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Evaluation of Suspected Child Physical Abuse

Evaluation of Suspected Child Physical Abuse. Based on May and June 2009 AAP recommendations. Standard Aproach. Utilizing a standard approach: Decreases missed abuse Decreases unneeded radiation exposure Simplifies training Reduces bias. Medical History.

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Evaluation of Suspected Child Physical Abuse

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  1. Evaluation of Suspected Child Physical Abuse Based on May and June 2009 AAP recommendations

  2. Standard Aproach • Utilizing a standard approach: • Decreases missed abuse • Decreases unneeded radiation exposure • Simplifies training • Reduces bias

  3. Medical History • No explanation, or vague explanation • Changing history • Inconsistent with child’s age / stage • Different witnesses disagree • History of other concerning injuries

  4. Bright Line v. discipline • Corporal punishment, although not recommended, is quite common. • The following clearly cross the line: • Striking a child with an object • Corporal punishment in a school or daycare setting • Causing bodily damage

  5. Diagnostic Evaluation • Complete physical: • complete skin exam • Palpation of head and all extremities • Initial lab tests: • Bruises – CBC, platelet, PT /PTT to start • Abdomen – LFTs, amylase, lipase • Fractures: Ca, P, alk phos, vit D, PTH

  6. Head injury evaluation • Required when: • Clinical manifestations of CNS damage • Physical findings related to head • Included elements: • History and physical • Head CT • Skeletal survey • Retinal exam (age <1 yo always)

  7. Radiologic Evaluation • Should be performed for all suspected physical abuse • Need to be reviewed by pediatric radiology staff member – requires specialized knowledge

  8. Skeletal Survey “The skeletal survey is mandated in all cases of suspected physical abuse in children under 2 years old. Its utility diminishes thereafter” AAP Section on Radiology, 2009

  9. Skeletal Survey components • Appendicular skeleton – all AP views • Arms, Forearms, Hands • Thighs, legs, feet • Axial skeleton • Thorax: spine and ribs (AP and lateral) • Abdomen: LS spine, pelvis • Lumbar spine (lateral) • C-spine (AP and lateral) • Skull ( Frontal and lateral)

  10. Skeletal Survey considerations • Each image is a standard view and does not require pediatric technician • Additional sensitivity – • Repeat in 2 weeks (healing fxs) • Radionuclide scan

  11. Head Trauma “High-energy forces associated with impact or violent shaking result in a variety of CNS injuries that can be detected my modern neuro-imaiging techniques. The evolution of these injuries, as well as . . Secondary [injuries], are often effectively displayed on serial imaging studies” AAP Section on Radiology, 2009

  12. Initial Evaluation • Head CT without contrast Most sensitive for acute hemorrhage Fractures visible on bone windows Rapid, often performed without sedation

  13. Subsequent Studies • Ultrasound – better look at extra-axial fluid when fontanelle is open • MRI – usually recommended f-u for positive CT scan • Better definition of brain injury • Sometimes better to delay 5-7 days • Highest sensitivity

  14. Summary

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