Intermediate Physical Abuse Curriculum

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


ConsIder

Abuse

Non-Walking Child

No Trauma History




Child Reports Abuse



Bruise with recognizable shape

Algorithm

Multiple injuries that occurred at different times


ConsIder

Abuse

Non-Walking Child

No Trauma History




Child Reports Abuse



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


ConsIder

Abuse

Non-Walking Child

No Trauma History




Child Reports Abuse



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


ConsIder

Abuse

Non-Walking Child

No Trauma History




Child Reports Abuse



Algorithm

Injury without history of trauma


ConsIder

Abuse

Non-Walking Child

No Trauma History




Child Reports Abuse



Algorithm

Inconsistencies in the given history


ConsIder

Abuse

Non-Walking Child

No Trauma History




Child Reports Abuse



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


ConsIder

Abuse

Non-Walking Child

No Trauma History




Child Reports Abuse



Algorithm

Injury complicated by delay in seeking medical care


ConsIder

Abuse

Non-Walking Child

No Trauma History




Child Reports Abuse



Delay in Care-seeking New Fracture Healing Fracture

Scenario: Patient A


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


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


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


Discussion: Patient C


Discussion: Patient D


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


Skin

Bruises Burns Scars

Pigmentary marks Texture Distensibility


Cranium

Fractures Swelling Sutures and fontanel Hair Scalp

Ear

Pinna bruises Blood in external/middle ear


Eye

Scleral petechiae Sub-conjunctival hemorrhages Blue sclerae Retinal hemorrhages

Mouth

Lip or buccal contusions Torn frenulae Pharyngeal laceration


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


Other Clotting

Von Willebrand’s disease panel Factor levels Thrombophilia

Basic Chemistries

Hypo/hyper- natremia Renal failure


ALT, AST, Amylase, Lipase

Internal injuries

Urinalysis

Internal injuries Renal diseases


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


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


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


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


Femur fracture No history No evidence of fragility Occult rib fractures

Diagnosis?: Patient B


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


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

Intermediate Physical Abuse Curriculum

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