1. Intermediate Physical Abuse Curriculum For Primary Care and Emergency Pediatrics

2. Scenario  A busy pediatric acute care facility  Four patients await you

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

4. 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

5. 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

6. 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

7. Discussion  Would any of these cases make you suspicious of abuse?  Why?  How would you proceed?

8. 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

9. 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

10. 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

11. Bruise with recognizable shape

18. 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

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

20. Multiple Injuries Different Ages

21. 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

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

23. Epidemiology of Accidental Bruising

24. Epidemiology of Fractures Abusive fractures Accidental Fractures

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

26. Epidemiology of Head Injury  Head injury death in infants under 2 years  80% child abuse 80%

27. 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

28. 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

29. 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

30. 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

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

32.  Common fractures  Clavicle  Skull  Others uncommon Fall Injuries  Uncommon head  Epidural  Small subdural  Death rare

33.  Visceral Injury  Very rare Fall Injuries  General rules  Exceptions exist  Probabilistic  Not deterministic

34. 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

35. 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

36. Delay in Care-seeking  New Fracture  Healing Fracture

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

38. Abuse Or Not Abuse  Injury of non-walking child  Injury with no trauma history

39. 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

40. Abuse Or Not Abuse  Injury mechanism is inadequate?  Complications from delayed care

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

42. Abuse Or Not Abuse  Not walking = very young age  Injury mechanism is inadequate?

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

44. Abuse Or Not Abuse  Child’s history?  Doesn’t meet other prompts BUT  Lots of injury  Worrisome social setting

45. BREAK When you return: Planning an evaluation

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

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

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

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

50. Secondary Assessment  Tools  History  Physical exam  Laboratory  Imaging  Consultation  Find evidence of other trauma  Find conditions that change the response to trauma

51. 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

52. History  Nutrition  Vitamin D sources  Sunlight exposure  Development  General trend  Current abilities

53. History  Growth  Height  Head circumference  Weight  Immunization  Up to date?  Recent vaccination

54. History  Past Medical Events  Traumas  ER visits  Hospitalizations  Unusual illnesses  Recent illnesses  Medications  Current  Chronic  Past

55. History  Review of Systems  Historical safety net  Family Medical History  Collagen disorders  Bleeding disorders  Medications in the house

56. History  Social Conditions  Household composition  Child’s other homes  Stressors  Violence

57. Physical Examination  General  Vigor  Developmental abilities  Behavior and temperament  Anthropometry  Weight  Height or length  Head circumference

58. Physical Examination  Skin  Bruises  Burns  Scars  Pigmentary marks  Texture  Distensibility

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

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

67. Physical Examination  Skeletal  Deformity  Crepitance  Swelling  Tenderness  Genitals  Sexual maturity  Acute injuries  Healed injuries

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

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

70. Laboratory Examination  ALT, AST, Amylase, Lipase  Internal injuries  Urinalysis  Internal injuries  Renal diseases

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

72. 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

73. Classic Metaphyseal Lesion

78. 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

81. Consultation  Genetics  Ophthalmology  Hematology  Child Abuse Pediatrics

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

83. 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

85. Scenario: Patient B  Two-year-old toddler  Fell from bed  Ruptured hollow viscus  Peritonitis

86. 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

87. Scenario: Patient C  Eight-month-old infant  Fell from bed  Unonsciousness  Erratic breathing  3 minute seizure

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

89. 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

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

91. 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)

92. BREAK When you return: Diagnosis and Management

93. Diagnosis?: Patient A  Four-month-old infant  Femur fracture  No history  No evidence of fragility  Occult rib fractures

94. Diagnosis?: Patient B  Two-year-old toddler  Fell from bed  Ruptured hollow viscus  Peritonitis  Liver and pancreas injury

95. Diagnosis?: Patient C  Eight-month-old infant  Fell from bed  Unconscious  Subdural hematoma  Retinal hemorrhage  Rib fracture, CML

96. Diagnosis?: Patient D  Three-year-old child  Bruises on buttocks and posterior thighs  Coagulopathy  Possible coumadin exposure

97. Management?: Patient A  Four-month-old infant  Battered child syndrome  Discharge plan?  Treatment plan?

98. Diagnosis?: Patient B  Two-year-old toddler  Serious inflicted abdominal injury  Discharge plan?  Treatment plan?

99. Diagnosis?: Patient C  Eight-month-old infant  Abusive head trauma  Discharge plan?  Treatment plan?

100. Diagnosis?: Patient D  Three-year-old child  Rat poison ingestion  Neglect?  Discharge plan?  Treatment plan?

101. Physical Abuse Curriculum The End