Friday Resident Conference: Adam A. Vukovic, MD December 19, 2014

Friday Resident
Conference
Adam A. Vukovic, MD
December 19, 2014
Case 1
11-month-old female presents through trauma
bay intubated after CPR in the field with
ROSC. Parents state that patient had severe
choking episode and became apneic and gray,
subsequently non-responsive, at which time
they called EMS. She was previously-healthy,
and was noted only to have approximately 4-5
scattered bruises on anterior chest wall and
left forearm, which parents attribute to falls
while patient has been cruising (learning to
walk). On fundoscopic examination, you find:
Case 2
Two-month-old male presents after
falling off changing table
approximately 4 hours prior to
presentation. Mother states that
boyfriend was changing dirty diaper
when incident occurred. While
boyfriend was disposing of dirty
diaper, infant reportedly rolled
himself off the changing table to the
carpeted floor below. Immediately
Case 3
16-month-old male with cognitive
and speech developmental delay
presents with scald injury. Mother
states that she was running a bath
for the patient when she stepped out
of the room to grab the phone. On
return, she found her son had
climbed over the side of the tub and
suffered scald injuries seen here:
Can these cases be related?

Case 1: choking with
cardiopulmonary arrest
Case 2: fall with left humerus
fracture
Case 3: scald injury
Non-accidental trauma
Child Abuse (Non-accidental

Trauma)
The phenomenon is complex and results from a

combination of individual, familial and societal factors.
The final common pathway for these factors is parental
behavior destructive to the process of normal growth,
development, and well-being of the child.
Wood, J. N., & Ludwig, S. (2010). Child Abuse. In G. R. Fleisher and S. Ludwig (Eds.), Textbook of
Pediatric Emergency Medicine, (pp. 1656-1700). Philadelphia: Lippincott Williams & Wilkins.
How do we define child

abuse?
Child Abuse Prevention and Treatment Act (CAPTA)
amended and reauthorized in 2003 as the Keeping
Children and Families Safe Act (Pub L No. 108-36)
defines child abuse and neglect as, at a minimum,
any recent act or failure to act:
Resulting in imminent risk of serious harm, death, serious
physical or emotional harm, sexual abuse or exploitation
Of a child (a person younger than 18, unless the child
protection law of the state in which the child resides
specifies a younger age for cases involving sexual abuse)
By a parent or caregiver (including any employee of a
residential facility or any staff person providing out-ofhome care) who is responsible for the childs welfare.
What should we keep in

mind?
Recognize that abuse not just occurs but also
occurs commonly
Include abuse in the DDx for injuries or
complaints that dont have an obvious etiology
The potential family crisis must be managed to
protect the child, yet maintain the abusive
parents motivation for help
Understand legal requirements for reporting
abuse to the proper social services or police
authority
How common is child

abuse?
All reports underrecognize true
incidence of abuse
Federal studies have
looked at incidence
Three million cases
reported annually
One million
substantiated cases
42 cases/1000
children
What are the mortality statistics

associated with child abuse?
1760 child fatalities in 2007
78% occurred in children < 3 years old

Perpetrator is most often an adult known to the
victim
Homicide is 5th leading cause of death in

children 1 4 years of age
2000 5000 deaths annually, or 5.4
deaths/100,000 children
Has increased sixfold since 1925 (CDC)
It is the 4th leading cause of death in

children 5 14 years of age
Who is at risk?
Children with prolonged neonatal
hospitalization
Children with physical disabilities
Children with developmental delay
Living situations in which nonbiological parents are present
Signs and Symptoms of

Abuse
d how we often miss the
Integument aka, The Skin

Most commonly affected organ in NAT
Specific or non-specific
As bruising moves centrally and becomes more
extensive, the likelihood of abuse rises
Bruising in young, non-ambulatory patients raises red
flags
Important considerations:
History of injury
Childs age and developmental level
Presence of other old or new injuries
Interaction between parents and child
Interaction between parents and ED staff

