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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

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Intermediate physical abuse curriculum
IntermediatePhysical Abuse Curriculum

For Primary Care and Emergency Pediatrics


Scenario
Scenario

  • A busy pediatric acute care facility

  • Four patients await you


Scenario patient a
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
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=39o P=125 R=35 BP=75/43


Scenario patient c
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
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
Discussion

  • Would any of these cases make you suspicious of abuse?

  • Why?

  • How would you proceed?


Recognizing abuse
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
Algorithm

Child Injury Evaluation

  • Recognition Algorithm

  • Prompt Card

ConsIder Abuse

Bruise withRecognizable Shape

Multiple Injuries of Differing Ages

Non-Walking Child

Child Reports Abuse

No Trauma History

Inconsistencies in the Given History

Minor Trauma withSevere Injuries

Injury Complicated By Delay


Algorithm1
Algorithm

Child Injury Evaluation

  • Bruise with recognizable shape

ConsIder Abuse

Bruise withRecognizable Shape

Multiple Injuries of Differing Ages

Non-Walking Child

Child Reports Abuse

No Trauma History

Inconsistencies in the Given History

Minor Trauma withSevere Injuries

Injury Complicated By Delay









Algorithm2
Algorithm

Child Injury Evaluation

  • Multiple injuries that occurred at different times

ConsIder Abuse

Bruise withRecognizable Shape

Multiple Injuries of Differing Ages

Non-Walking Child

Child Reports Abuse

No Trauma History

Inconsistencies in the Given History

Minor Trauma withSevere Injuries

Injury Complicated By Delay


Multiple injuries different ages
Multiple InjuriesDifferent Ages

  • Battered child syndrome

    • C Henry Kemp 1963

    • Multiple unexplained injuries

    • Different mechanisms

    • Different places

    • Different times


Multiple injuries different ages1
Multiple InjuriesDifferent Ages


Algorithm3
Algorithm

Child Injury Evaluation

  • Significant trauma in a non-walking child

ConsIder Abuse

Bruise withRecognizable Shape

Multiple Injuries of Differing Ages

Non-Walking Child

Child Reports Abuse

No Trauma History

Inconsistencies in the Given History

Minor Trauma withSevere Injuries

Injury Complicated By Delay


Abuse epidemiology

Head &Fracture

Burn &Abdomen

Abuse Epidemiology

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18



Epidemiology of fractures

Abusive fractures

Accidental Fractures

Epidemiology of Fractures


Epidemiology of head injury
Epidemiology of Head Injury

  • Serious infant head injuries

  • 50 - 95% abuse

50%

Auto Accidents

95%


Epidemiology of head injury1
Epidemiology of Head Injury

  • Head injury death in infants under 2 years

  • 80% child abuse

80%


Algorithm4
Algorithm

Child Injury Evaluation

  • Child gives a history of abuse

ConsIder Abuse

Bruise withRecognizable Shape

Multiple Injuries of Differing Ages

Non-Walking Child

Child Reports Abuse

No Trauma History

Inconsistencies in the Given History

Minor Trauma withSevere Injuries

Injury Complicated By Delay


Algorithm5
Algorithm

Child Injury Evaluation

  • Injury without history of trauma

ConsIder Abuse

Bruise withRecognizable Shape

Multiple Injuries of Differing Ages

Non-Walking Child

Child Reports Abuse

No Trauma History

Inconsistencies in the Given History

