial pressure. Chronic subdural
hematomas tend to occur unilaterally in older children and bilaterally in younger children. The
author indicates treatment has moved away from craniotomies and membranectomies to subdural
shunts and burr holes.
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Lucid Intervals/Asymptomatic SDH
Dacey R.G, Alves W, Rimel R, Winn R, and Jane J. Neurosurgical complications after
apparently minor head injury. Neurosurgery 1986; 65:203-10.
The authors studied 610 patients at a Washington trauma center. Of 66 patients with skull
fractures, 5 had intracranial hematomas, 13 had some type of neurosurgical complications.
Neurological complications and lucid intervals were more likely to be found in boys than girls,
and were more likely to occur in a fall rather than by some other mechanism. The increased ICP
is found after about 50% of severe head injuries. Skull fractures increase likelihood of
neurosurgical procedures. This article documents the existence of lucid intervals. The authors
found that 3% of minor head injury cases will deteriorate after experiencing a lucid interval.
Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay T. Analysis of missed cases of abusive head
trauma. Journal of the American Medical Association 1999; 281(7):621-626.
Interesting article that analyzes missed diagnosis of abusive head trauma, but in so doing,
documents the fact that many head injuries go unnoticed only to result in further complications at
a later date. This factor provides proof for the existence of a lucid interval and complicates
prosecutors’ theories that the last person holding the baby was to blame. In this study 40% of the
cases of head trauma resulted in complications from original injuries. The article sites the signs of
pre-existing injuries. These conditions included seizure disorders, chronic vomiting and
increasing head size because of increasing untreated subdural hematomas."
Greenes D, Schultzman S.A. Occult intracranial injury in infants. Annals of Emergency
Medicine 1998; 32(6):680-6.
The study looked at infants admitted to the emergency room of Children's Hospital
Harvard (over a 6.5 year period). Occult (asymptomatic) injuries (i.e. lucid intervals) were seen in
fourteen of the 52 infants (27%) under the age of 6 months, 5 of 34 babies (15%) 6 months to a
year and in none of the infants over one year old. 95% of the children had scalp contusions or
hematomas, and 95% had fractures. None of the infants with occult injuries required medical
assistance such as surgery, etc. to manage increased intracranial pressure.
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.
The authors agree with the Bruce-Zimmerman and Duhaime who say you must have
impact to create damages like those seen in SBS. This article discusses three cases of "shaking"
injury where children experienced lucid intervals of 3 hours, 3 days and 4 days. The last child
had bilateral retinal hemorrhages. The article concludes that there is very little data available to
suggest the actual time limits between fatal head injuries and death. This article shows that lucid
intervals do exist and that perpetrators cannot be narrowed down to the last person holding the
baby.
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Sample Voir Dire
22
Voir Dire Questions
What follows are some general areas of questioning for voir dire. If you get a chance to do a
questionnaire, these can easily be converted to questionnaire form.
1.
I don’t know you and
doesn’t know you, but we have to make a decision about who
among you are the best people to sit on this jury. That is why I am going to ask you some
questions about things that you believe.
2. This case is about a little baby who died. Knowing that fact alone, is there anyone who thinks that
they cannot sit on this jury for any reason?
3. Knowing that this case is about how a baby died, how many of you feel you can keep an open
mind throughout the trial, even through the deliberations with your fellow jurors?
4. Knowing what little you know about the case now, how many of you want to sit on this case as a
juror? Why do you want to sit on this case?
5.
How many of you, who did not raise your hands, do not want to be on this jury? Why not?
6. Has anyone in the panel ever been a mandatory reporter?
7. Do you or anyone in your immediate family have any training in the following areas: medicine,
engineering, biomechanics, biology, science, physics, nursing, daycare, social work or early
childhood development?
8. Does anyone in the group belong to any volunteer organizations involving children or child
abuse, domestic violence, family discord or anything of that nature?
9.
Has anyone on the panel spent any significant time, watching any high profile criminal cases?
a. Which if any of these cases have you followed?
b. Did following that case or other change influence your opinions about the justice system?
c. How?
10. How many of you have heard of "Shaken Baby Syndrome?"
a. What have you heard "Shaken Baby Syndrome?”
b. Anybody ever read any articles about “Shaken Baby Syndrome?”
11. Anybody follow the Nanny case back in 1997?
12. Serving on this panel means that you will not be allowed to do any research or reading of
information in any way related to this case. You must simply listen to the information presented
and make your decision based on that evidence. How many of you think you will have a hard
time doing that? (i.e. ignoring the urge to look for information outside of the courtroom?)
a. Will you be able to do that and return your verdict just based on the evidence that is
presented to you in this courtroom?
13. Recently there has been significant media coverage of a case involving a “Shaken Baby
Syndrome.”
a. Which, if any, of these cases have you followed?
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14. Do you/or have you ever watched Court TV’s coverage of any of these cases?
a. If so, please estimate the number of hours you spent watching the case.
15. Anybody ever read any articles about the medical controversies surrounding shaken baby
syndrome? Here, in England, or in Canada?
16. Here is the thing- we are going to be talking about all of those things during this trial. You are
going to learn that there have been congressional panels in Canada looking at this stuff, and that
there have been a bunch of cases overturned in England, Canada and here…. BUT- his/her honor
is going to tell you that you cannot go on the web and investigate any of this. You can’t read
about other cases, can’t read any medical articles and you can’t ask your family doctor his or her
opinion.
a. How many of you think you will have a hard time doing that?
b. Will you be able to do that and return your verdict just based on the evidence that is
presented to you in this court room?
