1. Physical Abuse Stephen Boos, MD, FAAP

2. The participant will be able to: Recognize historical and physical findings that should cause the learner to include child abuse in the differential diagnosis. Structure an appropriate evaluation for abuse when it is in the differential diagnosis. Make rational diagnoses of abuse based on all the findings. Initiate management of abuse within the systems of the host country. Learning Objectives

3. The participant will be able to: Strengthen medical documentation by writing child abuse in the differential diagnosis, when appropriate, and writing clear recommendations for the child’s physical and emotional well-being. Recognize ways in which Social Services and Law Enforcement are helpful partners to engage in the process of diagnosing/identifying abuse or neglect. Discuss with parents the concern of possible abuse/neglect and explain the next steps that need to occur in contacting Social Services and Law Enforcement. Learning Objectives

4. Scenario A busy pediatric acute care facility Five patients await you

5. Scenario: Patient A Four-month-old infant Found this morning in crib by mom Swollen, red thigh Doesn’t move thigh Tenderness

6. Scenario: Patient B Two-year-old toddler Fell from bed two mornings ago Abdominal pain since yesterday Vomiting all consumbed since last night Fever, severe pain this morning Temp=39 o Pulse=125 Respirations=35 Blood Pressure =75/43

7. 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

8. Scenario: Patient D Three-year-old child Returned yesterday from visiting dad This morning found to have bruises on buttocks and posterior thighs Walks reluctantly, stiffly

9. Scenario: Patient E 15-month-old toddler Mother is 15 years old and lives with her parents. Father is 16, and lives with his parents. Mother and baby stayed at father’s last night. Mother brings the child to you for a “skin rash.” A quick look shows a few unimportant marks When the child is undressed a large burn is seen.

10. Discussion What is your job? Does it involve identifying inflicted injury? Why does that matter? How would you do it?

11. Recognizing Inflicted Injury Difficulties in recognizing inflicted injury Thinking about inflicted injury 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

12. Responding To Inflicted Injury Difficulties in responding to inflicted injury Worry about being wrong Calling people a liar or abuser Knowing what to do next Dealing with courts and non-medical systems

13. Algorithm Recognition Algorithm Prompt Card Child Injury Evaluation ConsIderInflictionConsIderInfliction Non-Walking Child No Trauma History Minor Trauma with Severe Injuries Inconsistencies in the Given History Injury Complicated By Delay Child Reports Inflicted Injury Multiple Injuries of Differing Ages Bruise or burn with Recognizable Shape

14. Bruise or burn with recognizable shape Child Injury Evaluation ConsIderInflIctIonConsIderInflIctIon Non-Walking Child No Trauma History Minor Trauma with Severe Injuries Inconsistencies in the Given History Injury Complicated By Delay Child Reports Inflicted Injury Multiple Injuries of Differing Ages Bruise or burn with Recognizable Shape Algorithm

15. Bruise with recognizable shape

22. Burn with recognizable shape

23. Tub Immersion Burn

24. Algorithm Multiple injuries that occurred at different times Child Injury Evaluation ConsIderInflIctIonConsIderInflIctIon Non-Walking Child No Trauma History Minor Trauma with Severe Injuries Inconsistencies in the Given History Injury Complicated By Delay Child Reports Inflicted Injury Multiple Injuries of Differing Ages Bruise or burn with Recognizable Shape

25. Multiple Injuries Different Ages Battered child syndrome C. Henry Kemp 1962 Multiple unexplained injuries Different mechanisms Different places Different times

26. Multiple Injuries Different Ages

27. Algorithm Significant trauma in a non-walking child Child Injury Evaluation ConsIderInflIctIonConsIderInflIctIon Non-Walking Child No Trauma History Minor Trauma with Severe Injuries Inconsistencies in the Given History Injury Complicated By Delay Child Reports Inflicted Injury Multiple Injuries of Differing Ages Bruise or burn with Recognizable Shape

28. Inflicted Injury Epidemiology 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Head & Fracture Burn & Abdomen

29. Epidemiology of Accidental Bruising

30. Epidemiology of Fractures Inflicted fractures Accidental Fractures

31. Epidemiology of Head Injury Serious infant head injuries 50 - 95% Inflicted Injury  Auto Accidents 50% 95%

32. Epidemiology of Head Injury Head injury death in infants under 2 years 80% child Inflicted Injury 80%

33. Algorithm Child gives a history of Inflicted Injury Child Injury Evaluation ConsIderInflIctIonConsIderInflIctIon Non-Walking Child No Trauma History Minor Trauma with Severe Injuries Inconsistencies in the Given History Injury Complicated By Delay Child Reports Inflicted Injury Multiple Injuries of Differing Ages Bruise or burn with Recognizable Shape

