Child Abuse in Emergency Medicine Treatment & Management

• The prehospital emergency medical provider is in an ideal position to observe and document the initial appearance of the child and family in their home environment.

  • The provider must suspect abuse, yet be objective regarding his or her suspicions. Care must be taken regarding any questions or comments to the family so that the investigation is not tainted.
  • At the same time, the prehospital provider should treat injuries according to existing treatment protocols.
• The initial statement of mechanism of injury should be carefully documented. In cases of abuse, the family may change the story and the initial history is critical.

  • This may be important for comparison if the story changes.
  • Observations and concerns should be conveyed to hospital personnel, and a detailed descriptive report should be written.
• Most importantly, the emergency medical provider must report or see that a report is made to the appropriate authorities when abuse is suspected.

The initial medical treatment of the physically abused child in the ED should proceed no differently from treatment of the accidentally injured child, except that forensic data collection and analysis are of particular and pressing importance.

• Initial assessment and treatment of the seriously physically abused child should proceed according to established guidelines, such as those contained in the Advanced Trauma Life Support Course for Physicians or in the textbook of Advanced Pediatric Life Support. Priorities include recognition of airway, breathing, and circulatory problems, instituting airway and ventilatory management, and establishing vascular access for fluid resuscitation and medication administration.
• The child who is apneic, convulsing, or comatose requires airway support. In the face of cerebral edema, fluid restriction, steroids, hyperventilation, and osmolar drugs may be of benefit.

  • A subdural anterior fontanel tap may be indicated for diagnostic and therapeutic purposes.
  • Seizures, if present, should be treated according to standard guidelines.
• Intracranial lesions requiring surgical treatment are not common in the abused child with head injury. Such treatment should be guided by the results of a clinical examination, CT scan, and consultation with a pediatric neurosurgeon.
• Cervical spine injuries, though uncommon in child abuse, still require consideration, particularly in the child who is unresponsive or has a serious head injury.
• Blunt abdominal trauma from child abuse should be identified quickly and treated aggressively because of its attendant high mortality.
• Photographs should be taken of all visible cutaneous injuries before treatment. A detailed report, preferably typed and including appropriate drawings, should be prepared as soon as possible. Remember that such documentation does not necessarily require offering an opinion whether child abuse has occurred.
• Establishing an institutional protocol for the treatment of abuse cases is helpful. Such a protocol should state the following:

  • The diagnostic and therapeutic steps that are to be taken
  • Who should be consulted, such as institutional social services or a child abuse team
  • How to notify state child protective service agencies
• The infant who is brought to the hospital dead or who dies shortly after admission presents a particular diagnostic and therapeutic dilemma.

  • In this situation, the central differential diagnosis is often between sudden infant death syndrome (SIDS) and child abuse.
  • Depending on state or regional protocols, the medical examiner should be called immediately for decisions about further testing and disposition of the body.
  • Families in such circumstances should be managed supportively while appropriate investigative information is gathered.
  • Such a process often involves expeditious consultation with child protective services and law enforcement.
  • Although discussing the possible differential diagnosis (eg, SIDS) with the family may be appropriate, it is equally important to remember that SIDS is a diagnosis of exclusion requiring a complete autopsy and death scene investigation.
  • On the other hand, little is gained from an accusatory inconsiderate approach to families.

The ED, where many physical abuse cases first present, has the advantage of immediate social service consultation and multidisciplinary collaboration.

• The medical care of the seriously injured abused child should be team based and include a physician experienced in the treatment of pediatric emergencies, a surgeon experienced in managing childhood trauma, and a clinician experienced in the management of the abused child. The team may require the services of specialists in pediatric radiology, neurology, neurosurgery, and ophthalmology.
• Subspecialty child abuse consultation can be beneficial. Specialists such as child abuse pediatricians, available in many areas of the country, are able to assist the practitioner by establishing or corroborating a medicolegal diagnosis and by testifying in court as needed. A listing of such pediatricians is maintained by the Ray Helfer Society.
• Practitioners who suspect that a child has been or will be abused must immediately make a report to the appropriate mandatory reporting state agency.

  • Reporting should be completed before a child is discharged from the hospital, and, in some states, it is mandated to occur within a certain number of hours after the suspicion is made.
  • Usually, it is appropriate to notify parents when a report to child protective authorities is being made.
  • An exception to this rule can be made if such notification may cause the caregiver to flee with or without the child or otherwise cause harm to the child or significant disruption.
• Practitioners suspecting that a crime has been committed should make an expeditious report to the appropriate law enforcement agency. Indeed, some states require such a report.
• Nurses play critical roles as team members in identifying and treating the physically abused child. As mandated reporters, they are also responsible for reporting their suspicions.

  • Nursing history should be carefully documented and include direct quotes of questions and answers.
  • Such nursing history can be compared later to other histories for inconsistencies.