Non-accidental trauma - NAT - child abuse (0 - 18 years)



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Non-accidental trauma - NAT - child abuse (0 - 18 years)

Either of the following present?

  • Transfusion required
  • Signs of hypoxic-ischemic encephalopathy

Full, age-appropriate screening for occult injuries in any other child in the home of the patient.

Social work (and child abuse expert if available) consult and report to proper authorities. Consider trauma specialist evaluation if any suspicion or signs of trauma present.

Suspicion of sexual assault?

Head injury or abnormal brain imaging?

Intracranial bleeding without trauma?

Detailed medical history (including social/family history and observations by other caregivers and medical providers) and physical exam.

Febrile or petechiae?

Extensive soft tissue bruising?

Urine organic acids, Hematology consult, Thrombophilia Panel (Homocysteine, Antithrombin III Activity, Factor VIIIC, Protein C Activity, Free Protein S Antigen, DRVVT, Lupus Anticoagulant, Lupus Anticoagulant Hexagonal Phase, Factor V Leiden, Prothrombin Variant 20210A)

Creatine Phosphokinase (CPK), Serum
Prothrombin time (PT)
Partial Thromboplastin Time (PTT)
Aldolase, Serum
Myoglobin, Serum

Ophthalmology consult

Severe injuries or mental status changes?

< 12 months or developmentally delayed?

12-24 months or developmentally delayed?

Multiple fractures or bone deformities?

CT Head WO Contrast
Complete Blood Count, Serum
Complete Metabolic Panel, Serum
Urinalysis with micro, Urine
Urine Toxicology, Urine
Prothrombin time (PT)
Partial Thromboplastin Time (PTT)
Lipase, Serum
Bone survey infant (skeletal survey)

2- 6 years?

Consider sexual assult pathway

↑ LFTs, hematuria or abd. trauma?

Calcium, phosphorus, intact PTH, serum 25-hydroxy-vitamin-D

Bone survey infant (skeletal survey)
CT Abdomen/Pelvis W Contrast

Multidiciplinary decision of admission, discharge and follow up. Consider re-evaluation and possible reimaging with x-rays in 2 weeks if concern for missed fractures.

Fracture specificity for abuse

High

  • Classic metaphyseal lesions
  • Rib fractures, especially posterior
  • Scapular fractures
  • Spinous process fractures
  • Sternal fractures
  • Unexplained fracture in an infant
  • Moderate
  • Multiple fractures, especially bilateral
  • Fractures of different ages
  • Epiphyseal separations
  • Vertebral body fractures and subluxations
  • Digital fractures
  • Complex skull fractures
  • Low
  • Subperiosteal new bone formation
  • Clavicular fractures
  • Long bone shaft fractures, unless child pre-ambulatory
  • Linear skull fractures

Conditions that mimic abuse

Bruising

  • Mongolian spots/Slate grey patches
  • Erythema nodosum
  • Ink, paint, dye
  • Cupping
  • Coining
  • Phytodermatitis
  • HSP
  • ITP, DIC, Leukemia
  • Hemophilia
  • Ehlers-Danlos
  • Hemangioma
  • Vitamin K

Fractures

  • Osteogenesis Imperfecta
  • Osteopenia of prematurity
  • Rickets

Burns

  • Impetigo
  • Severe diaper rash
  • Frost bite
  • Chemical burns
  • Epidermolysis bullosa
  • Phytodermatitis
  • Moxibustion

Intracranial Hemorrhage

  • Glutaric aciduria type 1
  • Hemorrhagic disease of the newborn
  • Coagulopathies

Indicators for Suspected Abuse

Behavioral clues

  • Infants excessive crying or developmental delay
  • Fear, anxiety, clinging
  • Phobias
  • Nightmares, sleeping problems
  • Bed wetting
  • Social withdrawal
  • Hyperactivity
  • Poor concentration/distractibility
  • Decreased school performance
  • Chronic school absenteeism
  • Speech disorders
  • Regressive behavior for age
  • Seems afraid of parent
  • Eating issues
  • Depression, passivity
  • Increased verbal abuse or physically aggressive behavior with others
  • Destroys or injures objects or pets
  • Substance abuse
  • Self-harm such as cutting
  • Sexualized behavior
  • Symptoms of PTSD
  • Avoidance of undressing
  • Withdrawal to touch, afraid of exam
  • Overly compliant, especially with difficult or painful parts of the exam

Symptom clues

Headaches

  • Abdominal pain, chronic
  • Abdominal pain, acute – blunt trauma may not show external marks – look for distention, tenderness, absent bowel sounds
  • Vague somatic complaints, often chronic
  • Worsening medical problems, such as asthma
  • Frequent, unexplained sore throat
  • Abnormal weight gain or loss
  • Reluctance to use an extremity
  • Difficulty walking or sitting
  • Genital discomfort or painful urination or defecation
  • Unexplained symptoms - look for poisoning, forced ingestion of water, salt (Munchausen by proxy)
  • Vomiting, irritability or abnormal respiration may represent head trauma

