Restricting the time of injury in fatal inflicted head injuries.

Objective: To determine the normal clinical progression of fatal head injuries in children. Such information can then be used to estimate the time of injury in cases with obscure histories and will thus aid investigations of nonaccidental trauma.

Method: A retrospective chart review design was used. One hundred and thirty eight accidental fatalities involving head injury were identified and 95 of these were used as the study group. Details of the cases were reviewed and cases in which a child either had a Glasgow Coma Scale (GCS) of 14-15 or was described as having a "lucid interval" or as being "conscious" were further studied.

Results: One "lucid interval" case was identified. This case involved an epidural hematoma. Three other cases that partially met the criteria for a lucid interval were also identified; one of these cases did not meet the criteria for inclusion in the study group. Review of head CTs revealed that brain swelling could be detected as early as 1 hour and 17 minutes post injury.

Conclusions: The children studied were in obvious serious medical condition from the time of injury until death. If a history purports a lucid interval in a fatal head injury case that does not involve an epidural hematoma, that history is likely false and the injury is likely inflicted. The time of most fatal head injury events can be restricted to the time period after the last confirmed period of wellness for the child. In addition, the presence of brain swelling on a head CT scan is not helpful in restricting the time of injury.