4/7/2015November 20091© 2011 Boston Medical Center Evaluation of Suspected Child Physical Abuse Based on May and June 2009 AAP recommendations

4/7/2015November 20092© 2011 Boston Medical Center Standard Aproach Utilizing a standard approach: –Decreases missed abuse –Decreases unneeded radiation exposure –Simplifies training –Reduces bias

4/7/2015November 20093© 2011 Boston Medical Center Medical History No explanation, or vague explanation Changing history Inconsistent with child’s age / stage Different witnesses disagree History of other concerning injuries

4/7/2015November 20094© 2011 Boston Medical Center Bright Line v. discipline Corporal punishment, although not recommended, is quite common. The following clearly cross the line: –Striking a child with an object –Corporal punishment in a school or daycare setting –Causing bodily damage

4/7/2015November 20095© 2011 Boston Medical Center Diagnostic Evaluation Complete physical: –complete skin exam –Palpation of head and all extremities Initial lab tests: –Bruises – CBC, platelet, PT /PTT to start –Abdomen – LFTs, amylase, lipase –Fractures: Ca, P, alk phos, vit D, PTH

4/7/2015November 20096© 2011 Boston Medical Center Head injury evaluation Required when: –Clinical manifestations of CNS damage –Physical findings related to head Included elements: –History and physical –Head CT –Skeletal survey –Retinal exam (age <1 yo always)

4/7/2015November 20097© 2011 Boston Medical Center Radiologic Evaluation Should be performed for all suspected physical abuse Need to be reviewed by pediatric radiology staff member – requires specialized knowledge

4/7/2015November 20098© 2011 Boston Medical Center Skeletal Survey “The skeletal survey is mandated in all cases of suspected physical abuse in children under 2 years old. Its utility diminishes thereafter” AAP Section on Radiology, 2009

4/7/2015November 20099© 2011 Boston Medical Center Skeletal Survey components Appendicular skeleton – all AP views –Arms, Forearms, Hands –Thighs, legs, feet Axial skeleton –Thorax: spine and ribs (AP and lateral) –Abdomen: LS spine, pelvis –Lumbar spine (lateral) –C-spine (AP and lateral) –Skull ( Frontal and lateral)

4/7/2015November © 2011 Boston Medical Center Skeletal Survey considerations Each image is a standard view and does not require pediatric technician Additional sensitivity – – Repeat in 2 weeks (healing fxs) –Radionuclide scan

4/7/2015November © 2011 Boston Medical Center Head Trauma “High-energy forces associated with impact or violent shaking result in a variety of CNS injuries that can be detected my modern neuro-imaiging techniques. The evolution of these injuries, as well as.. Secondary [injuries], are often effectively displayed on serial imaging studies” AAP Section on Radiology, 2009

4/7/2015November © 2011 Boston Medical Center Initial Evaluation Head CT without contrast Most sensitive for acute hemorrhage Fractures visible on bone windows Rapid, often performed without sedation

4/7/2015November © 2011 Boston Medical Center Subsequent Studies Ultrasound – better look at extra-axial fluid when fontanelle is open MRI – usually recommended f-u for positive CT scan –Better definition of brain injury –Sometimes better to delay 5-7 days –Highest sensitivity

4/7/2015November © 2011 Boston Medical Center Summary Head CT > Suspicion of Head injury Skeletal Survey: 1)Suspicion of physical abuse 2)Age less than 2 years old History and Physical Looking for signs of possible physical abuse