138 J Accid Emerg Med 2000;17:138–139 J Accid Emerg Med: first published as 10.1136/emj.17.2.139 on 1 March 2000. Downloaded from CASE REPORTS Domestic violence: the shaken adult syndrome T D Carrigan, E Walker, S Barnes Abstract Her initial blood pressure was 119/72 mm A case of domestic violence is reported. Hg, pulse 88 beats/min, her pupils were equal The patient presented with the triad of and reactive directly and consensually, and her injuries associated with the shaking of Glasgow coma score was 13/15 (she was infants: retinal haemorrhages, subdural confused and was opening her eyes to com- haematoma, and patterned bruising; this mand). Examination of the head showed bilat- has been described as the shaken adult eral periorbital ecchymoses, nasal bridge swell- syndrome. This case report reflects the ing and epistaxis, a right frontal abrasion, and diYculties in diagnosing domestic vio- an occipital scalp haematoma. Ecchymoses lence in the accident and emergency were also noted on her back and buttocks, setting. being linear in fashion on both upper arms, (J Accid Emerg Med 2000;17:138–139) and her underpants were torn. Initial skull and Keywords: domestic violence; women; assault facial x ray films were normal, and she was admitted under the care of A&E for neurologi- cal observations. Domestic violence is an under-reported and Over the next 24 hours, her Glasgow coma major public health problem that often first score improved to 15/15, but she had vomited presents to the accident and emergency (A&E) five times and complained that her vision department. It accounts for half of all violent remained blurred. Visual acuity was only hand crimes against women, and two deaths per movements in the right eye and finger counting week have been linked to domestic violence in in the left. Ophthalmological review confirmed Britain.1 Indeed, the Department of Health has both retinal and preretinal haemorrhages in the issued statements to ensure health profession- right eye and a retinal haemorrhage on the left. als are aware of domestic violence in this con- Both maculae were aVected by the haemor- text when patients present with consistent rhage (fig 1). Haematological investigations, http://emj.bmj.com/ traumatic injuries.2 including a full blood count and a clotting The following case report reflects the screen, were within normal parameters, and diYculties in diagnosing domestic violence in computed tomography of the head revealed a the A&E setting, and stresses the timely small left temporal subdural haemorrhage with referral of such patients to the relevant adjacent oedema. authorities. It was only after 48 hours and repeated advice that she should seek help and report the Case report injuries to the police, that she admitted that on September 30, 2021 by guest. Protected copyright. A 34 year old woman was brought to the A&E domestic violence had occurred. department by ambulance at 0400 hours with Ongoing police and consultant medical head injuries. When handed over from the review showed photographic evidence of pat- ambulance crew an assault was queried, terned bruising to the upper arms, and also although the patient later stated she had fallen several circular burns to the face and arm, down stairs after moderate alcohol ingestion. similar to the type caused by the deliberate Accident and Emergency Department, Dewsbury District Hospital, Dewsbury T D Carrigan E Walker S Barnes Correspondence to: Dr T D Carrigan, Specialist Registrar, Accident and Emergency Department, St James’s University Hospital, Beckett Street, Leeds LS9 7TF Accepted 28 September Figure 1 Photographs showing (A) retinal haemorrhage in the right eye and (B) retinal and preretinal haemorrhages in 1999 the left eye. Airbag associated fatal head injury 139 J Accid Emerg Med: first published as 10.1136/emj.17.2.139 on 1 March 2000. Downloaded from application of lit cigarettes. She suVered The diagnosis of “shaken adult syndrome” postconcussional symptoms for two weeks. was eventually made, supported by delayed Five weeks after the initial injury she diagnosis of some of the classical signs consist- reattended with persistent atypical chest pain. ent with non-accidental injury. Three months later her visual acuity had Domestic violence victims are often dis- improved on the left to 6/24, but remained charged home the same day, thus losing that unchanged on the right, and a vitrectomy was window of opportunity to allow for intrinsically contemplated for that side. motivated acceptance of help. Not all A&E departments have access to their own observa- Discussion tion beds, though many departments are now This patient had the diagnostic triad of retinal managing head injuries, especially now that haemorrhages, subdural haematoma, and pat- neurosurgical care has centralised to regional terned bruising that is associated with forceful centres of excellence. and repeated shaking of infants. Such a triad The