Lesions:
Pattern bruises
Rope burns
Bites
Burns both from contact with hot solids
or hot liquids
Traction alopecia patches of broken
hair remain
Confused with tinea, seborrhea, eczema,
and alopecia areata
A. Strangulation mark
B. Bruises at various
stages of healing
C. Linear and loopshaped marks
D. Multiple loopshaped marks
Have we established normal

bruising?
Cross-sectional study of infants and
toddlers < 36 months attending
WCCs
Objectives:
Determine frequency and location of
bruises in normal infants and toddlers
Determine link between
age/developmental stage and risk of
bruising
Sugar, N. F., Taylor, J. A., Feldman, K. W., & the Pudget Sound Pediatric Research Network. (1999).
Bruises in infants and toddlers: Those who dont cruise rarely bruise. Archives of Pediatric and

bruising?
203/973 (20.9%) had
bruising that was not
medical or NAT
Association with age
and presence of
bruising on
examination
Association with
developmental stage
and presence of
bruising on
examination

bruising?
Where do we find
normal bruises?
93% of all bruises
identified in study
were over bony
prominences
Mean bruises per

injured child
1.3 in pre-cruisers
(range, 1-2)
2.4 in walkers (range,
1-11)

bruising?
Take home point???
ruising is rare before 9 months of age

ruising tends to be associated with developmental stage in addition to a
here are normal and abnormal sites of bruising
Have we established abnormal

bruising?
Systematic review of all-language literature
between 1954 and 2004 in which there are
defined patterns of bruising in abused or nonabused children < 18 y.o.
6984 1354 161 23 papers included in study
7 described non-abusive bruising
14 described abusive bruising
2 described both
Objective:
To investigate which patterns of bruising are
diagnostic or suggestive of child abuse
Maguire, S., Mann, M. K., Sibert, J., & Kemp, A. (2005). Are there patterns of bruising in childhood
which are diagnostic or suggestive of abuse? A systematic review. Archives of Disease in Childhood,

bruising?
Bruising is the commonest presentation
of abuse
Any part of body is a potential site of
abuse
Where do we find bruising?
Away from bony prominences
Head and neck (particularly face)*

Buttock
Trunk
Arms

bruising?
Large and often multiple

Occur in clusters
Associated with other injuries
Imprint bruising

bruising?
Mean number from 5.7 to 10
Larger than controls
White > Black
Presence of bruise
Open hand or paddle
Black > White

Cord or belt

bruising?
Level of evidence in abused children
poorer
Addressed issues other than bruising
Specific areas
Fatal cases
Narrow age groups
Retrospective analyses on existing
records
Definitions varied

bruising?
Kemp, A. M., Maguire, S. A., Nuttall, D., Collins, P., Dunstan, F. (2013). Bruising in children who are
assessed for suspected physical abuse. Archives of Disease in Children, 0, 1-6.

bruising?
Take home point???

There are few bruising patterns that reach diagnostic
significance
Exceptions: implement pattern, multiple bruises in similar
shape
Some patterns and locations are suggestive of potential abuse
and warrant
further exploration
All bruising must be interpreted in context
Are isolated bruises

isolated?
Secondary analysis of data from the ExSTRA
Research Network
58% of patients < 6 mo with bruises were
evaluated for isolated bruising
Half of these patients had additional injuries
identified by diagnostic testing
70% of patients underwent diagnostic testing
for bleeding disorders
Increased odds of testing with > 2 bruises (OR 6,
95% CI 2.5 14)
No bleeding disorders were identified
rper, N. S., et al. (2014). The Journal of Pediatrics
Are isolated bruises

