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Black, who was not involved in Joanna’s medical care, sees such injuries all the time among older patients, and said a blow to the head from one young girl to another could “absolutely” be sufficient to cause enough trauma to lead to death.

Punches to the head can often lead to delayed bleeding if a vein is torn, and that can lead to a clot when blood collects on the surface of the brain.

In a Tuesday column printed in The Press-Telegram of Long Beach, the trauma surgeon who treated Joanna in the emergency room said she suffered bleeding inside her skull and arrived at the hospital in grave condition. She went into cardiac arrest four times before she was finally pronounced dead, he said.

“Her eyes were `fixed and dilated,’ the worst sign possible. To a layperson, they look like the lifeless eyes of a little child’s doll,” Dr. Mauricio Heilbron Jr. of St. Mary’s Medical Center wrote in the column.

The death has rattled the school community at Willard Elementary, located in a working-class neighborhood just a few miles from a more affluent area of homes that front a bluff overlooking the Pacific Ocean.

School officials believe the fight occurred near the school in a 15-minute window between the time school let out and the start of Joanna’s after-school program at 2:30 p.m., said Chris Eftychiou, a spokesman for the Long Beach Unified School District.

Joanna didn’t have any visible injuries or show any signs of distress for about an hour, but she eventually told staff she felt unwell and was picked up by a relative, he said.

Symptoms _ such as headache, nausea, lethargy _ may not set in for hours and people can mistakenly think that they’re fine, Black said.

Typically, he said, the hit to the head would have to be fairly significant to cause a blood clot and often involves the head hitting walls or the ground, but a punch is enough.

Fights involving young children, including girls, are increasing nationally, in part because of the wired world children now live in, said Travis Brown, a national expert on bullying and school violence.

Children used to have a disagreement at school and would have a night or a weekend to cool down, but social media and text messaging mean students can continue their dispute 24 hours a day.

“There was a time when a kid had a way to escape the things at school, but now there’s no escape,” Brown said. “That stuff just escalates to a point where it gets out of hand. This is an everyday occurrence.”

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Associated Press writers Robert Jablon, Alicia Chang and Andrew Dalton in Los Angeles contributed to this report.