physical abuse and sentinel injuries - home | children's ......scapular fractures epiphyseal...
TRANSCRIPT
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Physical Abuse and
Sentinel Injuries
Suzanne Haney, MD
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Presenter Disclosures
Consultant/
Speakers bureaus
No Disclosures
Research funding No Disclosures
Stock ownership Corporate boards-employment
No Disclosures
Off-label uses No Disclosures
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Objectives
1. Describe common presentations of physical abuse.
2. Define sentinel injuries.
3. Discuss recommended medical care for children
who have experienced abuse.
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Physical abuse
• Bruising (sentinel injuries)
• Broken bones
• Abusive head trauma
• Abdominal trauma
• Burns
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Bruising
• Rare
• Sentinel injuries
• Not the result of minor trauma
• TEN-4-FACES
– Torso, Ear or Neck in child <4 years
– Any bruising on infant < or equal to 4 months
– Frenulum, Angle of the jaw, Cheek, Eyelid or Sclera
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Facial Bruising
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Frenular Injury
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Scleral (subconjunctival) hemorrhage
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Fractures
• Very common accidental injuries
• More concerning
– Non-ambulatory child
– History does not match the injury
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Fracture specificity
High Moderate Low
Common metaphyseal
lesions
Multiple fractures Subperiosteal new
bone formation
Rib fractures Fractures of different
ages
Clavicular fractures
Scapular fractures Epiphyseal separations Long bone shaft
fractures
Spinous Process
Fractures
Vertebral body
fractures
Linear skull fractures
Sternal fractures Digital fractures
Complex skull fractures
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Medical Conditions
• RARE
• Osteogenesis imperfecta – Brittle bone disease
– Temporary brittle bone disease (NOT)
• Osteopenia of prematurity – Must be premature AND significantly ill
• Rickets – Vitamin D deficiency
– Classic presentation
• THESE CASES STILL NEED A COMPLETE INVESTIGATION!!!!
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Abusive Head Trauma
• Shaken baby syndrome
– Including impact
• Universal language
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Statistics
• Approximately 15-20/100,000 children annually
– More than cancer
– More than type I diabetes
• Median age is 2-6 months
– Case reports of older children
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Presentation
• Head injury
– Vomiting, decreased level of consciousness, seizures (53%)
– Death (6%)
• History that is not consistent with the injury
– No history
– Short fall
• Chadwick, death from a short fall is less than 1 in one million…
• Large head, no history
– Much more difficult to determine (22% of cases)
Minns, 2006
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History
• May be an element of crying/frustration
– Diapering, feeding, video games
– Crying curve -- Barr et al.
• Other stressors
– Unrelated male caregiver
– Recent job loss, mother returning to work
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Findings
• Intracranial hemorrhage
– Subdural
– Subarachnoid
– Cerebral contusion
• Brain injury
• Retinal hemorrhage
• Other abusive injuries
– Bruises, fractures, spine injuries
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SDH
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Tentorial/Cerebellar
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Retinal Hemorrhages
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Abdominal Trauma
• Rare, but has a high fatality rate
– Commonly missed amongst other injuries
– Delay in care
• Injuries to hollow organs more than solid
– Intestines (duodenum, jejunum, ileum)
– Liver, spleen, kidneys
• Blunt force trauma
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Burns
• 5-10% of children admitted for burns are diagnosed
with abuse
• Younger
• More severe (abuse is an independent predictor of
mortality)
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Burns - risk factors
• Pattern injury
• History inconsistent with injury or child’s
developmental ability/multiple explanations
• Sibling or pet involved
• Toileting/diapering accident
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Questions?