ABSTRACT
SUMMARY. Controversies invariably exist when hypotheses about biological phenomena cannot be studied directly (in clinical settings where information is readily available) or indirectly (with the creation of biological models approximating the organism in question). This creates missing links in the chain of logic and results in incomplete faith in some conclusions about these phenomena. Such is the case in shaken baby / shaken impact syndrome. Because abusive head trauma occurs without witnesses other than the perpetrator in most cases, we need to infer certain information to fill the gaps of validated facts. This leaves room for scientific and legal challenge. But there is increasing clinical and research data elucidating this condition. Although SBS cannot be studied in the bench laboratory tradition or even in the tradition of the hospital-based research scientist, there is a generation of new knowledge that is providing answers. These answers are being found in studies done by a wide range of scientists who have contact with abusive head trauma cases at some point in the process of care. Emergency department clinicians, intensive care specialists, hospital attending clinicians, forensic pediatricians, pediatric ophthalmolo-
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KEYWORDS. Syndrome, bleed-rebleed, second impact, modeling, shaking plus impact, lucid interval
INTRODUCTION
The term syndrome has come into general usage in medicine and is defined as "a number of symptoms occurring together and characterizing a specific disease or condition" by Webster (1988) and "the sum of signs of any morbid state; a symptom complex" in Dorland's Medical Dictionary (1994) which contains 21 pages of various medical syndromes in usage. When modified by shaken baby or shaken impact, it is used to describe the condition characterized by a combination of historical information, clinical presentation, physical examination, and imaging findings in an infant or young child. The history of the injury may be one of a confessed or witnessed act of shaking and/or throwing the victim against a hard or soft surface, an accidental fall from a low height, or there may be no history of any kind of injury. The clinical signs are variable, with a combination of alteration of one or more vital signs (respiration, cardiac rate, temperature, blood pressure), and one or more neurological signs (poor feeding, vomiting, signs of increased intracranial pressure, lethargy, irritability, seizures, posturing, apnea, unresponsiveness, coma or death) being seen. There mayor may not be external signs of traumatic injury to the head or body. Retinal hemorrhages are present in the vast majority of cases; retinal folds and vitreous hemorrhages have been described in some. Head computerized tomograms (CT) and/or magnetic resonance imaging (MRI) show subdural or subarachnoid bleeding (or both) and may be combined with parenchymal alterations as well.