isolated?
Skeletal Injuries
Consider the mobility and strength of the child
with suspicious injuries
Injury types:
Simple transverse fractures
Impacted fractures
Spiral fractures
Metaphyseal fractures (metaphyseal chip fractures*)
Hypothesized that the periosteum is most tightly adhered
at the metaphysis
This can cause small bone fragments to avulse
Subperiosteal hematomas
Skeletal Injuries
Injury location:
Femur and/or ribs*,
suspicion of abuse
should increase
Vertebrae, sternum,
pelvis, or scapulae
Case series by Anderson
femur fractures < 2
y.o. , 19/24 were
confirmed abuse
Ribs tend to be
posterior ? AP
compression of ribs
Injury dating:
Based on callus and
remodeling
8-10 days for callus
formation in typical long
bone Fx
Lots of confounding
variables, not an exact
science
Differently-aged Fxs is
concerning for abuse
Flat bones not dated
the same way
A. Multiple skull fractures

in an infant
B. Left humerus fracture
and multiple old healing
rib fractures
C. Left femur fracture and
metaphyseal chip
avulsion fracture of the
right distal femur
D. Healing fracture of the
right femur with callus
formation and new
periosteal bone
formation
E. Bucket-handle
deformity of healing
distal tibial epiphyseal
fracture
How are we at recognizing nonaccidental fractures?

Retrospective review of children < 3 y.o. who
were diagnosed with non-accidental fracture
and previously-seen by a practitioner
Objective:
To determine how frequently abusive fractures
were missed by physicians during previous
examinations
Determine clinical predictors associated with
underrecognized abuse
Ravichandiran, N., Schuh, S., Bejuk, M., Al-Harthy, N., Shouldice, M., Au, H., & Boutis, K (2010).
Delayed identification of pediatric abuse-related fractures. Pediatrics, 125(60), 60-66.

Repeat injury occurs in 35% of all abuse cases
~17% in this study
5-10% of patients will die from abuse-related

injuries
We underestimate the possibility of abuse
One study noted 31/100 children < 3 y.o. with long
bone fxs had indicators of abuse, yet only 1 was
referred to CPS
One study noted that in children < 1 y.o. who were
later diagnosed with abuse, the possibility was
underestimated by ~28%

50% of cases reported to Child Abuse
practitioners were found to be NAT
~ 20% of abusive cases had at least
one previous physician visit at which
the abuse was missed
Median time to correct diagnosis:
8 days (range, 1 160)

What is an abusive
fracture?
Confession/witness
Inconsistent/inadequate
story
Inappropriate delay
Additional unexplained
injuries
Presence of fractures that
are atypical in the accidental
setting (metaphyseal fxs,
posterior rib fxs)
Take home point???

Detailed review of mechanism
Screen for other risk factors for abuse

Non-ambulatory patients are at highest risk
Consult CPS/SW/Child Abuse Team if unsure
CNS Injuries
Main cause of child abuse death
Direct trauma
Shaking injuries
Often receive a story of a fall from

height (bed or changing table)
Studies suggest skull fx in < 1-2% of
cases
More severe findings and < 8-10 ft fall
suspect abuse
CNS Injuries
Shaking injuries
CNS damage without external signs of
trauma
Whiplash injuries:
Large Head
Weak muscles
Injuries can be produced by shear and

contusive forces
Presentation:
Sepsis, Coma and Seizure
CNS Injuries
How are we at recognizing

abusive head trauma?
Retrospective chart review of 173
cases of abusive head trauma in
patients < 3 y.o. presenting between
Jan 1990 and Dec 1995
Objective:
To determine how frequently AHT was
previously missed by physicians in a
group of children with head injuries and
to K.determine
factors
associated
theof
Jenny, C., Hymel,
P., Ritzen, A., Reinert,
S. E., & Hay, T.
C. (1999). Analysis ofwith
missed cases
head trauma. JAMA, 282(7), 621-629.

More child abuse deaths occur from head
injuries than any other type of injury.
Infants and children who survive AHT
often have serious neurolgic sequelae
Symptoms are often non-specific
Vomiting
Fever
Irritability
Lethargy
Jenny, C., Hymel, K. P., Ritzen, A., Reinert, S. E., & Hay, T. C. (1999). Analysis of missed cases of

54/173 (31.2%) of
abused children with
head injury had been
seen by physicians after
AHT and not diagnosed
Mean time to diagnosis:
7 days (range, 0-189)
15 (27.8%) reinjured
22 (40.7%) experienced
medical complications

More likely unrecognized
in very young white
children from intact
families
More likely unrecognized
in children without
respiratory compromise
or seizure
Suggest 4/5 deaths in the
unrecognized AHT might
have been prevented by
earlier recognition of
abuse

Take home point???