17. How many of you have seen those Nanny Cam Videos? Or the videos with the kids being jerked
or shaken around? (Remember there are no video-taped shakings that produced subdural
hematomas and retinal hemorrhages.)
18. Is there anyone in the group who has a background in physics?
19. Is there anyone in the group who has ever watched one of those autopsy shows or the surgery
channel or something like that?
a. Is there anyone in the group who would never watch that stuff (too graphic)?
20. In this case it may become necessary for you to view autopsy photos or listen to the testimony of
a medical examiner describing injuries to a baby. How many of you think you would have a hard
time doing that without it coloring your take on the case?
21. Are there any of you who would have difficulty sitting in a trial wherein you would have to see
and hear about a baby’s body after he died?
22. It may be necessary during the course of this trial for you to listen to the testimony of a
pathologist who conducted medical tests on the deceased after death. Can you do so
dispassionately and without becoming upset?
23. Is there anyone in this panel who believes that the subject matter alone (the death of an infant) or
graphics might prejudice them or cause them to have trouble being completely fair in this case?
(As fair as you could be in any other criminal trial?).
24. Do you know or have you heard, seen, or read anything about this case from any source?
25. Have you formed any kind of opinion about this case as a result of what you have heard or seen?
a. What is that opinion?
26. Has anyone on the panel ever known anyone with a head injury or a subdural hematoma,
concussion etc?
a. What happened?
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27. Has anyone on the panel ever lost a child?
28. Has anyone ever been to the funeral of a child?
a. What were the circumstances
29. Do you have any particular sensitivity that we should know about regarding the viewing of head
injuries in babies?
30. Has anyone in the panel ever had a “freak accident”? By that I mean, you stepped off a curb and
sprained your ankle or landed just right that you broke something in a short fall….?
31. How many of you followed the Natasha Richardson case?
32. How about the Chick Hearns or Dr. Atkins cases? Have any of you followed those cases?
33. When you think of doctors, do you think of them as more or as less truthful than other people?
34. You will be hearing testimony from several doctors in this case, do you think that you would be
inclined to give them more or less credibility than other people?
35. It has been said that medicine is an art not a science, is there anyone on this panel that would
disagree with that?
36. This case will involve a great deal of highly technical medical evidence. We will try to make it as
understandable as possible, but are there any of you who feel you might not be a good juror for a
trial like this?
37. Has anyone on the panel ever sought a second opinion by a physician? Why?
38. Has anyone had doctors disagree on a diagnosis or a treatment?
39. Has anyone themselves disagreed with a doctor or a course of treatment taken?
40. Does anyone think that doctors cannot make mistakes?
41. Has anyone on the panel ever considered filing a law suit for medical malpractice?
And finally- because I always advise avoiding the word fair….
42. Knowing yourself better than anyone else in this courtroom and looking at all of your life
experiences, can you assure me as you sit here today, that you are one of the best jurors for this
type of case? Why?
43. Is there anything else that we should know about you before we select a jury in this case?
25
Sample Direct Examination
26
Sample Direct Examination
Qualifications
1. What kind of doctor are you?
2. Did I hire you to review the medical evidence in this case and come to an opinion as to the cause
of death? (Mechanisms of injury)
a. Did you do so?
b. What is that opinion?
3. Ok… let’s back up and tell the jury how you are qualified to give such an opinion?
a. Doctor, please tell the jury about your educational and employment background.
4. Are you board certified?
a. In what?
5. Would you explain these areas of board certification?
6. Where are you licensed to practice medicine?
7. What professional organizations do you belong to?
8. During your medical career have you had any professional appointments?
9. Doctor, your curriculum vitae lists numerous invited lectures; presentations and conferences,
could you give the jury a brief description of the topics you have studied and or presented on over
the years?
10. Doctor, have you published articles or studies on head injuries in children?
a. What journals?
11. Have you testified previously in the area of forensic pathology?
12. Have you testified previously regarding head injuries in children?
13. Have you testified previously with respect to what is being called “shaken baby syndrome?
14. How many times have you testified in the area of forensic pathology?
15. How many times have you testified in the area of childhood head injuries?
16. Who have you testified for most often over your career, the prosecution of the defense?
17. Are you being paid as an expert to testify before the jury today?
18. Doctor, how important is it to stay current in the scientific and medical literature on childhood
head injuries, if you are going to diagnose or testify about them?
a. And why is that?
27
19. Doctor, what documents have you reviewed in coming to your opinion today?
20. Do these medical records reflect any evidence of child abuse or that this baby was beaten or
battered?
21. Do these medical records reflect or show any evidence that this baby was shaken?
22. What evidence would you expect to see if this baby had been shaken?
a. Were there any neck injuries to this child?
b. Was there any rib fractures?
c. Was there any grip marks on the arms, to indicate someone had grabbed onto the child?
d. Any spinal cord injuries?
History of the Debate regarding “Shaken Baby Syndrome”
23. Has there been a shift in the literature or science in the area of what has been called “Shaken
Baby Syndrome” or “non-accidental trauma” over the last 10 years?
24. Can you explain to the jury what started the history of this debate and the basis of the recent
shift?
25. In reference to biomedical research or medical research in general, what is evidence-based
medicine?
26. How would this concept of evidence-based medicine apply to the study of impact injury in
children?
