PHYSICAL ABUSE: INITIAL EVALUATION AND MANAGEMENT **Child Protection MD is available by pager for questions or formal consultation ** I. RECOGNITION A. History 1. Unexplained or un-witnessed injury 2. Conflicting, inconsistent or developmentally inappropriate 3. Delay in seeking care B. Physical 1. Altered mental status 2. Closed head injury 3. Fractures: skull, rib, long bone, multiple fractures, differing ages 4. Oral injuries 5. Bruising in a non-mobile infant, regardless of location 6. Burns: circumferential, scalds, patterns, or diaper area 7. Subdural hematomas 8. Abdominal injury: liver lacerations, ruptured viscus II. II.A.1.References 9,11,16,19,20,27 II.A.2.References: 1,3,19,20,25, 29,32 II.A.3.References: 20,25,31 II.A.4.References: 19,23 II.A.5.References: 2,8,9,18,25, 26, 27,30 II.B.1.References: 7,10,14,16,24,28 II.B.2.References: 9,11,16,19,20,27 EVALUATION A. Children 0-12 months old [see Appendix 1] 1. Skeletal survey (2 cranial views, AP and lateral CXR, oblique views of the ribs, KUB, AP Pelvis, all long bones, hands and feet) 2. Head CT (non-contrast) a) If abnormal, ophthalmology consult for dilated funduscopic exam. b)if abnormal, consider neurosurgical consult 3. General Pediatric Surgery Consult in any case with exam or lab findings concerning for abdominal trauma[see Appendix 3] 4. Laboratory Collection a) Chem-10 b)non-accidental Trauma panel (CBC, PT, PTT, AST, ALT, ferritin) c) Amylase & lipase d)urinalysis e) If altered or seizing, order urine tox screen B. Children 12-24 months old [see Appendix 2] 1. Occult abdominal injury screening (AST/ALT) [see Appendix 3] 2. Skeletal survey based on chief complaint III. IV. 3. If there is a concern for inflicted neurotrauma based on H&P, proceed as above in #2-5 C. Children > 24 months old 1. Occult abdominal injury screening (AST/ALT) [see Appendix 3] 2. X-ray as indicated 3. Complete skeletal survey is recommended for specific patients: a) Burn victims or disabled children who are non-mobile b)multiple fractures suspected REPORTING A. Notify attending physician on duty of concern for inflicted injury B. Social worker on call is to be notified of any and all cases of suspected inflicted injury C. Ensure Child Protective Services is notified. 1-800-252-5400 DOCUMENTATION A. HPI: Timing and mechanism of injury. Source of history; if differing information, delineate different authors B. PMH: Screen for alternate medical explanations for injury C. PE: specifically describe appearance, location, and size of injury D. Reporting: Document agencies notified, note case numbers 1. Complete Physician s Report of Injury to a Child 2. Photodocumentation as needed V. DISPOSITION AND FOLLOW-UP A. Social work and CPS, once notified, will assist in disposition B. If fracture present on skeletal survey, or if patient age < 12 months, repeat skeletal survey in 2 weeks 1. Follow-up films will NOT include skull views 2. Indicate that follow-up film results should be reported to Child Protection MDs (Dr. Isaac or Dr. Donaruma) if the patient s PMD is not involved with case C. Sibling/cohort evaluation of all other children who share environment of the injured child is needed D. Follow-up appointment at Children s Protective Health Clinic if repeat assessment needed. 832-822-3453 II.C.1. References: 7,10,14,16,24,28 V.B. References: 5,17,19 Created by: Marcella Donaruma, M.D. 1.11.2008
