IntermediatePhysical Abuse
Curriculum
For Primary Care and Emergency Pediatrics
Scenario
A busy pediatric acute care facility
Four patients await you
Scenario: Patient A
Four-month-old infant
Found this morning in crib by mom Swollen, red thigh Doesn’t move thigh Tenderness
Scenario: Patient B
Two-year-old toddler
Fell from bed two mornings ago Abdominal pain since yesterday Vomiting all PO since last night Fever, severe pain this morning T=39o P=125 R=35 BP=75/43
Scenario: Patient C Eight-month-old infant
Fell from bed this morning Lost consciousness Unusual breathing Stiffened and 3 minutes of convulsion Obtunded, breathing, unresponsive
Scenario: Patient D
Three-year-old child
Returned yesterday from visiting dad This AM found to have bruises on buttocks and posterior thighs Walks reluctantly, stiffly
Discussion
Would any of these cases make you suspicious of abuse?
Why?
How would you proceed?
Recognizing Abuse
Difficulties in recognizing abuse
Thinking abuse is difficult, we want to think the best of people The effects of trauma can be occult on first inspection The history is usually, absent, false or purposefully misleading
Algorithm
Recognition Algorithm
Prompt Card
Child Injury Evaluation
ConsIder
Abuse
Non-Walking Child
No Trauma History
Minor Trauma withSevere Injuries
Inconsistencies in the Given History
Injury Complicated By Delay
Child Reports Abuse
Multiple Injuries of Differing Ages
Bruise withRecognizable Shape
Algorithm
Bruise with recognizable shape
Child Injury Evaluation
ConsIder
Abuse
Non-Walking Child
No Trauma History
Minor Trauma withSevere Injuries
Inconsistencies in the Given History
Injury Complicated By Delay
Child Reports Abuse
Multiple Injuries of Differing Ages
Bruise withRecognizable Shape
Bruise with recognizable shape
Bruise with recognizable shape
Bruise with recognizable shape
Bruise with recognizable shape
Bruise with recognizable shape
Bruise with recognizable shape
Bruise with recognizable shape
Algorithm
Multiple injuries that occurred at different times
Child Injury Evaluation
ConsIder
Abuse
Non-Walking Child
No Trauma History
Minor Trauma withSevere Injuries
Inconsistencies in the Given History
Injury Complicated By Delay
Child Reports Abuse
Multiple Injuries of Differing Ages
Bruise withRecognizable Shape
Multiple InjuriesDifferent Ages
Battered child syndrome
C Henry Kemp 1963 Multiple unexplained injuries Different mechanisms Different places Different times
Multiple InjuriesDifferent Ages
Algorithm
Significant trauma in a non-walking child
Child Injury Evaluation
ConsIder
Abuse
Non-Walking Child
No Trauma History
Minor Trauma withSevere Injuries
Inconsistencies in the Given History
Injury Complicated By Delay
Child Reports Abuse
Multiple Injuries of Differing Ages
Bruise withRecognizable Shape
Abuse Epidemiology
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Head &FractureHead &Fracture
Burn &AbdomenBurn &Abdomen
0
10
20
30
40
50
60
70
0--2 3--5 6--8 9--11 12--14 15--17 18--23 24--35
Precruisers Cruisers Walkers
Epidemiology of Accidental Bruising
0%
20%
40%
60%
80%
100%
Under 18months
18 monthsor older
0%
20%
40%
60%
80%
100%
Under 18months
18 monthsand older
Epidemiology of Fractures
Abusive fractures Accidental Fractures
Epidemiology of Head Injury
Serious infant head injuries
50 - 95% abuseAuto Accidents 50%
95%
Epidemiology of Head Injury
Head injury death in infants under 2 years