27. Is there an article specifically talking about evidence-based medicine in reference to SBS?
a. Mark Donohoe, 2003 Published in American Journal of Forensic Medicine & Pathology
28. What were the conclusions of Dr. Donohoe’s article?
Retinal Hemorrhages
29. Are you familiar with the articles and/or studies concerning closed head injury in children
presenting with subdural hematomas, retinal hemorrhage and cerebral edema and their origins?
30. Have any studies been done to show if shaking a baby can cause SDH and retinal hemorrhage?
31. Previous witnesses have come into court and testified that Retinal hemorrhages are diagnostic of
non-accidental trauma, and/or can only come from shaking. Do you agree with that theory?
a. Why not?
b. Have there been any studies done in this area?
c. Can you tell us about the research?
Short Falls
32. Previous witnesses have testified that short falls cannot cause subdurals. Do you agree with that?
a. Why not?
28
b. Have there been any studies done in this area?
c. Can you tell us about the research?
Chronic Subdural Hematomas and Rebleeds
(Use the Merrick and Monroe chart to document ages of SDH.)
33. We’ve had a lot of testimony about the formation of subdural hematomas. How many subdurals
did you find in on the baby in this case?
34. Could you tell this jury about the clotting process?
35. About how long does it take for blood in a subdural hematoma to clot into a mass like that
indicated in the photograph?
36. At what point does blood begin to adhere to the dura?
a. Is there any significance to that?
37. What is a chronic subdural?
38. Showing you what has been marked as peoples’ exhibit ____, have you seen this picture before?
(photo of SDH)
39. What color is the dura supposed to be?
40. Showing you defense exhibit _____, is this a normal appearance of dura?
a. Why not?
41. Is there anything which causes it to change or become dark in color?
42. How long does it take for a subdural hematoma to stain the dura?
43. Doctor, based on your analysis of the evidence in this case, did you form an opinion as to the age
of the subdural hematoma on this baby’s brain?
a. How did you come to that conclusion?
b. Could you show the jury what causes you to believe that there was an old subdural?
c. What is the youngest that subdural hematoma could have been to cause that kind of stain?
44. Do you have any idea what caused the old subdural hematoma?
45. Do babies sometimes suffer subdural hematomas during the birth process?
46. Do you know what percent of vaginal births result in subdural hematomas? (Rooks says 46%
and Looney says 26%)
47. Do subdural hematomas immediately stop bleeding after they are caused?
48. What are some things that can impede an SDH from clotting right away?
49. How long does it take for them to heal?
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50. What happens if it continues to bleed without treatment?
51. How much force does it take for a subdural hematoma to rebleed?
52. What sorts of things can cause subdural hematomas to rebleed or grow?
53. If a subdural hematoma is in existence, would it be more susceptible to re-injury than healthy
tissue? Why?
54. Does it matter if there is a capillary or venous bleed?
a. Why is that important?
55. If I told you that these doctors could not identify a particular vein from which this subdural
hematoma was bleeding, would that indicate anything to you?
56. Do you think this was a capillary or venous bleed?
57. Is there a point when the bleeding reaches a critical point?
a. What happens then?
58. If a child had a subdural hematoma of 2 to 5 days old, and fell off a bed, do you think he might be
more susceptible to re-injury in that same spot?
59. If the subdural had previously been asymptomatic, could this kind of fall make it symptomatic?
Lucid Intervals/Asymptomatic SDH
60. How long can a child have a subdural hematoma without having symptom?
61. How long can a subdural hematoma be in a child’s head without it resolving?
62. Could there be persistent bleeding in a subdural hematoma without any major symptoms?
63. What determines when a child becomes symptomatic?
64. Is there any literature out that supports your contention that a child can suffer a subdural
hematoma and by asymptomatic, only to later become symptomatic and/or die? (Jenny, Greenes)
30
Sample Cross Examination
31
Sample Cross Examination
Qualifications
1. You are not board certified in ___________, correct?
2. How many times have you testified in court on a case involving the allegations of “shaken baby”?
3. Have you written any articles or published in the field of biomechanics?
4. Have you written any articles or published in the field of child abuse?
5.
Have you written any articles or published in the field of retinal hemorrhages?
6. Have you written any articles or published on the pathology of subdural hemorrhages in children?
Retinal Hemorrhages
7. You are not an ophthalmologist, correct?
8. Dr. ______, do we know everything there is to know about retinal hemorrhages? (Answer No.
See: Riffenburgh 1991)
9. Isn’t there new literature coming out every day with regard to retinal hemorrhages?
10. Which ophthalmology journals do you subscribe to?
11. Are you at all familiar with the literature on retinal hemorrhages and their diagnostic reliability
with regard to accidental vs. non-accidental head injuries?
12. Can you give us some of the articles you rely on when forming your opinions of the diagnostic
reliability of retinal hemorrhages?
13. A couple of weeks ago, we sent to your office a stack of articles regarding retinal hemorrhages
and non-accidental trauma in children. They included articles by Donahoe; Jayawant;
Plunkett; Piatt; Lantz; Ommaya; and Nashelski, correct?
a. Did you get a chance to read any of those?
b. Those articles discuss retinal hemorrhages from causes other than shaking, correct?
14. Have you read the 1991 article by Dr. Andrea Tongue (Ophthalmology July 1992; 98(7))
entitled: The Ophthalmologist’s Role in Diagnosing Child Abuse?
a. Would you agree that Dr. Tongue concluded in that article that there is no evidence
establishing retinal hemorrhages are indicative of non-accidental trauma?
