Intermediate Physical Abuse Curriculum

1. IntermediatePhysical Abuse Curriculum For Primary Care and Emergency Pediatrics

2. Scenario • A busy pediatric acute care facility • Four patients await you

3. Scenario: Patient A • Four-month-old infant • Found this morning in crib by mom • Swollen, red thigh • Doesn’t move thigh • Tenderness

4. Scenario: Patient B • Two-year-old toddler • Fell from bed two mornings ago • Abdominal pain since yesterday • Vomiting all PO since last night • Fever, severe pain this morning • T=39o P=125 R=35 BP=75/43

5. Scenario: Patient C • Eight-month-old infant • Fell from bed this morning • Lost consciousness • Unusual breathing • Stiffened and 3 minutes of convulsion • Obtunded, breathing, unresponsive

6. Scenario: Patient D • Three-year-old child • Returned yesterday from visiting dad • This AM found to have bruises on buttocks and posterior thighs • Walks reluctantly, stiffly

7. Discussion • Would any of these cases make you suspicious of abuse? • Why? • How would you proceed?

8. Recognizing Abuse • Difficulties in recognizing abuse • Thinking abuse is difficult, we want to think the best of people • The effects of trauma can be occult on first inspection • The history is usually, absent, false or purposefully misleading

9. Algorithm Child Injury Evaluation • Recognition Algorithm • Prompt Card ConsIder Abuse Bruise withRecognizable Shape Multiple Injuries of Differing Ages Non-Walking Child Child Reports Abuse No Trauma History Inconsistencies in the Given History Minor Trauma withSevere Injuries Injury Complicated By Delay

10. Algorithm Child Injury Evaluation • Bruise with recognizable shape ConsIder Abuse Bruise withRecognizable Shape Multiple Injuries of Differing Ages Non-Walking Child Child Reports Abuse No Trauma History Inconsistencies in the Given History Minor Trauma withSevere Injuries Injury Complicated By Delay

11. Bruise with recognizable shape

12. Bruise with recognizable shape

13. Bruise with recognizable shape

14. Bruise with recognizable shape

15. Bruise with recognizable shape

16. Bruise with recognizable shape

17. Bruise with recognizable shape

18. Algorithm Child Injury Evaluation • Multiple injuries that occurred at different times ConsIder Abuse Bruise withRecognizable Shape Multiple Injuries of Differing Ages Non-Walking Child Child Reports Abuse No Trauma History Inconsistencies in the Given History Minor Trauma withSevere Injuries Injury Complicated By Delay

19. Multiple InjuriesDifferent Ages • Battered child syndrome • C Henry Kemp 1963 • Multiple unexplained injuries • Different mechanisms • Different places • Different times

20. Multiple InjuriesDifferent Ages

21. Algorithm Child Injury Evaluation • Significant trauma in a non-walking child ConsIder Abuse Bruise withRecognizable Shape Multiple Injuries of Differing Ages Non-Walking Child Child Reports Abuse No Trauma History Inconsistencies in the Given History Minor Trauma withSevere Injuries Injury Complicated By Delay

22. Head &Fracture Burn &Abdomen Abuse Epidemiology 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

23. Epidemiology of Accidental Bruising

24. Abusive fractures Accidental Fractures Epidemiology of Fractures

25. Epidemiology of Head Injury • Serious infant head injuries • 50 - 95% abuse 50% Auto Accidents 95%

26. Epidemiology of Head Injury • Head injury death in infants under 2 years • 80% child abuse 80%

27. Algorithm Child Injury Evaluation • Child gives a history of abuse ConsIder Abuse Bruise withRecognizable Shape Multiple Injuries of Differing Ages Non-Walking Child Child Reports Abuse No Trauma History Inconsistencies in the Given History Minor Trauma withSevere Injuries Injury Complicated By Delay

28. Algorithm Child Injury Evaluation • Injury without history of trauma ConsIder Abuse Bruise withRecognizable Shape Multiple Injuries of Differing Ages Non-Walking Child Child Reports Abuse No Trauma History Inconsistencies in the Given History Minor Trauma withSevere Injuries Injury Complicated By Delay

29. Algorithm Child Injury Evaluation • Inconsistencies in the given history ConsIder Abuse Bruise withRecognizable Shape Multiple Injuries of Differing Ages Non-Walking Child Child Reports Abuse No Trauma History Inconsistencies in the Given History Minor Trauma withSevere Injuries Injury Complicated By Delay

30. Inconsistency • Internal Inconsistency • History changes with repetition • distinguish from changing medical history taking or documentation • Inter-historian Inconsistency • Different history from different informants • distinguish from different perspectives or “telephone” errors

31. Inconsistency • Developmental Inconsistency • Child is reported to do something age inappropriate • Inconsistent cause • Epidemiologically unlikely • Biomechanically unlikely

32. Common fractures Clavicle Skull Others uncommon Fall Injuries • Uncommon head • Epidural • Small subdural • Death rare

33. Visceral Injury Very rare Fall Injuries • General rules • Exceptions exist • Probabilistic • Not deterministic

34. Algorithm Child Injury Evaluation • Severe injuries explained by minor trauma ConsIder Abuse Bruise withRecognizable Shape Multiple Injuries of Differing Ages Non-Walking Child Child Reports Abuse No Trauma History Inconsistencies in the Given History Minor Trauma withSevere Injuries Injury Complicated By Delay

35. Algorithm Child Injury Evaluation • Injury complicated by delay in seeking medical care ConsIder Abuse Bruise withRecognizable Shape Multiple Injuries of Differing Ages Non-Walking Child Child Reports Abuse No Trauma History Inconsistencies in the Given History Minor Trauma withSevere Injuries Injury Complicated By Delay

36. New Fracture Healing Fracture Delay in Care-seeking

37. Scenario: Patient A • Four-month-old infant • Found this AM in crib by mom • Swollen red thigh • Doesn’t move thigh • Tenderness

38. Abuse Or Not Abuse • Injury of non-walking child • Injury with no trauma history

39. At Surgery, ruptured jejunum, peritonitis Scenario: Patient B • Two-year-old toddler • Fell from bed • Abdominal pain • Vomiting all PO • Fever, severe pain this AM • T=39o P=125 R=35 BP=75/43

40. Abuse Or Not Abuse • Injury mechanism is inadequate? • Complications from delayed care

41. Scenario: Patient C • Eight-month-old infant • Fell from bed • Unconscious • Erratic breathing • 3 minute seizure

42. Abuse Or Not Abuse • Not walking = very young age • Injury mechanism is inadequate?

43. Scenario: Patient D • Three-year-old child • Returned from father • Bruises on buttocks and posterior thighs • Walks reluctantly, stiffly

44. Abuse Or Not Abuse • Child’s history? • Doesn’t meet other promptsBUT • Lots of injury • Worrisome social setting

45. BREAK When you return:Planning an evaluation

46. Discussion: Patient A • What do you want to do next?

47. Discussion: Patient B • What do you want to do next?

48. Discussion: Patient C • What do you want to do next?

49. Discussion: Patient D • What do you want to do next?

50. Secondary Assessment • Tools • History • Physical exam • Laboratory • Imaging • Consultation • Find evidence of other trauma • Find conditions that change the response to trauma