Be alert for bruises/abrasions on face/head in children with non-
specific symptoms
Consider trauma in DDx when evaluating infants and toddlers with
non-specific
symptoms
When collecting CSF in infants suspected for sepsis, evaluate for
xanthochromia
Pediatrically-trained radiologists should review imaging
Other Organ Systems to

Consider
Gastrointestinal
Injuries
Uncommon
Oral injury (dental,
frenulum)
Solid organ injuries
(liver or spleen)
Duodenum
Can be severe even
with minor external
findings
Cardiopulmonary
injuries
Genitourinary injuries
Direct trauma
Sexual abuse
Emotional abuse
Anywhere in the GU
tract can be a source
of bloody urine
Additionally, doesnt
have to be blood
Other Organ Systems to

Consider
Sensory
Eye
Periorbital ecchymosis,
corneal abrasion,
subconjunctival
hemorrhage, hyphema,
dislocated lens, retinal
hemorrhage, detached
retina
Ear
Ecchymosis,
hemotympanum,
perforated tympanic
membrane
&Nose
Wood, J. N.,
Ludwig, S. (2010). Child Abuse. In G. R. Fleisher and S. Ludwig (Eds.), Textbook of
How do we evaluate
NAT?
1. Suspect abuse
How do we evaluate
NAT?
History
Physical Exam
Does this make sense???
How do we evaluate
NAT?
Skeletal Survey
Any child younger than two
years presenting for an
injury suspicious for abuse
Limited use in children 2-5
years old
Any child with severe or
extensive fractures
Any child who has a history
of more than one fracture
A history in the child or the
family of soft or easy
broken bones
Any time there is suspicion
CT
Head PRN (esp 1 2 yrs suspect head
trauma)
Chest abdomen PRN
Essentially evaluates extensive injuries
MRI
As indicated when higher sensitivity
needed in specific injury evaluation
Labs
Blood tests for easy bleeding/bruising
CBC
PT/PTT/INR
von Willebrands panel
Clotting factors
Screening tests for abdominal trauma

AST/ALT
Amylase/Lipase
Toxicology screens
A comment on labs.
CBC/Coags
Often done in cases of bruising
But wait, we know that this is not high yield
Oftentimes takes it off the table during litigation
What about other clotting studies?

Not unless truly concerned by history
Doesnt have to happen in ED
Tox?
Shan says YES. Berkley says um, sure?
Honest answer is: in this setting, child is at high risk
for lots of things, and screening for potential drug
exposure is not harmful to the patient and is potential
helpful moving forward
A comment on labs
AST/ALT
Generally for occult trauma (i.e., its not
clear theres been intra-abdominal trauma)
Typically think 0-5 (when examination is
unreliable) and FOR sure in those 0-2 years
If either is > 80, they need scanned
This is lower than accidental trauma
thresholds
Why?
ROC curves suggest this optimizes Sen/Spe
Yield of Skeletal Survey

by Age
Retrospectively planned secondary analysis of
the ExSTRA Research Network Database
Patients < 5 yo included
57% of included patients had multiple fractures
identified on skeletal survey
36 mos appeared to be practice for stopping
transitioning away from skeletal surveys
60% versus < 35%
Skeletal surveys in older kids more often

positive
Likely represents suspicion for fractures
ndberg, et al. (2013). The Journal of Pediatrics
How do we evaluate
NAT?
Put the picture together
Social Work consult
Consultation with specialists in Child
Abuse (Mayerson Center)
Ophthalmology Consult
Notify patient and family
Respond to familys reaction
Determine a disposition
What is the victims

disposition?
Report all cases of suspected abuse
(including neglect) to Child Protective
Services
Consider hospitalization, especially
under certain circumstances (burns,
ingestion, head injury)
Consider evaluation the siblings
Those less than 2 years of age will also
require a skeletal survey
Do I need to report this?