15. Didn’t Dr. Tongue also state in that same article, that it has not been proven that retinal folds are
secondary to dynamic vitreous traction in shaking rather than in some other factors? (Id)
16. Didn’t she also state that it is imperative that ophthalmologists not equate retinal fold as child
abuse? (Id)
32
17. Dr. ______, are you aware of Dr. Jayawant’s 2005 study entitled: Neuroradiological Aspects of
Subdural Hemorrhages? (Arch Dis Child 2005; 90:947-951)
a. Didn’t Dr. Jayawant say that retinal hemorrhages are not an independent predictor of
non-accidental injury? (Id at Page 7)
18. Dr. ______, are you aware of Dr. Fung’s 2002 study entitled Unexplained Subdural Hematoma
in Children: Is it Always Abuse?
a. Didn’t that study concluded that “it is unresolved whether trivial or minor head injury can
cause retinal hemorrhages and subdural hematomas.” (Fung et al. Pediatrics
International 2002; 44: 37-42)
19. Dr. ______, are you aware of the 1998 study by Christine Duhaime in the New England Journal
of Medicine , June 18, 1998 entitled Non Accidental Head Injury in Infants? (New England
Journal of Medicine 1998; 338:1822-1829)
a. Didn’t that study conclude that retinal hemorrhages were not specific for the diagnosis of
shaken baby syndrome and that the diagnosis of inflicted head injury cannot rest on
retinal hemorrhages alone? (Id)
20. Are you aware of the literature that says that retinal hemorrhages can be found in children or
infants who have suffered short falls or other accidental head trauma?
21. Dr. ______, have your read the 2004 article by Patrick Lantz in the British Medical Journal
entitled: Perimacular Retinal Folds from Childhood Head Trauma? (British Medical Journal
2004; 328(27))
a. In that article, Dr. Lantz details the medical history of a child who was diagnosed with
retinal hemorrhages after he was witnessed having a TV set fall on his head.
b. Knowing that, are you still of the opinion that retinal hemorrhages cannot come from
anything other than shaking?
22. Doctor, are you familiar with an article by Dr. John Plunkett entitled: Fatal pediatric head
injuries caused by short distance falls? (American Journal of Forensic Medicine and Pathology
2001; 22:1-12)
a. Of the 18 child deaths, only 6 had eye exams following their falls correct?
b. And 4 of those 6 had retinal hemorrhages, correct?
c. Knowing that, are you still of the opinion that retinal hemorrhages cannot come from
anything other than shaking?
23. Can CPR cause RH?
a. Are you familiar with a study by Goetting MG and Sowa B. Retinal Hemorrhage after
Cardiopulmonary Resuscitation in Children: An Etiologic Re-evaluation? (Pediatrics
1990; 85:585-588)
b. The study showed retinal hemorrhages can come from CPR correct?
c. Knowing that, are you still of the opinion that retinal hemorrhages cannot come from
anything other than shaking?
24. Have you read the 1985 article by Kirschner entitled: The Mistaken diagnosis of Child Abuse?
(American Journal of Diseases in Childhood 1985; 139:873-5)
a. This study showed retinal hemorrhages in an infant after chest compressions were
performed, correct?
33
25. And if you know, did the baby in this case have CPR prior to his/her retinal exam?
26. If you know, can retinal hemorrhages be found with hydrocephalus?
27. Dr., have you read an article by Joseph Piatt in the Journal of Neurosurgery entitled A pitfall in
the Diagnosis of Child Abuse: External Hydrocephalus, Subdural Hematoma & Retinal
Hemorrhages. (Neurosurgical Focus 1999; 7(4):1-9.)
a. In that article Dr. Piatt details the case of a child with hydrocephalus and no signs of
abuse, the child had retinal hemorrhages, correct?
28. Dr. ______, retinal hemorrhages can be found in a variety of other conditions that are not related
to abuse, isn’t that correct?
29. Can bleeding disorders cause retinal hemorrhages? (3 of 12 #1, Donahoe , Page 6)
30. Can Meningitis cause a retinal hemorrhage? (Id)
31. Can Septicemia cause retinal hemorrhages? (Id)
32. Can Galactosaemia cause retinal hemorrhages? (Id)
33. Can hypertension or high blood pressure cause a retinal hemorrhage? (Id)
34. What is Hennoch-Schonlein Purpura?
a. Can you see retinal hemorrhage in kids with that disease? (Id)
35. What percentage of babies are born with retinal hemorrhages if you know?
a. Would it surprise you to know that 40% of vaginally delivered newborns are found to
have retinal hemorrhages at birth? (Kaur B; Taylor D. Current Topic: Retinal
Hemorrhages. Arch Dis. Child 1990; 65:1369-1372)
36. Have you read the study by Ommaya’s entitled: Biomechanics and Neuropathology of Adult and
Pediatric Head Trauma, which says retinal hemorrhages are not diagnostic for intentional
traumatic brain injury? (Ommaya, Biomechanics and Neuropathology of Adult and Pediatric
Head Trauma, 14, 3 of 8, Page 33)
37. In fact, doesn’t he say that the level of force required for retinal bleeding by shaking is
biomechanically improbable? (Id)
38. Isn’t it true that pretty much anything that causes a sudden increase in ICP can cause retinal
hemorrhages? (If he says, ‘not this kind’- ask him/her how he/she knows what kind they are, there
are no pictures, he/she is just going on a drawing and the interpretation of another doc- not
evidence).
a. Can an acute subdural cause increased ICP?
b. Did this baby have an acute subdural?
c. Can a chronic subdural cause increased ICP?
d. Did this baby have a chronic subdural?
