child abuse frank ferrucci, pa-c anna jacques hospital ed
TRANSCRIPT
Child Abuse
frank ferrucci, PA-C
anna Jacques Hospital ED
Introduction
Goals of this lecture
Limitations of this lecture
Photographs
Background
Types of child abuse
Child abuse rate in US: 12.3/1000 children
1/50 infants victims of nonfatal abuse
1500 children per year die of their injuries
What is most common age group to be abused??
Background
Consequences of abuse besides physical?
Demographics of abusers?
Gender differences in children who are abused?
Age?
When abuse is suspected
Child may present with abuser or other caregiver
HPI is vital
Interview should not be confrontational
Interview everyone separately (find an excuse)
Don’t forget about domestic/substance/other witnessed abuse
Suspect HPI
Poorly explained/justified injuries
Injuries not compatible with HPI
HPI not consistent
Delay in seeking treatment
Exam
General characteristics of abuse injuriesinjuries in various stages of healingmultiplanar injuriesinjuries with obvious patternassault like location of injuries
Exam
Bruising suggestive of abusebabies/infants located away from bony prominencesmultiple bruises of similar shape/sizegroupingscharacteristic pattern of bruisingwhat about old bruises?
Exam
Burnscigarette, stove, hot water immersionsuspicious burn exam findings??
Exam
Musculoskeletal InjuriesRoughly 30% of childhood injuries may be
inflicted75% of fractures in <1 y.o. inflictedAnterior/posterior rib fracturesHumeral/femoral fx <18 mosShape/location of fx less important than
location/age
Exam
Musculoskeletal Injuries continuedalways consider underlying medical reasonscommon fracture in children
clavicle, long bone, linear skull etc
Exam
Suspicious fracturesrib/scapulaspinous process/sternummultiplanar injuriesmultiple fxs of different agescomplex skull fxs
exam
Sexual abusetypical bruising patternsskin tearsSTDs
Head Injuries
Most commonly seen with abuseskull fx, subarachnoid bleed, subdural
hematoma, sheer injurieswhat about epidural hematomas?
Shaken Baby Syndrome
Definition
Exam finding typical for SBSeyesheadant/post rib fx metaphyseal long bone fxmay present in circulatory or CNS collapse
Risk Factors for Child Abuse
Socioeconomic
Parental stressors
Child
Triggers
Workup
Coagulation profile
Cbc
Skeletal bone survey
Photographs
If failure to thrivestool,urine,lead, hiv,sweat test,TB etc
ED Care
Initial treatment no different
Opthamology, trauma surgeon, SANE etc consults if necessary
Child abuse pediatricians
Ray Helfer Society (www.helfersociety.org)
Mandated reporting to state agencies, law enforcement etc PRIOR to discharge
Be sure to review nurses notes
ED Care
Severity of injuries not only factor for hospitalization
Child may have witnessed other abuse...this also should be reported to child protective services
Prevention
Multiple programs available for high risk parents/caregiversNurse-Family Partnership
(nursefamilypartnership.org)Early Start (www.ehsnrc.org)Triple P (www.triplep-america.com)
Medicolegal PitfallsProvider opinion on guilt“Reasonable Medical Certainty”
standard“Its possible...”No opinions based on feeling about
parent/caretakerLegal protectionGreater risk for missed abuseAge of bruises not reliable