way forward should be a more struc- has previously been documented postmortem tured method of follow up of suspected victims in a Palestinian adult who died under interro- of domestic violence that is initiated in the gation by the Israeli security forces, and has A&E department. As it is in suspected paediat- been described as the shaken adult syndrome.3 ric non-accidental injury, so one can prevent Even when the presenting history is misguid- repeat episodes to not only the patient, but also ing, all injuries must be thoroughly docu- to their children and other family members. mented, and appropriate treatment instituted. The A&E department should grasp this initia- Management also involves guiding the patient tive. to autonomously decide whether to accept help and/or legal assistance. In most states of Contributors America, it is mandatory to report domestic Thomas Carrigan, guarantor of the case report, initiated and violence related injuries, though the American coordinated the collection of the clinical history, investigation confirmation, and writing of the abstract. College of Emergency Physicians oppose this, Ed Walker was involved with interpretation of the case, back- stating that reporting should be in accordance ground research, and writing of the report. Dr Barnes was 4 involved with the critical revision of the report, and with the with the patient’s wishes. Confidentiality was collation of photographic evidence of the patient. considered in this case, and gradual discussion broke down the barriers of denial. Eventual Conflict of interest: none. admission of domestic violence took three days Funding: none. though, a luxury not often available to 1 Hall C. One in four women face violence in the home. Daily emergency clinicians. Telegraph, 1 July 1998. Early detection and documentation of inju- 2 Department of Health NHS Executive. Domestic violence. London. Department of Health, 1997. ries consistent with domestic violence must be 3 Pounder D. Shaken adult syndrome. Am J Forensic Med attempted, and in this case, earlier documenta- Pathol 1997:18:321–4. 4 American College of Emergency Physicians. Mandatory tion of visual acuity would have facilitated an reporting of domestic violence to law enforcement and earlier diagnosis of retinal haemorrhage. criminal justice agencies. Ann Emerg Med 1997;30:561. http://emj.bmj.com/ Airbag associated fatal head injury: case report and review of the literature on airbag injuries on September 30, 2021 by guest. Protected copyright. K Cunningham, T D Brown, E Gradwell, P A Nee Abstract in a moderate impact frontal collision Airbags have been shown to significantly where such severe injury would not nor- Whiston Hospital, reduce mortality and morbidity in motor mally have been anticipated. The range of Prescot, Merseyside vehicle crashes. However, the airbag, like airbag associated injuries is described and L35 5DR: Department the seat belt, produces its own range of predisposing factors such as lack of seat of Accident and injuries. With the increasing use of air- belt usage, short stature, and proximity to Emergency Medicine K Cunningham bags in the UK, airbag associated injuries airbag housing are discussed. The par- T D Brown will be seen more often. These are usually ticular dangers airbags pose to children P A Nee minor, but in certain circumstances se- are also discussed. vere and fatal injuries result. Such inju- (J Accid Emerg Med 2000;17:139–142) Department of ries have been described before in the Pathology Keywords: airbags; head injury E Gradwell medical literature, but hitherto most reports have been from North America. Correspondence to: This is the first case report from the UK of The introduction of airbags has led to a signifi- Dr Cunningham (e-mail: serious injury due to airbag deployment [email protected]) cant reduction in morbidity and mortality from and describes the case of a driver who was road traYc accidents.12 However, the airbag Accepted 10 November 1999 fatally injured when her airbag deployed like the seat belt produces its own range of 140 Cunningham, Brown, Gradwell, et al J Accid Emerg Med: first published as 10.1136/emj.17.2.139 on 1 March 2000. Downloaded from injuries. In the case of the airbag this ranges at the base of the brain. The spinal column from relatively minor injuries, such as abra- and nerve cord were normal. The immediate sions and superficial burns to unexpected cause of death was deemed to have been a fatalities. Case reports of such fatalities have severe head injury. appeared in the North American literature The subject of this report was a middle since 1993,34 but hitherto none have been aged woman of stout build, height 5' 7", weight reported from the UK. 92 kg. Crash investigators have postulated that the unexpectedly severe injuries sustained Case report were caused by her sitting too far forward A 47 year old woman driving a 1997 registered when the airbag was deployed.