Physical Abuse Curriculum

1
Physical Abuse Curriculum

• For Primary Care and Emergency Pediatrics

2
Scenario

• A busy pediatric acute care facility
• You arrive
• Four patients await you

3
Scenario Patient A

• Four-month-old infant
• Found this AM in crib by mom
• Swollen reddened thigh
• Doesnt 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 AM
• T39o P125 R35 BP75/43

5
Scenario Patient C

• Eight-month-old infant
• Fell from bed this AM
• 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
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
10
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
11
Bruise with recognizable shape
12
Bruise with recognizable shape
13
Bruise with recognizable shape
14
Bruise with recognizable shape
15
Bruise with recognizable shape
16
Bruise with recognizable shape
17
Bruise with recognizable shape
18
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
19
Multiple InjuriesDifferent Ages

• Battered child syndrome
• C Henry Kemp 1963
• Multiple unexplained injuries
• Different mechanisms
• Different places
• Different times

20
Multiple InjuriesDifferent Ages
21
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
22
Abuse Epidemiology
1 2 3 4 5 6 7 8 9 10 11
12 13 14 15 16 17 18
23
Epidemiology of Accidental Bruising
24
Epidemiology of Fractures

• 80 abuse fractures

• 2 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
• 80 child abuse

80
27
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
28
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
29
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
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
Epidemiology

• Common fractures
• Clavicle
• Skull
• Others uncommon

• Uncommon head
• Epidural
• Small subdural
• Death rare

33
Epidemiology

• Visceral Injury
• Very rare

• General rules
• Exceptions exist
• Probabilistic
• Not deterministic

34
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
35
Algorithm
Child Injury Evaluation

• Injury complicated by delay in careseeking

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
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 reddened thigh
• Doesnt 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
• T39o P125 R35 BP75/43

40
Abuse Or Not Abuse

• ?Injury mechanism is inadequate?
• Complications from delayed care

41
Scenario Patient C

• Eight-month-old infant
• Fell from bed
• Unonsciousness
• Erratic breathing
• 3 minutes of 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

• ?Childs history?
• Doesnt meet other prompts
  BUT
• Lots of injury
• Worrisome social setting

45
BREAK

• When you returnPlanning 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

• Find evidence of other trauma
• Find conditions that change the response to
  trauma
• Tools
• History
• Physical exam
• Laboratory
• Imaging
• Consultation

51
History

• Event
• Detail of trauma
• Source of information
• Detail of symptoms
• Childs condition for 72 hours
• Confirm absent trauma history

• Birth
• Weight
• Maturity
• Method of delivery
• 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
• 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
• Childs other homes
• Stresses
• 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

59
(No Transcript)
60
(No Transcript)
61
(No Transcript)
62
Physical Examination

• Cranium
• Fractures
• Swelling
• Sutures and fontanel
• Hair
• Scalp

• Ear
• Pinna bruises

63
(No Transcript)
64
Physical Examination

• Eye
• Scleral pettechia
• Sub-conjunctival hemorrhages
• Blue sclerae
• Retinal hemorrhages

• Oral
• Lip or buccal contusions
• Torn frenulae
• Pharyngeal laceration

65
(No Transcript)
66
(No Transcript)
67
Physical Examination

• Skeletal
• Deformity
• Crepitance
• Swelling
• Tenderness

• Genitals
• Sexual maturity
• Acute injuries
• Healed injuries

68
Laboratory Examination

• CBC
• Anemia
• Thrombocytopenia
• Infection
• Leukemia

• PT, INR, PTT
• Hemophilia
• DIC
• Consumptive coagulopathy

69
Laboratory Examination

• Other Clotting
• Von Willebrands disease panel
• Factor levels
• Thrombophilia

• Basic Chemistries
• Hypo / hyper natremia
• Renal failure

70
Laboratory Examination

• ALT, AST, Amylase
• Internal injuries

• Urinalysis
• Internal injuries
• Renal diseases

71
Laboratory Examination

• CPK Myoglobin
• Myonecrosis following crush injury

• Many others possible
• Select labs to match patients condition

72
Imaging

• Skeletal X-ray Survey
• All children
• Unresponsive children 3 to 5-years-old
• Select others

• AP Lat Skull
• AP Lat Chest
• Lat C-L-S Spine
• Abdomen/Pelvis
• AP Humerus
• AP Radius/ulna
• AP Femur
• AP Tibia/fibula
• Oblique hands
• AP feet

• May repeat in two weeks

73
(No Transcript)
74
(No Transcript)
75
(No Transcript)
76
(No Transcript)
77
(No Transcript)
78
Imaging

• Intracranial Imaging
• CT
• MRI
• Children
• Children rib fractures or CML

• Abdominal Imaging
• CT
• Ultrasound
• Plain radiolgraphy
• Contrast radiography

79
(No Transcript)
80
(No Transcript)
81
Consultation

• Genetics
• Ophthalmology
• Hematology
• Child Abuse Pediatrics

82
Scenario Patient A

• Four-month-old infant
• Found this AM in crib by mom
• Swollen reddened thigh
• Doesnt move thigh
• Tenderness

83
Work Up?

• Proposed W/U
• Skeletal X-ray survey
• Basic labs
• Genetics consult
• Head CT or MRI
• Outcome
• No fragility concerns
• Normal sub-periosteal new bone
• Normal Head

84
(No Transcript)
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 minutes of 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, multiple level retinal
  hemorrhages
• Slightly prolonged PTT
• Multiple rib fractures, CML at knees and ankles
• Hematology and Neruosurgery 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 returnDiagnosis 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
• Unonsciousness
• Subdural hematoma
• Retinal Hemorrhage
• Rib Fx, 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