PREVALENCE OF RETINAL HEMORRHAGES IN PEDIATRIC-PATIENTS AFTER IN-HOSPITAL CARDIOPULMONARY-RESUSCITATION - A PROSPECTIVE-STUDY

Objective. Child abuse occurs in 1% of children in the United States e very year; 10% of the traumatic injuries suffered by children under 5 years old are nonaccidental, and 5% to 20% of these nonaccidental inju ries are lethal. Rapid characterization of the injury as nonaccidental is of considerable benefit to child protection workers and police inv estigators seeking to safeguard the child care environment and apprehe nd and prosecute those who have committed the crime of child abuse. Ph ysically abused children present with a variety of well-described inju ries that are usually easily identifiable. In some cases, however, par ticularly those involving children with the shaken baby syndrome, obvi ous signs of physical injury may not exist. Although external signs of such an injury are infrequent, the rapid acceleration-deceleration fo rces involved often cause subdural hematomas and retinal hemorrhages, hallmarks of the syndrome. Frequently, retinal hemorrhages may be the only presenting sign that child abuse has occurred. Complicating the i nterpretation of the finding of retinal hemorrhages is the belief by s ome physicians that retinal hemorrhages may be the result of chest com pressions given during resuscitative efforts. The objective of this st udy is to determine the prevalence of retinal hemorrhages after inpati ent cardiopulmonary resuscitation (CFR) in pediatric patients hospital ized for nontraumatic illnesses in an intensive care unit. Design. Pro spective clinical study. Setting. Pediatric intensive care unit. Patie nts. Forty-three pediatric patients receiving at least 1 minute of che st compressions as inpatients and surviving long enough for a retinal examination. Patients were excluded if they were admitted with evidenc e of trauma, documented retinal hemorrhages before the arrest, suspici on of child abuse, or diagnosis of near-drowning or seizures. All of t he precipitating events leading to cardiopulmonary arrest occurred in our intensive care unit, eliminating the possibility of physical abuse as an etiology. Interventions. None. Measurements. Examination of the retina was performed by one of two pediatric ophthalmologists within 96 hours of CPR. The chart was reviewed for pertinent demographic info rmation; the platelet count, prothrombin time, and partial thromboplas tin time proximate the CPR were recorded if they had been determined. Results. A total of 43 pediatric patients hospitalized with nontraumat ic illnesses survived 45 episodes of inpatient CPR. The mean age was 2 3 months (range, 1 month to 15.8 years), and 84% of the patients were under 2 years old. The majority of the patients (44%) were admitted to the intensive care unit after surgery for congenital heart disease, a nd another 21% were admitted for respiratory failure. The mean duratio n of chest compressions was 16.4 minutes +/- 17 minutes with 58% lasti ng between 1 and 10 minutes. Five patients had chest compressions last ing >40 minutes, and two patients had open chest cardiac massage. All patients survived their resuscitative efforts. Ninety-three percent of patients had an elevated prothrombin time and/or partial thromboplast in time while 49% were thrombocytopenic. Sixty-two percent of the pati ents had low platelet counts and an elevated prothrombin time and/or p artial thromboplastin time. Small punctate retinal hemorrhages were fo und in only one patient. Conclusions. Retinal hemorrhages are rarely f ound after chest compressions in pediatric patients with nontraumatic illnesses, and those retinal hemorrhages that are found appear to be d ifferent from the hemorrhages found in the shaken baby syndrome. Despi te the small number of patients in this prospective study, we believe that these data support the idea that chest compressions do not result in retinal hemorrhages in children with a normal coagulation profile and platelet count. A larger number of patients should be evaluated in a prospective multi-institutional study to achieve statistical signif icance in a nondescriptive study.