Physical Abuse (Case 53)

Chapter 96 Physical Abuse (Case 53)



Sara L. Beers, MD




Case


A 15-month-old boy was brought in by emergency medical services after becoming unresponsive in the bathtub while in the care of his mother’s boyfriend, who stated that the child may have fallen off the couch earlier in the afternoon.




Differential Diagnosis











Abusive head trauma Abusive abdominal trauma
Abusive fractures Abusive burns


Speaking Intelligently


Nonaccidental trauma or physical abuse should always be considered when there is no history or only a minor history of trauma with significant findings. Cervical spine (C-spine) precautions should be implemented immediately. The child’s airway, breathing, and circulation should be assessed and supported. The child needs to be completely undressed, while simultaneously being placed on cardiopulmonary monitors. A quick secondary survey needs to be performed. This includes log-rolling the child while holding C-spine precautions to assess the child’s back and buttocks. A Glasgow Coma Scale (GCS) score should be assigned. If the GCS score is altered, the child needs to have a stat computed tomography (CT) scan of the head. One should strongly consider obtaining an abdominal CT at the same time when nonaccidental trauma is on the differential. Intravenous access should be obtained with bedside testing for glucose, hemoglobin, and venous blood gas levels. Additional blood should be obtained for complete blood count (CBC), prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR), aspartate aminotransferase (AST), alanine aminotransferase (ALT), amylase, lipase, and a type and crossmatch. Obtaining blood should not delay going to the CT scanner.



Patient Care



Clinical Thinking



• Support airway, breathing, and circulation.

• The differential is broad when initially evaluating a child with abuse because rarely is that given in the history.

• Things to consider include ingestion, infection, seizure, and hypoglycemia.


History


Obtain and document a thorough history of the explanation of the injury and/or the day’s events from the caregiver. This information may later become important to the investigators and/or prosecutors. The following are aspects of a history that may be particularly concerning for abuse:


• No explanation or vague explanation with a significant injury.

• An important detail of the explanation changes significantly.

• An explanation that is inconsistent with the pattern, age, or severity of the injury or injuries.

• An explanation that is inconsistent with the child’s physical and/or developmental capabilities.

• Different witnesses provide markedly different explanations for the injury or injuries.

• Delay in seeking care.


Physical Examination



• Always completely undress the child because some injuries resulting from physical abuse may be missed otherwise (e.g., burns to the bottoms of the feet).

• A complete neurologic assessment, including reflexes, cranial nerves, sensorium, gross motor, and fine motor abilities, should be performed.

• Take note of any tenderness or swelling, especially when palpating the child’s extremities, head, and ribs because there may be new or healing fractures.

• Look closely in the child’s mouth for caries (which may indicate neglect) and at the frenulum (which often is torn in cases of forced feeding).

• A thorough examination of the child’s skin is very important, looking for bruises, lacerations, burns, or bites. (Remember to look at the child’s ears because this is often a site of bruising from the ears being pulled.)

• If the child is stable, the height, weight, and fronto-occipital (FOC) circumference should be carefully measured and plotted on a growth chart.

• Always perform a thorough genitourinary (GU) examination on children with suspected physical abuse to check for signs of sexual abuse.


Tests for Consideration



• CBC with differential $53

• Diffuse intravascular coagulation (DIC) panel (PT, PTT, fibrinogen, D-dimer) $75

• Liver enzymes (AST, ALT) $75

• Pancreatic enzymes (amylase, lipase) $45

• Urinalysis $38


Imaging Considerations


→ Head computed tomography (CT): Abnormal neurologic examination, scalp/head swelling or bruising on physical examination, or a child less than 2 years old with other injuries of concern for physical abuse. $750


→ Head magnetic resonance imaging (MRI): Not as readily available as CT. Often obtained after a CT. Better characterization of cerebral edema, more sensitive for subtle intracranial injuries, better dating of intracranial injuries. $1800


→ Abdominal CT: If concern for abdominal trauma (IV contrast). $950


→ Skeletal survey: Recommended for all children under the age of 2 years with injuries concerning for physical abuse. Consider repeating in 2 weeks. $225


→ Radionuclide bone scan: Better for acute rib fractures and subtle nondisplaced long-bone fractures. $560

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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Physical Abuse (Case 53)

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