Laboratory Evaluation Child 0-12 months Concern for inflicted injury Skeletal survey Appendix 1 Child Protection Physician consult available by pager! 9,11,16,19, 20, 27, 32 Chem-10, NAT Panel (Includes: CBC, PT, PTT, AST, ALT, Ferritin), Amylase, Lipase, Urinalysis Bicarbonate < 15 mmol/l 2,25,26,30 Age<12 months with: Developmental delay, Abnormal OFC Abnormal findings including: signs of abdominal injury on physical exam or laboratory evaluation +Head or facial trauma Head CT + Abnormal findings including: acute/chronic bleed, cerebral edema, cortical contusion, infarct 1,3,19,20,25, 29,32 + Abnormal findings including: acute fractures, callous formation, periosteal reaction Multiple fractures of long bones Follow-Up Will require follow-up study in 2 weeks. Indicate to send results to Dr. Isaac or Dr. Donaruma on order request Blood gas Surgical Consult Laboratory evaluation 5,17,19 Altered mental status or seizures Toxicology Screen 8,9,18,26 Ammonia, urine amino acids, urine organic acids serum amino acids 27 Ophthalmologic exam 20,25,31 Consider Neurosurgical consult Ca, Phos, Alk Phos, PTH, 1, 25-OH Vit D, 25 OH-Vit D 13,32 If needed, may schedule f/u appointment at Children s Protective Health Clinic 832-822-3453 Created by: Marcella Donaruma, MD 1.11.2008
AST/ALT Screen for occult abdominal injury. [See Appendix 3 ] Child 12-24 months Concern for inflicted injury If clinically indicated: Patient is not yet ambulatory, visible swelling/deformity, refusal to move limb, refusal to bear weight Appendix 2 If physical exam abnormalities present (i.e., altered mental status, bruising) Abnormal findings including: signs of abdominal injury on physical exam or laboratory evaluation If clinically indicated: Altered mental status, seizures, abnormal neurological exam, developmental delay Skeletal survey 9,11,16,19, 20, 27, 32 Laboratory evaluation 2,25,26,30 Chem-10, Non-Accidental Trauma Panel (Includes: CBC, PT, PTT, AST, ALT, Ferritin), Amylase, Lipase, Urinalysis Altered mental status or seizures noted Toxicology Screen 8,9,18,26 Surgical Consult 19,23 Child Protection Physician consult available by pager! + Head or facial trauma Ophthalmology consult 20,25,31 Head CT + Abnormal findings including: acute/ chronic bleed, cerebral edema, cortical contusion, infarct 1,3,19,20,25,29,32 Consider Neurosurgical consult + Skull fracture or C-spine injury Will require follow-up study in 2 weeks. Indicate to send results to Dr. Isaac or Dr. Donaruma on order request 5,17,19 Created by: Marcella Donaruma, MD 1.11.2008 + Abnormal findings including: acute fractures, callous formation, periosteal reaction Follow-Up If needed, may schedule f/u appointment at Children s Protective Health Clinic 832-822-3453
Guidelines for the Use of Elevated Liver Transaminases in Detecting Occult Liver Injury in Child Abuse Age 0-60 months with concerns for acute inflicted injury Findings may include but are not limited to unexplained bruising, burns, bleeding, fractures Appendix 3 7,10,14,16,24,28 Hemodynamically stable and GCS > 13 Hemodynamically stable and GCS > 13 Hemodynamically unstable or GCS < 13 Proceed with trauma protocol Measure AST and ALT (fingerstick) Unreliable/ changing abdominal exam Axial bruising AST < 200 and ALT < 100 AST > 200 and/or ALT >100 Thoracic injury of any type No further intervention recommended CT scan Abdomen with contrast Created by: Marcella Donaruma, MD 1.11.2008 Consult pediatric surgery
References for Appendix 1, Appendix 2, and Appendix 3 (PHYSICAL ABUSE: INITIAL EVALUATION AND MANAGEMENT) 1. Child abuse and the eye. The Ophthalmology Child Abuse Working Party. Eye, 1999. 13 ( Pt 1): p. 3-10. 2. Diagnostic imaging of child abuse. Pediatrics, 2000. 105(6): p. 1345-8. 3. Agran, P.F., et al., Rates of pediatric injuries by 3-month intervals for children 0 to 3 years of age. Pediatrics, 2003. 111(6 Pt 1): p. e683-92. 4. Bays, J., Feldman, Kenneth W., ed. Child Abuse by Posioning. Child Abuse: Medical Diagnosis and Treatment, ed. R. Block, Ludwig, Stephen. 2001, Lippincott, Williams & Wilkins: Philadelphia. 5. Belfer, R.A., B.L. Klein, and L. Orr, Use of the skeletal survey in the evaluation of child maltreatment. Am J Emerg Med, 2001. 