Minor Trauma withSevere Injuries

Injury Complicated By Delay


Algorithm6
Algorithm

Child Injury Evaluation

  • Inconsistencies in the given history

ConsIder Abuse

Bruise withRecognizable Shape

Multiple Injuries of Differing Ages

Non-Walking Child

Child Reports Abuse

No Trauma History

Inconsistencies in the Given History

Minor Trauma withSevere Injuries

Injury Complicated By Delay


Inconsistency
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


Inconsistency1
Inconsistency

  • Developmental Inconsistency

    • Child is reported to do

      something age inappropriate

  • Inconsistent cause

    • Epidemiologically unlikely

    • Biomechanically unlikely


Fall injuries

Common fractures

Clavicle

Skull

Others uncommon

Fall Injuries

  • Uncommon head

    • Epidural

    • Small subdural

  • Death rare


Fall injuries1

Visceral Injury

Very rare

Fall Injuries

  • General rules

  • Exceptions exist

  • Probabilistic

  • Not deterministic


Algorithm7
Algorithm

Child Injury Evaluation

  • Severe injuries explained by minor trauma

ConsIder Abuse

Bruise withRecognizable Shape

Multiple Injuries of Differing Ages

Non-Walking Child

Child Reports Abuse

No Trauma History

Inconsistencies in the Given History

Minor Trauma withSevere Injuries

Injury Complicated By Delay


Algorithm8
Algorithm

Child Injury Evaluation

  • Injury complicated by delay in seeking medical care

ConsIder Abuse

Bruise withRecognizable Shape

Multiple Injuries of Differing Ages

Non-Walking Child

Child Reports Abuse

No Trauma History

Inconsistencies in the Given History

Minor Trauma withSevere Injuries

Injury Complicated By Delay


Delay in care seeking

New Fracture

Healing Fracture

Delay in Care-seeking


Scenario patient a1
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
Abuse Or Not Abuse

  • Injury of non-walking child

  • Injury with no trauma history


Scenario patient b1

At Surgery, ruptured jejunum, peritonitis

Scenario: Patient B

  • Two-year-old toddler

    • Fell from bed

    • Abdominal pain

    • Vomiting all PO

    • Fever, severe pain this AM

    • T=39o P=125 R=35 BP=75/43


Abuse or not abuse1
Abuse Or Not Abuse

  • Injury mechanism is inadequate?

  • Complications from delayed care


Scenario patient c1
Scenario: Patient C

  • Eight-month-old infant

    • Fell from bed

    • Unconscious

    • Erratic breathing

    • 3 minute seizure


Abuse or not abuse2
Abuse Or Not Abuse

  • Not walking = very young age

  • Injury mechanism is inadequate?


Scenario patient d1
Scenario: Patient D

  • Three-year-old child

    • Returned from father

    • Bruises on buttocks and posterior thighs

    • Walks reluctantly, stiffly


Abuse or not abuse3
Abuse Or Not Abuse

  • Child’s history?

  • Doesn’t meet other promptsBUT

  • Lots of injury

  • Worrisome social setting


Break
BREAK

When you return:Planning an evaluation


Discussion patient a
Discussion: Patient A

  • What do you

    want to do

    next?


Discussion patient b
Discussion: Patient B

  • What do you

    want to do

    next?


Discussion patient c
Discussion: Patient C

  • What do you

    want to do

    next?


Discussion patient d
Discussion: Patient D

  • What do you

    want to do

    next?


Secondary assessment
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


History1

Nutrition

Vitamin D sources

Sunlight exposure

Development

General trend

Current abilities

History


History2

Growth

Height

Head

circumference

Weight

Immunization

Up to date?

