Carolinas Case Conference - Dr. S. Lawson

Working in a pediatric ED isn't just diagnosing viruses - child abuse/neglect is more prevalent than we'd like to think:

• 2-10% of children presenting to the ED are victims of abuse or neglect
• children that are abused often have multiple healthcare visits before it is recognized

 
Providers should be mindful of sentinel injuries - injuries without a plausible explanation

• soft tissue injuries - bruising in children who cannot cruise, or in high risk areas
• remember TEN-4 - ANY bruising in a child less than 4 months, or bruising on the Trunk, Ears, and Neck in a child less than 4 years

 
Skeletal injuries are the second most common presentation of abuse - certain fractures should raise your suspicion for abuse

• rib fractures (make sure you check that CXR ordered to look for pneumonia)
• any fracture in a child that cannot walk
• long bone fractures in an infant or toddler

 
Abusive head trauma (formally known as “shaken baby syndrome”)

• This is the most common cause of death following abuse
• 30% of cases are missed initially – remember to consider it in cases of excessive fussiness or altered mental status

 
Chest and abdominal injuries

• the abdomen can hide injuries and hold a lot of blood
• elevated liver enzymes or lipase should raise your concern for occult intra-abdominal injury

 
What can you do to help prevent a missed diagnosis of abuse?

• Perform a “top-toe” exam on every patient and examine their skin for bruising (this means everyone should be in a gown)
• Make sure the explanation of the injury makes sense developmentally – “those who don’t cruise rarely bruise”
• If you’re concerned about possible abuse, initiate a screening work up or admit the child to a service that can complete an abuse evaluation
• Remember that you are a mandated reporter – involve Social Work early, even if you plan to refer the child to another hospital for evaluation.