|
|
(4 intermediate revisions by one other user not shown) |
Line 1: |
Line 1: |
| ==Background==
| | #REDIRECT[[Nonaccidental trauma]] |
| *Infant and children with disabilities are at higher risk
| |
| *In >80% of cases, the parent or primary guardian is the abuser
| |
| *Report suspicion
| |
| **Transparent, frank discussion with caregivers
| |
| **Social work or child protection agency involvement
| |
| ***Protect the child first, admit if suspicious
| |
| ***Social work may follow-up as outpatient for very low risk cases
| |
| | |
| ===Risk Factors===
| |
| *Domestic violence
| |
| *Maternal depression
| |
| *Drug and alcohol abuse
| |
| *Premature birth
| |
| *Children with disabilities or children who require significant medical care
| |
| *Unrealistic expectations for the child
| |
| | |
| ===Red flags===
| |
| *History given is inconsistent with the mechanism of injury
| |
| *Changes in caregivers report
| |
| *Significant delays in care
| |
| *Any injury to a young, pre-ambulatory infant
| |
| *Injuries to multiple organ systems
| |
| *Injuries in different stages of healing;
| |
| *Patterned injuries
| |
| *Injuries to nonbony or other unusual locations, (torso, ears, face, neck, or upper arms)
| |
| *Significant injuries that are unexplained
| |
| *Other evidence of child neglect.
| |
| | |
| ==Clinical Features==
| |
| ===Bruises===
| |
| *Bruises, ecchymosis, and soft-tissue injuries on the face, cheeks, buttocks, ears, torso, neck if the child is not cruising yet
| |
| *Bruises in clusters or patterned marks
| |
| *Bruising of any child less than or equal to 6 months of age (or non-ambulatory) warrants a full child abuse work-up
| |
| | |
| ===Oral injuries===
| |
| *Torn frenulum in premobile children is highly associated with physical abuse
| |
| *Other reported oral injuries include laceration/bruising to the lips, mucosal lacerations, dental trauma, tongue injuries, and gingival lesions
| |
| | |
| ===[[Burns]]===
| |
| *Most commonly immersion injuries of the extremities, buttocks, or perineum
| |
| *More likely symmetrical with clear upper margins
| |
| *Many will also have occult fractures; children <24mo should undergo a skeletal survey
| |
| | |
| ===Fractures===
| |
| *[[Fractures]] highly suspicious of abuse:
| |
| **[[Rib fracture]], especially posterior
| |
| **Metaphyseal or [[Corner Fracture (Bucket Handle)]]
| |
| **[[Scapula fracture]]
| |
| **Spinous process fractures
| |
| **[[Sternum fracture]]
| |
| **Fracture not consistent with developmental stage (any fracture in non-ambulatory child)
| |
| | |
| *Fractures moderately suspicious of abuse:
| |
| **Long-bone transverse or spiral fracture of the diaphysis of the femur, humerus, tibia
| |
| **Multiple bilateral fractures
| |
| **Different stages of healing with multiple fractures
| |
| **Epiphyseal separations
| |
| **Vertebral body separation
| |
| **Complex [[Skull fracture (peds)|skull fractures]]
| |
| **[[Pelvic fractures]]
| |
| | |
| ===[[Pediatric head trauma|Head Trauma]]===
| |
| *Leading cause of death in abused children <2 years old
| |
| *[[Shaken baby syndrome]] - Retinal Hemorrhages
| |
| **Present in up to 75% of cases and are virtually pathognomonic
| |
| **Described as “dot and blot” hemorrhages or flame or splinter hemorrhages
| |
| | |
| ===Abdominal Trauma===
| |
| *Most from a direct blow or from being thrown
| |
| *Any abrasion or bruise on the abdominal area should prompt an evaluation for possible trauma
| |
| *Consider abuse in preschool aged children with any hollow viscus or pancreatic injury
| |
| | |
| ==Differential Diagnosis==
| |
| {{Template:Child abuse DDX}}
| |
| {{Crying infant DDX}}
| |
| | |
| ==Evaluation==
| |
| *Skeletal survey for all children < 2 years of age, non-verbal, or severe developmental delay. Note: Follow-up skeletal survey should be performed within 10 to 14 days
| |
| **Skull AP and lateral view (left and right)
| |
| **Chest AP and lateral view
| |
| **Right and left oblique of the chest
| |
| **AP of the abdomen to include pelvis and hips
| |
| **AP and lateral spine to include cervical, thoracic, and lumbar vertebrae
| |
| **AP bilateral humerus
| |
| **AP bilateral forearms
| |
| **AP bilateral femurs
| |
| **AP bilateral tibia and fibula
| |
| **Posterior view of the hands
| |
| **Dorsoplantar view of the feet
| |
| *[[Head CT]] without contrast for any child < 1 year with suspicion of abuse or >1 year with concerning signs of head trauma
| |
| *Trauma labs: CBC, CMP, PT, PTT, lipase, and urinalysis (looking for blood; use bag specimen). Consider urine tox screen
| |
| **Consider CPK and platelet function studies if extensive bruising is present
| |
| **If trauma labs are abnormal, obtain a CT of abdomen/pelvis with IV contrast
| |
| *Consider a dilated fundoscopic exam if under 2 years
| |
| *Photograph injuries
| |
| *Obtain a social work consult
| |
| ===Inpatient Workup<ref>Children's Hospital of Georgia NAT Workup Protocol. Medical College of Georgia at Augusta University. Last reviewed 2016.</ref>===
| |
| *Ophtho consult for retinal hemorrhages
| |
| *CBC
| |
| *CMP, Mg, phos
| |
| *PT/INR/aPTT, fibrinogen
| |
| *PTH, iCa, 25-hydroxy-Vit D, 1,25-dihydroxy-Vit D
| |
| *vW panel (vW AT, ristocetin cofactors, factor VIII)
| |
| | |
| ==Management==
| |
| *Treat injuries as indicated
| |
| *Report abuse to the appropriate state child protection authority
| |
| | |
| ==Disposition==
| |
| *Admit for medical treatment or if any question of child's safety
| |
| | |
| ==See Also==
| |
| *[[Trauma (peds)]]
| |
| | |
| ==External Links==
| |
| *[http://pemplaybook.org/podcast/vomiting-in-the-young-child-nothing-or-nightmare/ Pediatric Emergency Playbook -- Vomiting in the Young Child: Nothing or Nightmare]
| |
| | |
| ==References==
| |
| <references/>
| |
| | |
| [[Category:Pediatrics]]
| |