34. Algorithm Injury without history of trauma Child Injury Evaluation ConsIderInflIctIonConsIderInflIctIon Non-Walking Child No Trauma History Minor Trauma with Severe Injuries Inconsistencies in the Given History Injury Complicated By Delay Child Reports Inflicted Injury Multiple Injuries of Differing Ages Bruise or burn with Recognizable Shape

35. Algorithm Inconsistencies in the given history Child Injury Evaluation ConsIderInflIctIonConsIderInflIctIon Non-Walking Child No Trauma History Minor Trauma with Severe Injuries Inconsistencies in the Given History Injury Complicated By Delay Child Reports Inflicted Injury Multiple Injuries of Differing Ages Bruise with Recognizable Shape

36. 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

37. Inconsistency Developmental Inconsistency Child is reported to do something age inappropriate Inconsistent cause Epidemiologically unlikely Biomechanically unlikely

38. Common fractures Clavicle Skull Others uncommon Fall Injuries Uncommon head Epidural Small subdural Death Rare

39. Visceral Injury Very rare Brain Injury Very rare Fall Injuries General rules Exceptions exist Probabilistic Not deterministic

40. Algorithm Severe injuries explained by minor trauma Child Injury Evaluation ConsIderInflIctIonConsIderInflIctIon Non-Walking Child No Trauma History Minor Trauma with Severe Injuries Inconsistencies in the Given History Injury Complicated By Delay Child Reports Inflicted Injury Multiple Injuries of Differing Ages Bruise or burn with Recognizable Shape

41. Algorithm Injury complicated by delay in seeking medical care Child Injury Evaluation ConsIderInflIctIonConsIderInflIctIon Non-Walking Child No Trauma History Minor Trauma with Severe Injuries Inconsistencies in the Given History Injury Complicated By Delay Child Reports Inflicted Injury Multiple Injuries of Differing Ages Bruise or burn with Recognizable Shape

42. Delay in Care-seeking New Fracture Healing Fracture

43. Scenario: Patient A Four-month-old infant Found this morning in crib by mom Swollen red thigh Doesn’t move thigh Tenderness

44. Inflicted Injury Or Not Inflicted Injury Injury of non-walking child Injury with no trauma history

45. 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

46. Inflicted Injury Or Not Inflicted Injury Injury mechanism is inadequate? Complications from delayed care

47. Scenario: Patient C Eight-month-old infant Fell from bed Unconscious Erratic breathing 3 minute seizure

48. Inflicted Injury Or Not Inflicted Injury Not walking = very young age Injury mechanism is inadequate?

49. Scenario: Patient D Three-year-old child Returned from father Bruises on buttocks and posterior thighs Walks reluctantly, stiffly

50. Inflicted Injury Or Not Inflicted Injury Lots of injury without trauma history Multiple injury of differing ages? Social concerns? BUT What does the child say?

51. Scenario: Patient E 15-month-old

52. Scenario: Patient E

54. Inflicted Injury Or Not Inflicted Injury Burn in a recognizable pattern? No trauma history for “rash”

55. BREAK When you return Planning an evaluation

56. Discussion: Patient A What do you want to do next?

57. Discussion: Patient B What do you want to do next?

58. Discussion: Patient C What do you want to do next?

59. Discussion: Patient D What do you want to do next?

60. Discussion: Patient E What do you want to do next?

61. Secondary Assessment Tools History Physical exam Laboratory Imaging Consultation Find evidence of other trauma Find conditions that make children fragile Find conditions that “mimic” trauma

62. History Event Detail of trauma (develop a timeline) Source of information Detail of symptoms Child’s condition for 72 hours Confirm absent trauma history Past Medical Events Traumas ER visits Hospitalizations Unusual illnesses Recent illnesses

63. Development General trend Current abilities History Nutrition Vitamin D sources Sunlight exposure Breastfeeding, diet Problems feeding Perinatal Period Pregnancy Birth weight Maturity Method of delivery Complications Nursery course

64. Growth Height Head circumference Weight History Immunization Up to date? Recent vaccination Medications Current Chronic Past Social Conditions Household composition Child’s other homes Stressors Violence Past police or social services involvement

65. History Review of Systems Historical safety net Family Medical History Collagen disorders Bleeding disorders Medications in the house Mental health or chronic disease Consanguinity

