The Anesthesiologist's Role in Treating Abusive Head Trauma

Abusive head trauma (AHT) is the most common cause of severe traumatic brain injury (TBI) in infants and the leading cause of child abuse-related deaths. For reasons that remain unclear, mortality rates after moderate AHT rival those of severe non-intentional TBI. The developing brain’s vulnerability to injury may be partially responsible for the poor outcomes observed after AHT. AHT is mechanistically more complex than non-intentional TBI. The acute-on-chronic nature of the trauma along with synergistic injury mechanisms that include rapid rotation of the brain, diffuse axonal injury, blunt force trauma, and hypoxia-ischemia make AHT challenging to treat. The anesthesiologist must understand the complex injury mechanisms inherent to AHT, as well as the pediatric TBI treatment guidelines, in order to decrease the risk of persistent neurologic disability and death. In this review we discuss the epidemiology of AHT, differences between AHT and non-intentional TBI, the severe pediatric TBI treatment guidelines in the context of AHT, anesthetic considerations, as well as ethical and legal reporting requirements.