Physical clues

  • Poor hygiene
  • Dressed inappropriately for weather
  • Failure to thrive, poor weight gain, malnutrition
  • Lack of care of medical needs; wound care, medication
  • Dislocations
  • Defensive injuries on forearms
  • Bites - human bites are more superficial than animal, and show up better 2-3 days later
  • Burns – (in 6-20% of abused children) cigarette, rope, immersion, or shape of hot object
  • Severity of the burn inconsistent with length of contact by history
  • Cigarette burns circular, 8-10mm deep, heaped margin - may be confused with impetigo or moxibustion
  • Stun gun burns occur in pairs, 0.5cm diameter and 5cm apart
  • Immersion burns have sharp line of demarcation without drip or splash marks
  • Signs of restraints on axilla or extremities
  • Trauma to ear
  • Lacerations
  • Traumatic hair loss
  • Facial injuries without good explanation
  • Oral/dental injuries, such as torn or bruised frenulum, lips, teeth, palate, tongue or oral mucosa
  • Injuries from non-ambulatory child may be 'bottle jamming'
  • Lacerations or tissue damage to oral structures may come from eating utensils, scalding or caustic liquids
  • Scarring/bruising at corners of mouth from being gagged
  • Oral injuries/STDs from forced oral sex
  • Head injury, mental status change
  • Retinal hemorrhage
  • Subdural hematoma
  • Intra-abdominal trauma, usually to multiple organs
  • Bruising, tearing, bleeding, discharge from genital or rectal area
  • Diagnosed STD or pregnancy

Skeletal Survey Xrays

APPENDICULAR SKELETON

  • Humeri (AP)
  • Forearms (AP)
  • Hands (PA)
  • Femurs (AP)
  • Lower legs (AP)
  • Feet (PA) or (AP)

AXIAL SKELETON

  • Thorax (AP, lateral and right and left oblique projections), to include ribs, thoracic and upper lumbar spine
  • Pelvis (AP), to include the mid lumbar spine
  • Lumbosacral spine (lateral)
  • Cervical spine (AP and lateral)
  • Skull (frontal and lateral)

Pattern of bruises suggestive of abuse

  • Multiple bruises, especially on the trunk
  • Any bruising in a non-ambulatory baby
  • Hand prints or oval finger marks
  • Belt marks
  • Loop pattern from cord, rope or wire that has been doubled up
  • Petechiae or pattern on buttocks from paddling, severe spanking
  • Ligature pattern on neck, wrists, ankles
  • Gag pattern on corners of the mouth
  • Any oral injury in an infant

Location

  • Upper thighs, especially inner thighs
  • Trunk, buttocks
  • Upper arms
  • Sides of face, ears, neck
  • Genitalia

Consider workup for meningitis if symptomatic

Complete Blood Count, Serum
Blood Culture (Aerobic and Anaerobic), Serum
Urinalysis with micro, Urine
Prothrombin time (PT)
Partial Thromboplastin Time (PTT)
Complete Blood Count, Serum
Complete Metabolic Panel, Serum
Urinalysis with micro, Urine
Urine Toxicology, Urine
Prothrombin time (PT)
Partial Thromboplastin Time (PTT)
Lipase, Serum

CT or MRI head

MRI Brain WO Contrast
CT Head WO Contrast

If the patient presents with mental status changes or concerns for ingestion consider obtaining toxicology testing.

Inclusion Criteria
  • Any clinical suspicion of abuse
  • Subdural hemorrhage in child less than 2 years
  • Suspicious burns (patterend, widely sperated or bilateral, different stages of healing, unusual areas such as backs of hands, torso or buttocks)
  • Any widespread retinal hemorrhage
  • Any injury without trauma history in child less than 2 years (head trauma, long bone fractures, etc.)
  • Any bruise in an infant < 4 months old or non-mobile child, OR bruising of the torso, neck or ears in children < 4 years without trauma history
Exclusion Criteria
  • Obvious nonabusive cause of injury

Hematology consult, Thrombophilia Panel (Homocysteine, Antithrombin III Activity, Factor VIIIC, Protein C Activity, Free Protein S Antigen, DRVVT, Lupus Anticoagulant, Lupus Anticoagulant Hexagonal Phase, Factor V Leiden, Prothrombin Variant 20210A)

Treat appropriately

Forensic evidence collection

  • Collect clothing if it is to be disposed, especially what the child was wearing when they arrived and, allow it to dry and place into a bag with a patient's label.
  • Consider swabbing any bite marks
  • Take photos of ANY all ALL visible injuries
  • Include a photo of patient's label/ID bracelet
  • Include a standard ruler if possible
  • Photograph each injury separately, first at a distance, then close-up




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