19(2): p. 122-4. 6. Case, M.E., et al., Position paper on fatal abusive head injuries in infants and young children. Am J Forensic Med Pathol, 2001. 22(2): p. 112-22. 7. Coant, P.N., et al., Markers for occult liver injury in cases of physical abuse in children. Pediatrics, 1992. 89(2): p. 274-8. 8. Dias, M.S., et al., Serial radiography in the infant shaken impact syndrome. Pediatr Neurosurg, 1998. 29(2): p. 77-85. 9. Duhaime, A.C. and M.D. Partington, Overview and clinical presentation of inflicted head injury in infants. Neurosurg Clin N Am, 2002. 13(2): p. 149-54, v. 10. Gross, M., et al., Management of pediatric liver injuries: a 13-year experience at a pediatric trauma center. J Pediatr Surg, 1999. 34(5): p. 811-6; discussion 816-7. 11. Helfer, R.E., T.L. Slovis, and M. Black, Injuries resulting when small children fall out of bed. Pediatrics, 1977. 60(4): p. 533-5. 12. Hennes, H.M., et al., Elevated liver transaminase levels in children with blunt abdominal trauma: a predictor of liver injury. Pediatrics, 1990. 86(1): p. 87-90. 13. Hoffman, R.J. and L. Nelson, Rational use of toxicology testing in children. Curr Opin Pediatr, 2001. 13(2): p. 183-8. 14. Holmes, J.F., et al., Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med, 2002. 39(5): p. 500-9. 15. Hymel, K.P., et al., Comparison of intracranial computed tomographic (CT) findings in pediatric abusive and accidental head trauma. Pediatr Radiol, 1997. 27(9): p. 743-7. 16. Jenny, C., Evaluating infants and young children with multiple fractures. Pediatrics, 2006. 118(3): p. 1299-303. 17. Kemp, A.M., et al., Which radiological investigations should be performed to identify fractures in suspected child abuse? Clin Radiol, 2006. 61(9): p. 723-36. 18. Kempe, C.H., et al., The battered-child syndrome. Jama, 1962. 181: p. 17-24.
19. Kleinman, P.K., Diagnostic Imaging of Child Abuse. 2nd ed. 1998, Saint Louis: Mosby, Inc. 20. Liesner, R., I. Hann, and K. Khair, Non-accidental injury and the haematologist: the causes and investigation of easy bruising. Blood Coagul Fibrinolysis, 2004. 15 Suppl 1: p. S41-8. 21. Maguire, S., Mann, M.K., Sibert, J., Kemp, A., Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review. Arch Dis Child, 2005. 90(2): p. 182-186. 22. Minns, R.A., Brown, J. Keith, ed. Shaking & Other Non-accidental Head Injuries in Children. 2005, MacKeith Press: London. 23. Murphy, J., et al., Accidental poisoning preceding nonaccidental injury. Arch Dis Child, 1981. 56(1): p. 78-9. 24. Oldham, K.T., et al., Blunt hepatic injury and elevated hepatic enzymes: a clinical correlation in children. J Pediatr Surg, 1984. 19(4): p. 457-61. 25. O'Neill, J.A., Jr., et al., Patterns of injury in the battered child syndrome. J Trauma, 1973. 13(4): p. 332-9. 26. Paschall, R., ed. The Chemically Abused Child. Child Maltreatment, ed. A.P. Giardino. Vol. 1. 2005, GW Medical Publishing. 27. Reece, R., Nicholson, Carol E., ed. Inflicted Childhood Neurotrauma. 2003, American Academy of Pediatrics: Bethesda. 28. Roaten, J.B., et al., Visceral injuries in nonaccidental trauma: spectrum of injury and outcomes. Am J Surg, 2005. 190(6): p. 827-9. 29. Sugar, N.F., J.A. Taylor, and K.W. Feldman, Bruises in infants and toddlers: those who don't cruise rarely bruise. Puget Sound Pediatric Research Network. Arch Pediatr Adolesc Med, 1999. 153(4): p. 399-403. 30. Thomas, A.E., The bleeding child; is it NAI? Arch Dis Child, 2004. 89(12): p. 1163-7. 31. Woodcock, R.J., P.C. Davis, and K.L. Hopkins, Imaging of head trauma in infancy and childhood. Semin Ultrasound CT MR, 2001. 22(2): p. 162-82. 32. Zimmerman, S., et al., Utility of follow-up skeletal surveys in suspected child physical abuse evaluations. Child Abuse Negl, 2005. 29(10): p. 1075-83.