1. Child Abuse frank ferrucci, PA-C anna Jacques Hospital ED

2. Introduction Goals of this lecture Limitations of this lecture Photographs

11. Background Types of child abuse Child abuse rate in US: 12.3/1000 children 1/50 infants victims of nonfatal abuse 1500 children per year die of their injuries What is most common age group to be abused??

12. Background Consequences of abuse besides physical? Demographics of abusers? Gender differences in children who are abused? Age?

13. When abuse is suspected Child may present with abuser or other caregiver HPI is vital Interview should not be confrontational Interview everyone separately (find an excuse) Don’t forget about domestic/substance/other witnessed abuse

14. Suspect HPI Poorly explained/justified injuries Injuries not compatible with HPI HPI not consistent Delay in seeking treatment

15. Exam General characteristics of abuse injuries injuries in various stages of healing multiplanar injuries injuries with obvious pattern assault like location of injuries

16. Exam Bruising suggestive of abuse babies/infants located away from bony prominences multiple bruises of similar shape/size groupings characteristic pattern of bruising what about old bruises?

17. Exam Burns cigarette, stove, hot water immersion suspicious burn exam findings??

18. Exam Musculoskeletal Injuries Roughly 30% of childhood injuries may be inflicted 75% of fractures in <1 y.o. inflicted Anterior/posterior rib fractures Humeral/femoral fx <18 mos Shape/location of fx less important than location/age

19. Exam Musculoskeletal Injuries continued always consider underlying medical reasons common fracture in children clavicle, long bone, linear skull etc

20. Exam Suspicious fractures rib/scapula spinous process/sternum multiplanar injuries multiple fxs of different ages complex skull fxs

21. exam Sexual abuse typical bruising patterns skin tears STDs

22. Head Injuries Most commonly seen with abuse skull fx, subarachnoid bleed, subdural hematoma, sheer injuries what about epidural hematomas?

23. Shaken Baby Syndrome Definition Exam finding typical for SBS eyes head ant/post rib fx metaphyseal long bone fx may present in circulatory or CNS collapse

24. Risk Factors for Child Abuse Socioeconomic Parental stressors Child Triggers

25. Workup Coagulation profile Cbc Skeletal bone survey Photographs If failure to thrive stool,urine,lead, hiv,sweat test,TB etc

26. ED Care Initial treatment no different Opthamology, trauma surgeon, SANE etc consults if necessary Child abuse pediatricians Ray Helfer Society (www.helfersociety.org)www.helfersociety.org Mandated reporting to state agencies, law enforcement etc PRIOR to discharge Be sure to review nurses notes

27. ED Care Severity of injuries not only factor for hospitalization Child may have witnessed other abuse...this also should be reported to child protective services

28. Prevention Multiple programs available for high risk parents/caregivers Nurse-Family Partnership (nursefamilypartnership.org) Early Start (www.ehsnrc.org)www.ehsnrc.org Triple P (www.triplep-america.com)www.triplep-america.com

29. Medicolegal Pitfalls Provider opinion on guilt “Reasonable Medical Certainty” standard “Its possible...” No opinions based on feeling about parent/caretaker Legal protection Greater risk for missed abuse Age of bruises not reliable