33 of Ohios 88 counties use
Differential Response
What you need to know:
You are mandated to report:
Any child < 18 y.o. or < 21 y.o. with a
disability
If not, then you can be charged with a
misdemeanor, 4th degree, or civil crimes
Anyone can make a report: 1-855-OHCHILD
References
Harper, N. S., Feldman, K. W., Sugar, N. F., Anderst, J. D., & Lindberg, D. M.
(2014). Additional injuries in young infants with concern for abuse and
apparently isolated bruises. The Journal of Pediatrics, 165(2), 383-388.
Jenny, C., Hymel, K. P., Ritzen, A., Reinert, S. E., & Hay, T. C. (1999).
Analysis of missed cases of head trauma. JAMA, 282(7), 621-629.
Kemp, A. M., Maguire, S. A., Nuttall, D., Collins, P., Dunstan, F. (2013).
Bruising in children who are assessed for suspected physical abuse.
Archives of Disease in Children, 0, 1-6.
Lindberg, D. M., Berger, R. P., Reynolds, M. S., Alwan, R. M., & Harper, N. S.
(2014). Yield of skeletal survey by age in children referred to abuse
specialists. The Journal of Pediatrics, 164(6), 1268-1273.
Maguire, S., Mann, M. K., Sibert, J., & Kemp, A. (2005). Are there patterns of
bruising in childhood which are diagnostic or suggestive of abuse? A
systematic review. Archives of Disease in Childhood, 90, 182-186.
Ravichandiran, N., Schuh, S., Bejuk, M., Al-Harthy, N., Shouldice, M., Au, H.,
& Boutis, K (2010). Delayed identification of pediatric abuse-related
fractures. Pediatrics, 125(60), 60-66.
Sugar, N. F., Taylor, J. A., Feldman, K. W., & the Pudget Sound Pediatric
Research Network. (1999). Bruises in infants and toddlers: Those who dont
cruise rarely bruise. Archives of Pediatric and Adolescent Medicine, 153,
399-403.

Friday Resident Conference: Adam A. Vukovic, MD December 19, 2014

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Friday Resident

Can these cases be related?

Child Abuse (Non-accidental

The phenomenon is complex and results from a

How do we define child

What should we keep in

How common is child

What are the mortality statistics

1760 child fatalities in 2007

78% occurred in children < 3 years old

Homicide is 5th leading cause of death in

It is the 4th leading cause of death in

Signs and Symptoms of

d how we often miss the

Integument aka, The Skin

Integument aka, The Skin

Integument aka, The Skin

Integument aka, The Skin

Have we established normal

Have we established normal

Have we established normal

Mean bruises per

Have we established normal

Take home point???

ruising is rare before 9 months of age

Have we established abnormal

Have we established abnormal

Head and neck (particularly face)*

Have we established abnormal

Large and often multiple

Have we established abnormal

Black > White

Have we established abnormal

Have we established abnormal

Have we established abnormal

Take home point???

Are isolated bruises

rper, N. S., et al. (2014). The Journal of Pediatrics

Are isolated bruises

A. Multiple skull fractures

How are we at recognizing nonaccidental fractures?

How are we at recognizing nonaccidental fractures?

5-10% of patients will die from abuse-related

How are we at recognizing nonaccidental fractures?

How are we at recognizing nonaccidental fractures?

How are we at recognizing nonaccidental fractures?

How are we at recognizing nonaccidental fractures?

How are we at recognizing nonaccidental fractures?

How are we at recognizing nonaccidental fractures?

Take home point???

Screen for other risk factors for abuse

Often receive a story of a fall from

Injuries can be produced by shear and

How are we at recognizing

How are we at recognizing

How are we at recognizing

How are we at recognizing

How are we at recognizing

Take home point???

Other Organ Systems to

Other Organ Systems to

Does this make sense???