39. Dr. ______, would it surprise you that 10 out of 13 studies between 1964 and 1967 confirm that
the mechanism of retinal hemorrhages was increased venous pressure, increased intracranial
pressure (acting on orbital veins), where passages of blood through intracranial subarachnoid
34
space? (Kaur B; Taylor D. Current Topic: Retinal Hemorrhages. Arch Dis. Child 1990; 65:13691372)
40. Did you take any pictures of the retinal hemorrhages in this case so that other doctors could
evaluate the pattern, number and extensiveness of the hemorrhages?
Short Falls
41. Part of your reason for diagnosing this case as one of non-accidental trauma is based on your
belief that short falls cannot cause subdural hematomas or death, correct?
42. Did you take any classes in physics or biomechanics in medical school?
a. What is biomechanics?
43. Have you done any in depth study in the physics or the biomechanics of childhood head injuries?
44. Do you have any idea how many g forces are created in a short fall?
45. Do you have any idea how many g forces it takes to create a subdural hematoma?
46. Do you have any idea how many g forces can be created by a human being, during a shaking?
47. Are you aware of the study by Dr. Christine Duhaime et al in 1987 entitled – SBS: A Clinical,
Pathological and Biomechanical Study? (Journal of Neurosurgery 1987; 66:409-415)
a. If I said the results of this study show that shaking alone cannot cause the injuries
associated with SBS, would you agree with my reading of that study?
b. Would you agree the study found there must be impact of the head to cause the
constellation of injuries found in these cases?
c. Did you find an impact site on this child’s head?
48. Dr. ______, have you read the 2001 article by John Plunkett in the British Medical Journal
entitled Fatal pediatric head injuries caused by short distance falls? (American Journal of
Forensic Medicine and Pathology 2001; 22:1-12.)
a. This study analyzed information from the Consumer Product Safety Commission’s
database regarding falls from playground equipment, correct?
b. The author showed 18 deaths from falls of less than 10 feet, correct?
c. Of those 18 deaths, 13 children had subdural hematomas, correct?
d. And 12 had lucid intervals, ranging from 5 minutes to 48-hours, correct?
e. And again, 4 of the 6 that had retinal exams had retinal hemorrhages correct?
49. So would it be correct to say that the Plunkett study showed us that subdural hematomas and
retinal hemorrhages can come from short falls?
50. Are you aware of a 2000 study by the same author, where he discusses the videotaped death of a
23 month old girl that fell from less than 2 feet, and received subdural hematomas and retinal
hemorrhages?
51. Have you read the Howard article entitled: The pathophysiology of infant subdural haematomas?
(Howard M, Bell B.A, and Uttley D. British Journal of Neurosurgery 1993; 7: 355-6.)
35
a. You would not disagree with me that in that study two of the children with accidental
falls experienced subdural hematomas, correct?
52. Are you aware of articles by Ayub Ommaya? (Ommaya, et al. British Journal of Neurosurgery
2002; 16 (3) 220-242, 226.)
a. In that study, doesn’t he say that the assumptions underlying shaken baby syndrome
“individually and in concert are ambiguous or incorrect although they have been used as
the bases for differential diagnosis of the mechanisms of pediatric head injuries usually
without reference to available biomechanical analysis using reconstruction methods?”
(Ommaya, et al, British Journal of Neurosurgery 2002; 16 (3) 220-242, 226.)
53. Have you read the 1993 article by Gregory Reiber entitled: Fatal Falls in Childhood? (The
American Journal of Forensic Medicine and Pathology 1993; 14(3): 201-207)
a. Didn’t this article document three cases in which children who experienced short falls
had fatal injuries?
b. Didn’t it also present a case in which the child fell onto a carpeted surface from 6 feet and
sustained fatal injuries?
54. Are you familiar with the original article by Dr. Caffey, the founder of the so-called shaken baby
syndrome, about what he would expect to see in a “shaken baby?”
a. So you are (or are not) aware that Caffey said that he would expect to see things like
whiplash, rib fractures and long bone fractures in a child who had been shaken?
55. Were there any external signs of abuse? Bruises, burns, welts, grip marks etc?
56. Did you find any rib fractures on this child?
57. Were there any long bone fractures?
58. Where there any grip marks from where the child would have to be grabbed to shake with that
force?
59. Can babies get whiplash?
60. Do you have any idea how many g forces it takes to cause whiplash?
a. Would you agree with me that generally, with car accidents and other deceleration
injuries you generally get whiplash before you get a subdural?
61. Were there any whiplash injuries to the neck?
62. Are you aware of a 2005 study by Faris Bandak entitled Shaken Baby Syndrome: A
Biomechanics Analysis of Injury Mechanisms? (Forensic Science International 2005; 15(1): 7179).
a. Wasn’t the conclusion of that study, that the threshold of a SDH is much higher than that
of whiplash?
b. Didn’t Bandak say absent neck injuries, the SDH cannot be caused by shaking alone?
63. Part of the treatment of any patient is to get a history of events leading up to the immediate
incident, correct?
