Child Abuse in Emergency Medicine Workup

  • Author: Lawrence R Ricci, MD; Chief Editor: Richard G Bachur, MD   more...
 
Updated: Jun 30, 2011
 

Laboratory Studies

  • Complete blood count including hematocrit may be indicated. Chronic anemia may be found in infants who are neglected and undernourished, but anemia in the setting of unexplained tachycardia or abdominal trauma may be indicative of internal hemorrhage.
  • Urinalysis
    • Hematuria may indicate kidney or urethral trauma.
    • Occult blood without red blood cells may indicate rhabdomyolysis.
  • A urine toxicology screen may be indicated in the infant with an altered level of consciousness.
  • Routine drug testing of children assessed for abuse and neglect is recommended. A study of children presenting to the University of Iowa Hospitals and Clinics with alleged maltreatment found that 15% of those screened tested positive for exposure to illicit drugs.[6]
  • Stool guaiac may be useful if a history of gastrointestinal bleeding or suspicion of occult abdominal trauma is present.
  • In any child with suspicious bruising, a coagulation profile is helpful if exclusion of bleeding diatheses is needed. Prothrombin time, activated partial thromboplastin time, and platelet count may be obtained. Other coagulation screens should be dictated by the clinical presentation and may require consultation with a hematologist.
  • Elevated liver transaminases and amylase levels may be indicative of abdominal trauma and should point to the need for abdominal CT scan with contrast as the next step.
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Imaging Studies

  • Radiographic bone survey
    • A full radiographic abuse survey (skeletal survey) is indicated in any child aged 2 years or younger with evidence or strong suspicion of physical abuse.
    • The bone survey should include at a minimum 2 views of each extremity (individual long bones are highly recommended rather than single views of the entire extremity), anteroposterior (AP) and lateral skull, AP and lateral spine, chest, abdomen, pelvis, hands, and feet. Films should be reviewed carefully for classic metaphyseal lesions and healing fractures—particularly of the posterior ribs.
    • In several studies, the incidence of occult clinically asymptomatic fractures is 15% in physically abused children younger than 2 years. An 8-month-old infant who is brought into the ED bAn 8-month-old infant who is brought into the ED by his mother with the history of having fallen from a changing table. Note the acute transverse midshaft humerus fracture. This fracture is most consistent with a snapping injury, not a fall onto a flat surface. The mother subsequently described grabbing the child's arm to lift him after the fall and hearing a snap. A 2-month-old infant presented to the ED with the A 2-month-old infant presented to the ED with the history from the father that the child had slipped in the tub the night before. Note the periosteal callus formation, indicating that the fracture is at least 1 week old and, thus, inconsistent with the history being offered.
  • A noncontrast CT scan of the head is indicated in any infant thought to have inflicted intracranial trauma, either because of the history of possible mechanism of injury, such as violent shaking, or because of suspicious CNS signs or symptoms. Head CT scan of a 15-month-old infant who allegedlHead CT scan of a 15-month-old infant who allegedly fell 5 feet from a bunk bed onto new one-half-inch thick carpet and pad over plywood at daycare. Large acute left frontoparietal subdural hematoma is present with midline shift. Surgical evacuation was required. Bilateral retinal hemorrhages were also present. This severe head injury particularly with associated retinal hemorrhages is inconsistent with a 5-foot fall and is more consistent with shaken impact baby syndrome.
  • An abdominal CT scan may be useful in the child who is unconscious or in whom abdominal trauma is suspected, particularly if bleeding is present and a source cannot be identified. Very often, a CT scan of the chest can be combined with the abdominal views to look for rib and lung injury.
  • While CT scans of the brain are useful for rapid identification of CNS injury, MRI may be more sensitive for detecting diffuse axonal injury and for detecting and dating subdural hematomas and parenchymal brain injury.
  • Three-dimensional reconstruction of CT imaging for rib and skull fractures has shown very good results in detecting these injuries. This technique involves greater exposure to radiation but may offer improved specificity in making a diagnosis of inflicted injury.
  • A radionucleotide bone scan may be useful to detect rib fractures prior to callous formation and to confirm the presence of fractures that are not well delineated on the skeletal survey.
  • Some use of the magnetic resonance imaging technique, short inversion time inversion-recovery (STIR), to survey the skeleton for fractures has been reported. This technique, developed for detection of metastatic bone lesions, may offer improved sensitivity for occult fractures, but findings must be verified by radiographic survey to ensure against false-positive findings. Little has been published on the use of this technique in the detection of traumatic injuries.
  • Photographs of all visible injuries should be taken as soon as possible. This can often be completed by law enforcement or child protective services but particularly when such photographic assistance is not available photographs should be obtained by the medical personnel caring for the child. It is particularly important to obtain photographs of burns before a dressing is applied.
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Other Tests