Recent

vaccination

History


History3

Past Medical Events

Traumas

ER visits

Hospitalizations

Unusual illnesses

Recent illnesses

Medications

Current

Chronic

Past

History


History4

Review of Systems

Historical

safety net

Family Medical History

Collagen disorders

Bleeding disorders

Medications in the house

History


History5

Social Conditions

Household composition

Child’s other homes

Stressors

Violence

History


Physical examination

General

Vigor

Developmental

abilities

Behavior and

temperament

Anthropometry

Weight

Height or

length

Head

circumference

Physical Examination


Physical examination1

Skin

Bruises

Burns

Scars

Pigmentary marks

Texture

Distensibility

Physical Examination


Physical examination2

Cranium

Fractures

Swelling

Sutures and

fontanel

Hair

Scalp

Ear

Pinna bruises

Blood in

external/middle

ear

Physical Examination


Physical examination3

Eye

Scleral petechiae

Sub-conjunctival

hemorrhages

Blue sclerae

Retinal

hemorrhages

Mouth

Lip or buccal

contusions

Torn frenulae

Pharyngeal

laceration

Physical Examination


Physical examination4

Skeletal

Deformity

Crepitance

Swelling

Tenderness

Genitals

Sexual maturity

Acute injuries

Healed injuries

Physical Examination


Laboratory examination

CBC

Anemia

Thrombocytopenia

Infection

Leukemia

PT/PTT, INR

Hemophilia

DIC

Consumptive

coagulopathy

Laboratory Examination


Laboratory examination1

Other Clotting

Von

Willebrand’s

disease panel

Factor levels

Thrombophilia

Basic Chemistries

Hypo/hyper-

natremia

Renal failure

Laboratory Examination


Laboratory examination2

ALT, AST, Amylase, Lipase

Internal

injuries

Urinalysis

Internal injuries

Renal diseases

Laboratory Examination


Laboratory examination3

CPK, Myoglobin

Myonecrosis

following crush

injury

Many others possible

Select labs to

match patient’s

condition

Laboratory Examination


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

Imaging



Imaging1

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

Imaging


Consultation
Consultation

  • Genetics

  • Ophthalmology

  • Hematology

  • Child Abuse Pediatrics


Scenario patient a2
Scenario: Patient A

  • Four-month-old infant

    • Found this AM in crib by mom

    • Swollen red thigh

    • Doesn’t move thigh

    • Tenderness


Work up
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 b2
Scenario: Patient B

  • Two-year-old toddler

    • Fell from bed

    • Ruptured hollow viscus

    • Peritonitis


Work up1
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 c2
Scenario: Patient C

  • Eight-month-old infant

    • Fell from bed

    • Unonsciousness

    • Erratic breathing

    • 3 minute seizure


Work up2
Work Up?

  • Proposed work up

    • Skeletal X-ray survey

    • Head MRI

    • Ophthalmology consults

    • Clotting studies, transaminases,

      amlyase

    • Genetics Consult, family history?


Work up3
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 d2
Scenario: Patient D

  • Three-year-old

    child

    • Returned from father

    • Bruises on buttocks

      and posterior thighs

    • Walks reluctantly,

      stiffly


Work up4
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)


Break1
BREAK

When you return:Diagnosis and Management


Diagnosis patient a
Diagnosis?: Patient A

  • Four-month-old

    infant

    • Femur fracture

    • No history

    • No evidence of

      fragility

    • Occult rib fractures


Diagnosis patient b
Diagnosis?: Patient B

  • Two-year-old toddler

    • Fell from bed

    • Ruptured hollow

      viscus

    • Peritonitis

    • Liver and pancreas

      injury


Diagnosis patient c
Diagnosis?: Patient C

  • Eight-month-old infant

    • Fell from bed

    • Unconscious

    • Subdural

      hematoma

    • Retinal

      hemorrhage

    • Rib fracture, CML


Diagnosis patient d
Diagnosis?: Patient D

  • Three-year-old child

    • Bruises on buttocks

      and posterior thighs

    • Coagulopathy

    • Possible coumadin

      exposure


Management patient a
Management?: Patient A

  • Four-month-old infant

    • Battered child syndrome

  • Discharge plan?

  • Treatment plan?


Diagnosis patient b1
Diagnosis?: Patient B

  • Two-year-old toddler

    • Serious inflicted abdominal injury

  • Discharge plan?

  • Treatment plan?


Diagnosis patient c1
Diagnosis?: Patient C

  • Eight-month-old infant

    • Abusive head trauma

  • Discharge plan?

  • Treatment plan?


Diagnosis patient d1
Diagnosis?: Patient D

  • Three-year-old child

    • Rat poison ingestion

    • Neglect?

  • Discharge plan?

  • Treatment plan?



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