36
64. Did you take a history from the parents and the daycare provider as to whether there had been any
head impacts or short falls in the recent or distant past?
a. How many falls did this child have in her history?
Chronic Subdural Hematomas and Rebleeds
65. You are not a neurosurgeon correct?
66. And you are not a neurologist correct?
67. And you are not a pediatric radiologist, correct?
68. Have you done any specialized reading about subdural hematomas in children?
69. Do you have any specialized knowledge regarding the evolution of subdural hematomas during
the course of their healing process in infants?
70. Do you have any specialized knowledge regarding rebleeding in subdural hematomas in infants?
71. Have you read any of the studies pertaining to rebleeding subdural hematomas in infants?
72. So you are not here to talk to us about the amount of force needed to make a chronic subdural
rebleed, or to say that they don’t rebleed correct?
73. Have you read Joseph Piatt’s 1999 article entitled A Pitfall in the Diagnosis of Child Abuse:
External Hydrocephalus? (Neurosurgical Focus 1999; 7(4):1-9)
a. Didn’t that study conclude that anything that occupies in subdural space can cause a
bleed?
74. Are you familiar with Swift’s 2000 article entitled: Chronic Subdural Hematomas in Children?
a. Doesn’t he say in this article that subdurals can rebleed?
75. Have you read Sherwood’s 1930 article entitled: Chronic Subdural Hematomas in Infants?
(Journal of Chronic Subdural Hematomas July 2000; 11(3))
a. So we have known since then infants rebleed, correct?
76. Have you read the 1992 study by Parent entitled: Pediatric Chronic Subdural Hematoma: A
Retrospective Comparative Analysis? (Pediatric Neurosurgery 1992; 18:266-271).
a. Parent also shows subdurals can rebleed in children, correct?
77. This baby had an old subdural correct?
78. Did you observe this yourself on the CT or MRI scans?
79. Are you aware that this child had a history of a previous fall?
80. How old is the subdural hematoma on this baby’s brain?
81. Have you had a neuropathologist date this subdural?
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82. In fact you're not a neuropathologist are you?
83. So you're not really the person to date subdural hematomas correct?
84. So you have no idea how old the subdural hematoma on this baby was? Correct?
85. When they are dating subdurals, they talk about acute, subacute and chronic subdural hematomas.
If another doctor came in here and said that it is generally said that an acute subdural hematoma is
1-3 days old, subacute is 4-7 and chronic is 10 days or more, you wouldn’t disagree with
someone who said subacute is 4-10 days old, correct? (see Merrick and Munroe chart in Spitz
and Fisher or Leestma’s book on forensic neuropathology.)
Lucid Intervals/Asymptomatic Subdurals
86. Would you agree that not all subdural hematomas become immediately symptomatic?
a. Some subdurals are asymptomatic correct?
b. Do subdurals heal instantly?
c. And subdurals can wax and wane during the healing process, correct?
87. When they are symptomatic, what types of symptoms do we see? What are the signs of increased
intracranial pressure?
a. Lethargy?
b. Vomiting?
c. Failure to feed?
d. Seizures?
88. Have you read the 1998 study by Greenes and Schultzman entitled: Occult Intracranial Injury in
Infants? (Annals of Emergency Medicine 1998; 32(6):680-686).
a. That study examined 86 children less than one year of age admitted to the emergency
room of Children’s Hospital Harvard, correct?
b. The authors showed that 19 of the 86 kids (27% of the children under 6 months and 15%
of those 6 months to one year of age) had asymptomatic subdural hematomas, correct?
89. Have you read the 1999 article by Jenny et al. entitled, Analysis of Missed Cases of Abusive
Head Trauma? (Journal of the American Medical Association 1992; 281(7):621-626)
a. Didn’t the Jenny et al. study document lucid intervals/asymptomatic SDH’s in children,
40% of which resulted in later complications?
90. Have you read the 1995 article by Nahelsky and Dix entitled: The Time Interval Between Lethal
Infant Shaking and the Onset of Symptoms: A Review of the Shaken Baby Syndrome? (The
American Journal of Forensic Medicine and Pathology 1995; 16(2):154-157).
a. Didn’t that article, present three cases where children experienced lucid intervals of 3
hours, 3 days and 4 days between the time of injury and the onset of symptoms?
91. Have you read the 1986 study by Dacey et al. entitled: Neurosurgical Complications after
Apparently Minor Head Trauma? (Neurosurgery 1986; 65:203-210).
a. Isn’t it correct that the authors of this study found that lucid intervals are more common
among male patients?
b. And isn’t it also correct that the authors found that falls were more likely than other
mechanisms to result in a lucid interval in a patient?
38
92. Are you familiar with the 2007 study Looney et al. entitled: Intracranial Hemorrhage in
Asymptomatic Neonates: Prevalence on MR Images and Relationship to Obstetric and Neonatal
Risk Factors? (Radiology Feb. 2007; 242(2) 535-541).
a. Isn’t it correct that this study found that 26% of all infants born through natural, vaginal
births with no complications have intracranial hemorrhages?
b. And weren’t all of those cases asymptomatic?
93. Have you read the 2008 article by Rooks et al. entitled: Prevalence and Evolution of Intracranial
Hemorrhage in Asymptomatic Term Infants? (American Journal of Neuroradiology April 3,
2008; 1-8)
a. Isn’t it correct that the authors of this study found that out of 101 infants studied at the 37 days, 2 weeks, 1 month, and 2 month marks after birth, 46 were found to have SDH’s
within 72 hours after birth by either cesarean section or vaginal delivery?
b. And weren’t all of those cases asymptomatic?