66. Physical Examination General General hygiene Vigor Developmental abilities Behavior and temperament Observed interaction with caregiver Anthropometry Weight Height or length Head circumference

67. Physical Examination Skin Bruises Burns Scars Pigmentary marks Texture Distensibility

71. Physical Examination Cranium Fractures Swelling Sutures and fontanel Hair Scalp Ear Pinna bruises Blood in external/middle ear

72. Injuries from pulling violently and yanking

73. Physical Examination Eye Scleral petechiae Sub-conjunctival hemorrhages Blue sclerae Retinal hemorrhages Mouth Lip or buccal contusions Torn frenulae Pharyngeal laceration

76. Physical Examination Skeletal Deformity Crepitance Swelling Tenderness Genitals Sexual maturity Acute injuries Healed injuries

77. Laboratory Examination CBC Anemia Thrombocytopenia Infection Leukemia PT/PTT, INR Hemophilia DIC Consumptive coagulopathy

78. Laboratory Examination Other Clotting Von Willebrand’s disease panel Factor levels Thrombophilia Basic Chemistries Hypo/hyper- natremia Renal failure

79. Laboratory Examination ALT, AST, Amylase, Lipase Internal injuries Urinalysis Internal injuries Renal diseases

80. Laboratory Examination CPK, Myoglobin Myonecrosis following crush injury Many others possible Select labs to match patient’s condition

81. 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

82. Classic Metaphyseal Lesion

87. 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

90. Consultation Genetics Ophthalmology Hematology Child Abuse Pediatrics Child Protection Agencies Social Services and Police Scene investigation, interviews of other family members

91. Scenario: Patient A Four-month-old infant Found this morning in crib by mom Swollen red thigh Doesn’t move thigh Tenderness What do you want to order?

92. 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

94. Scenario: Patient B Two-year-old toddler Fell from bed Ruptured hollow viscus Peritonitis What do you want to order?

95. 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

96. Scenario: Patient C Eight-month-old infant Fell from bed Unonsciousness Erratic breathing 3 minute seizure What do you want to order?

97. Work Up? Proposed work up Skeletal X-ray survey Head MRI Ophthalmology consults Clotting studies, transaminases, amlyase Genetics Consult, family history?

98. 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 Inflicted Injury

99. Scenario: Patient D Three-year-old child Returned from father Bruises on buttocks and posterior thighs Walks reluctantly, stiffly What do you want to order?

100. 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)

101. Discussion: Patient E 15- month-old Burn Bruises and abrasions to neck and face

102. Work Up? Proposed work up Skeletal Survey Consider coagulation studies for infants/toddlers with bruises Scene investigation by police department Involvement of social services

103. Work Up? Outcome Skeletal survey negative PT 15, INR 1.2, PTT 28 Know your lab’s values for normal. Scene investigation Soiled bed Skin in tub Family heats water on the stove

104. Hot water causes burns quickly F 45 50 55 60 65 70 C Min Sec 1666 166 16 1.6

105. BREAK When you return Diagnosis and Management

106. Diagnosis? Patient A Four-month-old infant Femur fracture No history No evidence of fragility Occult rib fractures What is your diagnosis?

107. Diagnosis? Patient B Two-year-old toddler Fell from bed Ruptured hollow viscus Peritonitis Liver and pancreas injury What is your diagnosis?

108. Diagnosis? Patient C Eight-month-old infant Fell from bed Unconscious subdural hematoma Retinal hemorrhage Rib fracture, CML What is your diagnosis?

109. Diagnosis? Patient D Three-year-old child Bruises on buttocks and posterior thighs Coagulopathy Possible coumadin exposure What is your diagnosis?

110. Diagnosis? Patient E 15- month-old Burn Bruises and abrasions to neck and face What is your diagnosis?

111. Diagnosis? Patient E

112. Management? Patient A Four-month-old infant Inflicted skeletal injury Inflicted means someone did it, but does not discern abuse versus accident. Investigations by police and social services are vital. Discharge plan? Treatment plan?

113. Management? Patient B Two-year-old toddler Serious inflicted abdominal injury Discharge plan? Treatment plan?

114. Management? Patient C Eight-month-old infant Abusive head trauma Discharge plan? Treatment plan?

115. Management? Patient D Three-year-old child Rat poison ingestion Neglect? Physical abuse? Discharge plan? Treatment plan?

116. Management? Patient E 15- month-old Abuse: Immersion Burn and bruises Discharge plan? Treatment plan?

117. Inflicted Injury Curriculum The End