Rosen & Barkin's 5-Minute Emergency Medicine Consult (24 page)

• 995.80 Adult maltreatment, unspecified
  
• 995.81 Adult physical abuse
  
• 995.82 Adult emotional/psychological abuse
  

BASICS

• Child abuse impacts up to 14 million or 2–3% of US children each year.
  
• 1,200–1,400 children die of maltreatment each year in the US. Of these, 80% <5 yr and 40% <1 yr.
  
• Mandated reporters of suspected abuse or neglect include all health care workers.
  
• Risk factors:
  
  • Child: Usually <4 yr, often handicapped, retarded, or special needs (“vulnerable child”), premature birth, or multiple birth
    
  • Abusive parent: Low self-esteem, abused as child, violent temper, mental illness history, rigid and unrealistic expectations of child, or young maternal age
    
  • Family: Monetary problems, isolated and mobile, or marital instability
    
  • Poor parent–child relationship, unwanted pregnancy
    
  • Abuse crosses all religious and socioeconomic groups
    

DIAGNOSIS

• History and mechanism inconsistent with the injury or illness:
  
  • Unexplained death, apnea, and injury
    
  • Unexplained ingestion or toxin exposure
    
  • Recurrent injury
    
  • Parent/caregiver reluctant to give information or denies knowledge of how injury occurred
    
  • Begin with open-ended questions about injury and mechanism
    
  • Discrepancy or inconsistencies among different caregivers
    
  • Developmentally, child unable to experience mechanism
    
  • Inappropriate response of care provider to injury or illness; delay in seeking care
    
  • If alleged anogenital/sexual abuse, history credible
    
• Munchausen by proxy:
  
  • Recurrent illness without medical explanation
    
  • Unexplained metabolic disorder suspicious for poisoning
    
• Failure to thrive:
  
  • Inadequate caloric intake secondary to poor maternal bonding/neglect
    
  • Review of past ED encounters and contact with the patient’s primary care physician may be helpful.
    

• Injury not consistent with history
  
• Cutaneous bruising/contusions:
  
  • Regular pattern, straight line of demarcation, regular angles, slap marks from fingers, dunking burns (stocking or glove burns or doughnut shaped on buttock), bites, strap, buckle, cigarette burns
    
  • Location: Buttocks, hips, face (not forehead), arms, back, thighs, genitalia, or pinna
    
  • Aging:
    
    • Often different ages of bruises
      
    • Yellow bruises are older than 18 hr
      
    • Red, blue and purple, or black color may occur from 1 hr after injury to resolution
      
    • Red may be present irrespective of age
      
    • Bruises of identical age and cause on the same person may appear to be different.
      
• Skeletal trauma:
  
  • Usually multiple, unexplained, various stages of healing
    
  • Metaphyseal or corner (classic metaphyseal lesions) fractures (pathognomonic)
    
  • Skull fractures that cross suture lines
    
  • Posterior rib fractures (rib fractures almost never occur in infants from CPR)
    
  • Spiral fractures of long bones
    
  • Subperiosteal new bone formation
    
  • Uncommon fractures (vertebrae, sternum, scapula, spinous process) without significant mechanism
    
• CNS:
  
  • Altered mental status or seizure
    
  • Head trauma is leading cause of death in child abuse.
    
  • Skull fracture: Must consider child abuse in children <1 yr
    
  • Subdural hematoma, subarachnoid hemorrhage
    
  • Shaken baby syndrome with shearing and rotational injury
    
• Ocular findings:
  
  • Retinal hemorrhage or detachment:
    
    • 53–80% of abusive head injury has retinal hemorrhage (commonly bilateral) while present in only 0–10% severe accidental trauma
      
    • Rare in the absence of evidence of head trauma and normal neuroimaging
      
  • Hyphema
    
  • Corneal abrasion/conjunctival hemorrhage
    
• Oral trauma
  
• Abdominal injuries:
  
  • Lacerated liver, spleen, kidney, or pancreas
    
  • Intramural hematoma (duodenal most common)
    
  • Retroperitoneal hematoma
    
• Anogenital/sexual abuse:
  
  • Contusion, erythema, open wounds, scarring, or foreign material (hair, debris, or semen)
    
  • Presence of STD or pregnancy in child <12 yr
    
• Death:
  
  • Unexplained death
    

• Formal oral and written report to appropriate child welfare agency
  
• Family and environmental evaluation, usually in cooperation with responsible child welfare agency
  
• Diagram or photograph of bruises is helpful.
  