  • Dilated eye examination by an ophthalmologist is particularly important in the infant suspected of SBS.
  • Children with concerns about injuries to the genital area should have a skilled evaluation to look for forensic evidence of sexual abuse.
  • In cases of neglect, particularly when failure to thrive is in question, a workup for organic problems may be undertaken. Such a workup may include the following:
    • Stool sample for ova and parasites
    • Urine culture and urinalysis
    • Sweat test
    • Lead level
    • HIV testing
    • The most common cause of failure to thrive is nonorganic failure to thrive, which is often because of social and economic factors within the family. This diagnosis is best made following an extended inpatient stay, careful monitoring of the child, and a comprehensive family assessment.
    • Tuberculin skin testing
    • Some child abuse experts recommend a chest radiograph to look for occult rib fractures in a child with nonorganic failure to thrive.
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Procedures

  • Lumbar puncture
    • A spinal or subdural tap may be diagnostic of a subarachnoid hemorrhage if blood is present in the CSF.
    • Xanthochromia should be noted, particularly if the differential is between a traumatic lumbar puncture and old subarachnoid blood.
    • Careful thought should be given before performing a lumbar puncture (LP) because of the possibility of cerebellar herniation. A CT scan prior to LP may be warranted.
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Contributor Information and Disclosures
Author

Lawrence R Ricci, MD  Director of Spurwink Child Abuse Program, Assistant Professor, Department of Pediatrics, University of Vermont College of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Ann S Botash, MD  Director, Child Abuse Referral and Evaluation Program, Professor and Vice Chair for Educational Affairs, Department of Pediatrics, State University of New York Upstate Medical University

Ann S Botash, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American Pediatric Society, Helfer Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Dylan M McKenney, MD  Resident Physician, Department of Psychiatry, Maine Medical Center, Portland

Dylan M McKenney, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Kirsten A Bechtel, MD  Associate Professor, Department of Pediatrics, Yale University School of Medicine; Attending Physician, Department of Pediatric Emergency Medicine, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH  Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD  Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston

Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research

Disclosure: Nothing to disclose.

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A 4-year-old boy who was forcibly grabbed about the neck by his father. The 2 anterior chest bruises are consistent with thumbprints.
A 5-year-old girl who presented within 24 hours of being slapped on the leg. The markings are bruises and not erythema. The linear parallel lines are virtually diagnostic of a human handprint.
A 6-year-old girl who presents a few days after being disciplined on the buttocks with a wooden spoon by her mother. This pattern of bruises is of suspicious shape, number, and location.
An 8-month-old infant who is brought into the ED by his mother with the history of having fallen from a changing table. Note the acute transverse midshaft humerus fracture. This fracture is most consistent with a snapping injury, not a fall onto a flat surface. The mother subsequently described grabbing the child's arm to lift him after the fall and hearing a snap.
A 2-month-old infant presented to the ED with the history from the father that the child had slipped in the tub the night before. Note the periosteal callus formation, indicating that the fracture is at least 1 week old and, thus, inconsistent with the history being offered.
Head CT scan of a 15-month-old infant who allegedly fell 5 feet from a bunk bed onto new one-half-inch thick carpet and pad over plywood at daycare. Large acute left frontoparietal subdural hematoma is present with midline shift. Surgical evacuation was required. Bilateral retinal hemorrhages were also present. This severe head injury particularly with associated retinal hemorrhages is inconsistent with a 5-foot fall and is more consistent with shaken impact baby syndrome.
 
 
 
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