39
Spelling Sheet of Names and Terms for the Court Reporter
(Names are bolded)
Abrasion
Acute Subdural Hematoma
Asymptomatic
Bilateral
Bilirubin
Blunt Force Trauma
Bridging Veins
Bruise
Caffey, J.
CAT Scan
Cause of Death
Cephalic Presentation
Cerebrospinal Fluid (CSF)
Chronic Subdural Hematoma
Clinician
Coagulopathy
Congenital
Conjunctiva
Contusion
Crepitus
Cutaneous
Cyanotic
Diagnosis
Diffuse Axonal Injury
Donohoe, Mark
Duhaime, Christine
Dural hemorrhage
Ecchymosis
Edema
Encephalitis
Encephalopathy
Ependyma
Forensic Pathology
Fracture
Fundoscope
Fung
G-force
Gestational diabetes
Goetting, M.G.
Goldsmith
Hematoidin
Hemosiderin
Herniation
Howard
Hydrocephalus
Hydrocephaly
Hypoxic Ischemia
Hypoxia
Impact
Infaret
Injury
Ischemia
Jayawant
Jaundice
Kaur
Kirschner
Laceration
Lantz
Leestma, Jan
LeFanu, J.
Looney
Lucid interval
Manner of death
Marguiles
Mass Effect
Magnetic Resonance Imaging
(MRI)
Merrick and Monroe
Nashelski
Neomembrane
Neuropathology
Nuchal cord
Oligiohydramnios
Omaya, Ayub
Parent, A.D.
Piatt, J.
Parenchyma
Pathology
Platelets
Prang, Michael
Plunkett, John
Polyhydramnios
Prescription
Reiber, G.
Retina
Retinal Hemorrhage
Riffenburgh
Rooks
Seizure
Sowa, B.
Spitz and Fisher
Squire
Subacute Subdural
Hematoma
Subarachnoid Hemorrhage
(SAH)
Subctaneous
Subdural
Hemorrhage/Hematoma
(SDH)
Subgaleal Hemorrhage
Swift
Tachycardia
Tentorium
Transverse lie presentation
Traumatic axonal Injuries
Unilateral
Vertex birth presentation
White blood cell count
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Glossary
Acute Subdural Hematoma: subdural hematoma that is zero to 3 days old. There are clinical, gross,
radiological and pathological characteristics for these.
Bilateral: relating to both sides.
Bilirubin: A yellow-orange compound produced by the breakdown of hemoglobin from red blood cells.
High Bilirubin rates indicate jaundice.
Blunt Force Trauma (BFT): physical trauma caused to a body part, either by impact injury. This can be
caused by a blunt object striking a body part, or a body part striking a blunt object, such as the floor.
Does not mean non-accidental.
Bridging Veins: small veins that channel blood from the brain surface to the superior sagittal and other
intradural venous channels that cross the subarachnoid space. Breakage or injury of these vessels is
thought to cause subdural hemorrhages.
Bruise: an injury that involves some degree (usually capillary) of bleeding into a tissue.
CAT Scan: an image made by computed tomography.
Cephalic Presentation: Born head first.
Cerebrospinal Fluid (CSF): the watery, clear fluid secreted by the choroids plexus, and probably the
brain itself, that collects in the ventricles of the brain and surrounds the brain. It is produced at a constant
rate at all times and must be correspondingly absorbed to maintain normal intracranial pressures.
Chronic Subdural Hematoma: Greater than 10 days old (usually when a neomembrane encloses or
nearly encloses a hematoma).
Clinician: a physician who treats patients (internist, surgeon, pediatrician, etc.).
Coagulopathy: an abnormality of blood coagulation (generally either too much or too little). Can be
assessed by platelet count, levels of clotting factors and other measures of blood clotting in the laboratory.
There are hundreds, if not thousands of blood disorders—only a few of which are tested on regular blood
tests or routine clotting tests.
Congenital: A condition that is congenital is one that is present at birth.
Conjunctiva: the outer covering the eyeball (the white of the eye).
Contusion: a bruise.
Crepitus: A clinical sign in medicine characterized by a peculiar crackling, crinkly, or grating feeling or
sound under the skin, around the lungs, or in the joints.
Cutaneous: of, relating to, or affecting the skin.
Cyanotic: Showing cyanosis (bluish discoloration of the skin and mucous membranes due to not enough
oxygen in the blood).
Diffuse Axonal Injuries: axonal injury that is widespread over the brain. The pathologist must take
multiple samples, from different locations in the brain to document diffuse nature (Geddes).
Dural Hemorrhages: The outermost, toughest, and most fibrous of the three membranes (meninges)
covering the brain and the spinal cord. Dura is short for dura mater (from the Latin for hard mother).
Ecchymosis: the escape of blood into the tissues from ruptured blood vessels. Also, a small hemorrhagic
spot, larger than a petechiae, in the skin or mucous membrane forming a non-elevated, rounded or
irregular, blue or purplish patch.
Edema: Swelling
Encephalopathy: Inflammation of the brain generally from a disease process. It may eventuate in central
nervous system impairment or death. Depending on the cause of the inflammation, this may include
antibiotics, anti-viral medications, and anti-inflammatory drugs.