80% child abuse 80%
Algorithm
Child gives a history of abuse
Child Injury Evaluation
ConsIder
Abuse
Non-Walking Child
No Trauma History
Minor Trauma withSevere Injuries
Inconsistencies in the Given History
Injury Complicated By Delay
Child Reports Abuse
Multiple Injuries of Differing Ages
Bruise withRecognizable Shape
Algorithm
Injury without history of trauma
Child Injury Evaluation
ConsIder
Abuse
Non-Walking Child
No Trauma History
Minor Trauma withSevere Injuries
Inconsistencies in the Given History
Injury Complicated By Delay
Child Reports Abuse
Multiple Injuries of Differing Ages
Bruise withRecognizable Shape
Algorithm
Inconsistencies in the given history
Child Injury Evaluation
ConsIder
Abuse
Non-Walking Child
No Trauma History
Minor Trauma withSevere Injuries
Inconsistencies in the Given History
Injury Complicated By Delay
Child Reports Abuse
Multiple Injuries of Differing Ages
Bruise withRecognizable Shape
Inconsistency Internal Inconsistency
History changes with repetition distinguish from changing medical history taking or documentation
Inter-historian Inconsistency Different history from different informants distinguish from different perspectives or “telephone” errors
Inconsistency
Developmental Inconsistency Child is reported to do something age inappropriate
Inconsistent cause Epidemiologically unlikely Biomechanically unlikely
Common fractures Clavicle Skull
Others uncommon
Fall Injuries Uncommon head
Epidural Small subdural
Death rare
Visceral Injury Very rare
Fall Injuries General rules Exceptions exist Probabilistic Not deterministic
Algorithm
Severe injuries explained by minor trauma
Child Injury Evaluation
ConsIder
Abuse
Non-Walking Child
No Trauma History
Minor Trauma withSevere Injuries
Inconsistencies in the Given History
Injury Complicated By Delay
Child Reports Abuse
Multiple Injuries of Differing Ages
Bruise withRecognizable Shape
Algorithm
Injury complicated by delay in seeking medical care
Child Injury Evaluation
ConsIder
Abuse
Non-Walking Child
No Trauma History
Minor Trauma withSevere Injuries
Inconsistencies in the Given History
Injury Complicated By Delay
Child Reports Abuse
Multiple Injuries of Differing Ages
Bruise withRecognizable Shape
Delay in Care-seeking New Fracture Healing Fracture
Scenario: Patient A
Four-month-old infant
Found this AM in crib by mom
Swollen red thigh Doesn’t move thigh Tenderness
Abuse Or Not Abuse
Injury of non-walking child
Injury with no trauma history
Scenario: Patient B
Two-year-old toddler
Fell from bed Abdominal pain Vomiting all PO Fever, severe pain this
AM T=39o P=125 R=35
BP=75/43At Surgery, ruptured jejunum, peritonitis
Abuse Or Not Abuse
Injury mechanism is inadequate?
Complications from delayed care
Scenario: Patient C
Eight-month-old infant
Fell from bed Unconscious Erratic breathing 3 minute seizure
Abuse Or Not Abuse
Not walking = very young age
Injury mechanism is inadequate?
Scenario: Patient D
Three-year-old child
Returned from father Bruises on buttocks
and posterior thighs Walks reluctantly,
stiffly
Abuse Or Not Abuse
Child’s history? Doesn’t meet other prompts
BUT
Lots of injury Worrisome social setting
BREAK
When you return:Planning an evaluation
Discussion: Patient A
What do you want to do next?
Discussion: Patient B
What do you want to do next?
Discussion: Patient C
What do you want to do next?
Discussion: Patient D
What do you want to do next?
