Intermediate Physical 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=39 o 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 AbuseConsIder Abuse Non-Walking Child No Trauma History Minor Trauma with Severe Injuries Inconsistencies in the Given History Injury Complicated By Delay Child Reports Abuse Multiple Injuries of Differing Ages Bruise with Recognizable Shape

Algorithm  Bruise with recognizable shape Child Injury Evaluation ConsIder AbuseConsIder Abuse Non-Walking Child No Trauma History Minor Trauma with Severe Injuries Inconsistencies in the Given History Injury Complicated By Delay Child Reports Abuse Multiple Injuries of Differing Ages Bruise with Recognizable Shape

Bruise with recognizable shape

Algorithm  Multiple injuries that occurred at different times Child Injury Evaluation ConsIder AbuseConsIder Abuse Non-Walking Child No Trauma History Minor Trauma with Severe Injuries Inconsistencies in the Given History Injury Complicated By Delay Child Reports Abuse Multiple Injuries of Differing Ages Bruise with Recognizable Shape

Multiple Injuries Different Ages  Battered child syndrome  C Henry Kemp 1963  Multiple unexplained injuries  Different mechanisms  Different places  Different times

Multiple Injuries Different Ages

Algorithm  Significant trauma in a non-walking child Child Injury Evaluation ConsIder AbuseConsIder Abuse Non-Walking Child No Trauma History Minor Trauma with Severe Injuries Inconsistencies in the Given History Injury Complicated By Delay Child Reports Abuse Multiple Injuries of Differing Ages Bruise with Recognizable Shape

Abuse Epidemiology Head & Fracture Burn & Abdomen

Epidemiology of Accidental Bruising

Epidemiology of Fractures Abusive fractures Accidental Fractures

Epidemiology of Head Injury  Serious infant head injuries  % abuse  Auto 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 AbuseConsIder Abuse Non-Walking Child No Trauma History Minor Trauma with Severe Injuries Inconsistencies in the Given History Injury Complicated By Delay Child Reports Abuse Multiple Injuries of Differing Ages Bruise with Recognizable Shape

Algorithm  Injury without history of trauma Child Injury Evaluation ConsIder AbuseConsIder Abuse Non-Walking Child No Trauma History Minor Trauma with Severe Injuries Inconsistencies in the Given History Injury Complicated By Delay Child Reports Abuse Multiple Injuries of Differing Ages Bruise with Recognizable Shape

Algorithm  Inconsistencies in the given history Child Injury Evaluation ConsIder AbuseConsIder Abuse Non-Walking Child No Trauma History Minor Trauma with Severe Injuries Inconsistencies in the Given History Injury Complicated By Delay Child Reports Abuse Multiple Injuries of Differing Ages Bruise with Recognizable 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 AbuseConsIder Abuse Non-Walking Child No Trauma History Minor Trauma with Severe Injuries Inconsistencies in the Given History Injury Complicated By Delay Child Reports Abuse Multiple Injuries of Differing Ages Bruise with Recognizable Shape

Algorithm  Injury complicated by delay in seeking medical care Child Injury Evaluation ConsIder AbuseConsIder Abuse Non-Walking Child No Trauma History Minor Trauma with Severe Injuries Inconsistencies in the Given History Injury Complicated By Delay Child Reports Abuse Multiple Injuries of Differing Ages Bruise with Recognizable 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=39 o P=125 R=35 BP=75/43 At 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