Ependyma: the cellular covering (lining) of the brain's ventricular cavities. These are ciliated low
cuboidal cells that facilitate movement of cerebrospinal fluid through the ventricles.
Forensic Pathology: the medical subspecialty within pathology devoted to the medical-legal aspects of
pathology. Forensic pathologists usually function as a medical examiner's pathologist and have special
statutory responsibilities.
G-force: the force of gravity. Acceleration or deceleration is often expressed in Gs, representing the
added "gravity" force acting on a body. If someone weighed 100 lbs. at rest, and experienced a force of
3G acceleration, they would experience the feeling of weight of 300 lbs. Tissues of the body have
tolerance limits to G forces, and these limits are known and studied by the field of biomechanics.
Gestational Diabetes: A form of diabetes mellitus that appears during pregnancy (gestation) in a woman
who previously did not have diabetes and usually goes away after the baby is born.
Factors that increase the chance of a woman's developing gestational diabetes include her age (if she's
over 25), her ethnic background (high-risk groups include Hispanic, African American, Native American,
South or East Asian, Pacific Islander, and Indigenous Australian), her weight (if she's overweight), her
family history (if there's a relative with diabetes) and her history of past pregnancies (with gestational
diabetes in a past pregnancy, or if she's had a stillbirth or a very large baby).
The children of mothers with gestational diabetes are at higher risk for respiratory distress syndrome
(which makes it hard for the newborn baby to breathe); they are more likely to be overweight as children
or adults: and they are at higher risk for getting diabetes themselves as they grow older.
Hematoidin: a yellow pigment not containing iron that is the product of blood degradation.
42
Hemosiderin: a brown-yellow pigment that contains iron and is a product of degradation of blood,
usually found in scavenger cells called "siderophages." Generally an indicator that the hematoma is more
than 3 days old.
Herniation: a breakthrough of a body organ or part of an organ through a tear or part of a membrane,
muscle, or other tissue.
Hydrocephaly (Hydrocephalus): too much cerebrospinal fluid in and/or over the brain that is usually
associated with increased intracranial pressure in children.
Hypoxic Ischemia: injury from lack of blood and/or oxygen to the brain. Often mistaken for diffuse
axonal injury.
Hypoxia: not enough oxygen to an organ.
Impact: force directed against a body by any means (can include blow, falls and other impacts).
Infaret: dead and dying tissue due to insufficient blood or nutrient supply.
Ischemia: not enough blood supply to an organ.
Jaundice: Yellow staining of the skin and sclerae (the whites of the eyes) by abnormally high blood
levels of the bile pigment bilirubin. The yellowing extends to other tissues and body fluids.
Lucid Interval: Asymptomatic subdural hematoma.
Mass Effect: damage to the brain due to the bulk of a tumor, the blockage of fluid or excess accumulation
of fluid within the skull.
MRI (Magnetic resonance imaging): a noninvasive diagnostic technique that produces computerized
images of internal body tissues and is based on nuclear magnetic resonance of atoms within the body
induced by the application of radio waves.
Neomembrane: a membrane of inflammatory cells, reactive cells (fibroblasts), newly formed vessels and
scar tissue (collagen) formed in the course of time after a subdural hemorrhage occurs. Generally an
indicator that the hematoma is not acute (more than 3 days old). The age of this process can be estimated
microscopically.
Neuropathology: the medical subspecialty of the pathology devoted to the diseases of the nervous
system.
Oligiohydramnios: A condition characterized by a reduced level of amniotic fluid. Increased clavicle
breaks and respiratory illnesses.
Parenchyma: working tissue of an organ, as opposed to supporting or connective tissue
Pathology: the medical specialty devoted to understanding the mechanisms, causes and manifestations of
disease processes (cancer, infection, traumatic injury, toxic injury, congenital anomalies, etc.).
43
Pathologists do autopsies, examine tissues from surgery, and use a variety of laboratory technologies and
research methods. Pathologists generally do not treat patients or admit them to hospital.
Platelets: microscopic cellular elements of the blood vital to clotting.
Polyhydramnios: Too much amniotic fluid.
Retina: the light-sensing element in the back of the eye.
Subacute Subdural Hematoma: Subdural hematoma that is 4-10 days.
Subarachnoid Hemorrhage: bleeding in the subarachnoid space (space normally filled with
cerebrospinal fluid, below the arachnoid membrane and above the brain.
Subcutaneous: under the skin.
Subdural Hemorrhage or Hematoma: bleeding beneath the dura and above the arachnoid.
Subgaleal Hemorrhage: bleeding in the deep tissues of the scalp just above the skull.
Tachycardia: A rapid heart rate, usually defined as greater than 100 beats per minute.
Tentorium: a fold of the dura mater which separates the cerebellum from the cerebrum and often
encloses a process or plate of the skull called the bony tentorium.
Transverse Lie Presentation: means the fetus is oriented from one side of the mother to the other and
neither the head nor the butt is coming out first.
Traumatic Axonal Injuries: axonal injury due to trauma. Generally observed as focal injuries.
Unilateral: Having, or relating to, one side.
Vertex Birth Presentation: the top of the baby's head comes first at delivery.
Useful Medical Abbreviations
Dx: Diagnosis
Plt: Platelet
Rx: Prescription
WBC: White Blood cell count
Hx: History
SDH: Subdural Hemorrhage or Hematoma
Fx: Fracture
SAH:
Sx: Seizure
RH: Retinal Hemorrhage
44