Secondary Assessment
Tools History Physical exam Laboratory
Imaging Consultation
Find evidence of other trauma
Find conditions that change the response to trauma
History Event
Detail of trauma (develop a timeline)
Source of information Detail of symptoms Child’s condition for 72 hours Confirm absent trauma history
Birth
Weight Maturity Method of
delivery Complications Nursery course
History
Nutrition Vitamin D sources Sunlight exposure
Development General trend Current abilities
History
Growth
Height Head
circumference
Weight
Immunization
Up to date? Recent vaccination
History Past Medical
Events
Traumas ER visits Hospitalizations Unusual illnesses Recent illnesses
Medications
Current Chronic Past
History
Review of Systems
Historical safety net
Family Medical History
Collagen disorders Bleeding disorders Medications in the
house
History
Social Conditions
Household composition Child’s other homes Stressors Violence
Physical Examination
General
Vigor Developmental abilities Behavior and temperament
Anthropometry
Weight Height or length Head circumference
Physical Examination
Skin
Bruises Burns Scars
Pigmentary marks Texture Distensibility
Physical Examination
Cranium
Fractures Swelling Sutures and fontanel Hair Scalp
Ear
Pinna bruises Blood in external/middle ear
Physical Examination
Eye
Scleral petechiae Sub-conjunctival hemorrhages Blue sclerae Retinal hemorrhages
Mouth
Lip or buccal contusions Torn frenulae Pharyngeal laceration
Physical Examination
Skeletal
Deformity Crepitance Swelling Tenderness
Genitals
Sexual maturity Acute injuries Healed injuries
Laboratory Examination
CBC
Anemia Thrombocytopenia Infection Leukemia
PT/PTT, INR
Hemophilia DIC Consumptive coagulopathy
Laboratory Examination
Other Clotting
Von Willebrand’s disease panel Factor levels Thrombophilia
Basic Chemistries
Hypo/hyper- natremia Renal failure
Laboratory Examination
ALT, AST, Amylase, Lipase
Internal injuries
Urinalysis
Internal injuries Renal diseases
Laboratory Examination
CPK, Myoglobin
Myonecrosis following crush
injury
Many others possible
Select labs to match patient’s condition
Imaging Skeletal X-ray Survey
All children <2-years-old Unresponsive children 3 to 5- years-old Select others
May repeat in 2 weeks
AP lateral skull AP lateral chest Lateral spine Abdomen/pelvis AP humerus AP radius/ulna AP femur AP tibia/fibula Oblique hands AP feet
Classic Metaphyseal Lesion
Imaging Intracranial Imaging
CT MRI Children
<6 months-old Children <1 year-old
with face or head injuries, rib fractures or CML
Abdominal Imaging
CT
Ultrasound Plain
radiography Contrast
radiography
Consultation
Genetics
Ophthalmology
Hematology
Child Abuse Pediatrics
Scenario: Patient A
Four-month-old infant
Found this AM in crib by mom
Swollen red thigh Doesn’t move thigh Tenderness
Work Up? Proposed Work up
Skeletal X-ray survey Basic labs Genetics consult Head CT or MRI
Outcome No fragility concerns Normal sub-periosteal new bone Normal Head
Scenario: Patient B
Two-year-old toddler
Fell from bed Ruptured hollow viscus Peritonitis
Work Up? Proposed work up
Skeletal X-ray survey Clotting studies, CBC, Basic labs Transaminases, amylase CT? Genetics Consult, family history
Outcome Increased transaminases, amylase Mild pancreatic edema
Scenario: Patient C
Eight-month-old infant
Fell from bed Unonsciousness Erratic breathing 3 minute seizure
Work Up?
Proposed work up
Skeletal X-ray survey Head MRI Ophthalmology consults Clotting studies, transaminases, amlyase Genetics Consult, family history?
Work Up? Outcome
Single traumatic acute SDH Multiple, extensive retinal hemorrhages in several layers Slightly prolonged PTT Multiple rib fractures, CML at knees and ankles Hematology and Neurosurgery consultant diagnose abuse
Scenario: Patient D
Three-year-old child
Returned from father Bruises on buttocks and posterior thighs Walks reluctantly, stiffly
Work Up? Proposed work up
Clotting studies, CBC, Basic labs CPK, myoglobin, urinalysis
Outcome Significantly increased PT and PTT Corrected with FFP and vitamin K History, playing in area baited with
rat poison (coumadin)
BREAK
When you return:Diagnosis and Management
Diagnosis?: Patient A
Four-month-old infant
Femur fracture No history No evidence of fragility Occult rib fractures
Diagnosis?: Patient B
Two-year-old toddler
Fell from bed Ruptured hollow viscus Peritonitis Liver and pancreas injury
Diagnosis?: Patient C
Eight-month-old infant Fell from bed Unconscious Subdural hematoma Retinal hemorrhage Rib fracture, CML
Diagnosis?: Patient D
Three-year-old child
Bruises on buttocks and posterior thighs Coagulopathy Possible coumadin exposure
Management?: Patient A
Four-month-old infant Battered child
syndrome Discharge plan? Treatment plan?
Diagnosis?: Patient B
Two-year-old toddler Serious inflicted
abdominal injury Discharge plan? Treatment plan?
Diagnosis?: Patient C
Eight-month-old infant Abusive head
trauma Discharge plan? Treatment plan?
Diagnosis?: Patient D
Three-year-old child Rat poison ingestion Neglect?
Discharge plan? Treatment plan?
Physical Abuse Curriculum
The End