• Bleeding screen if there is a history of recurrent bruising or bruising is the prominent manifestation; may usually be done electively: CBC, platelets, PT/PTT, or bleeding time (or PFA collagen epinephrine)
  
• If significant blunt trauma, CBC, LFT, amylase, and urinalysis
  
• Toxicology, chemistry, and metabolic screens in children with altered mental status
  
• Consider other differential considerations.
  

• Global assessment:
  
  • Indicated for children <2 yr to exclude unsuspected injuries
    
  • In children 2–5 yr, in selected cases where physical abuse is strongly suspected
    
  • In older children, radiographs of individual sites of injury suspected on clinical grounds
    
  • Radiographic skeletal survey:
    
    • Anteroposterior (AP) and lateral skull
      
    • Lateral cervical spine
      
    • AP and lateral thoracic and lumbar spine
      
    • AP and obliques of chest
      
    • AP pelvis
      
    • AP humerus, forearm, and hands (bilateral)
      
    • AP femur, tibia, and feet (bilateral)
      
  • If fracture identified, get at least 2 views, 90° to original view.
    
  • May need coned-down view of joints for visualization of classic metaphyseal lesions
    
  • Skeletal scintigraphy provides adjunctive screening if suspicion exists beyond skeletal survey.
    
• Visceral imaging:
  
  • Suspected thoracoabdominal injury:
    
    • Abdominal CT scan with IV and possibly oral contrast
      
• Neuroimaging:
  
  • Nonenhanced head CT with brain, subdural, and bone windowing
    
  • MRI:
    
    • Adjunctive in evaluation of acute, subacute, and chronic intracranial injury; useful for shear injuries, evolving hemorrhage, contusion, or secondary hypoxic/ischemic injury
      

• General:
  
  • Trauma—accidental or birth/obstetrical
    
• Cutaneous:
  
  • Burn—accidental
    
  • Infection
    
  • Impetigo/cellulitis
    
  • Staphylococcal scalded skin syndrome
    
  • Henoch–Schönlein purpura
    
  • Purpura fulminans/meningococcemia
    
  • Sepsis
    
  • Dermatitis: Contact or photo
    
  • Hematologic/oncologic disorder (idiopathic thrombocytopenic purpura [ITP], leukemia)
    
  • Bleeding diathesis (hemophilia, von Willebrand)
    
  • Nutritional deficiency: Scurvy
    
  • Cultural healing practices (coining, cupping)
    
• Skeletal:
  
  • Osteogenesis imperfecta
    
  • Nutritional (rickets, copper deficiency, or scurvy)
    
  • Menkes syndrome
    
  • Peripheral sensory impairment (indifference to pain)
    
• Ocular:
  
  • Conjunctivitis
    
• Abdomen and GU tract:
  
  • GI disease (obstruction, peritonitis, or inflammatory bowel disease)
    
  • GU tract infection/anomaly
    
• CNS:
  
  • Intoxication, ingestion (CO, lead, or mercury)
    
• Infection:
  
  • Metabolic: Hypoglycemia
    
  • Epilepsy
    
• Death:
  
  • SIDS, apparent life-threatening event (ALTE)
    

TREATMENT

• Diagnosis relies on physical evidence in child and inconsistency with the history and mechanism.
  
• Examination of the scene may be useful:
  
  • Evaluate validity of mechanisms
    
  • General appearance of home
    
  • Consistency of history by multiple caregivers
    
  • Evaluation of parent–child interaction
    

As indicated by specific injury

• Medical and trauma management as required
  
• Mandatory reporting to local child welfare agency of any suspected child abuse to determine appropriate social disposition:
  
  • This does
    not
    imply or require 100% certainty of abuse.
    
  • Expedited family, environmental, and social evaluation
    
  • Essential to be nonjudgmental
    
• Communication with family about report and primary concern is responsibility of child welfare.
  
  • Security may be required to protect child and staff.
    
• Siblings and other household children must be examined in appropriate time frame.