Non Accidental Trauma 2 - PEM Pearls

PEM Pearls 03: Non Accidental Trauma pt. 2

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Welcome back to PEM Pearls: the CanadiEM Infographic Series focused on providing approaches and high-yield pearls for important pediatric EM topics! This is part 2 of our 2 part Non-Accidental Trauma posts. Today we will be discussing the workup, investigations, and management for potential non-accidental trauma cases.​1​

There are a variety of goals of care that emergency physicians should perform when managing a potential non-accidental trauma case. In short, remember to treat, record, and report. Specifically, treat the serious injuries, thoroughly document the pertinent history and exam findings, and report the case to government agencies. Lastly, emergency physicians should consider the other siblings and family members in the household, and inquire if they are safe.

Workup

It is important to be thorough when documenting a potential child abuse case, as your assessment may be used as evidence in the investigation. Make sure your note includes a developmental history, social history, and growth curve. Additionally, when documenting physical exam findings it is useful to include a body outline to precisely label the patient’s injuries. Make sure to use quotations for charting quotes, and avoid documenting specific dates and times to ensure there is no discrepancies between legal documents.

There are a variety of investigations available to identify injuries and rule out other causes of injuries. Firstly, a coagulation and metabolic panel should be ordered in all suspected child abuse cases. Furthermore, these adjunctive investigations can be ordered based on the clinical picture:

  • Toxicology/STI Screening: order if there is a clinical suspicion of an ingestion or sexual abuse
  • AST, ALT, Lipase, Urinalysis: order if there are signs of an abdominal injury, which can include abdominal pain, vomiting, or guarding
  • Neuroimaging and Pediatric Ophthalmology Referral: order if there is any clinical suspicion of a head injury. Additionally, consider neuroimaging in the presence of rib fractures, multiple fractures, or in a child aged <6 months. Above all, remember that head trauma is the leading cause of morbidity and mortality
  • Skeletal Survey: order in children aged less than 24 months with suspected non-accidental trauma. However, it is reasonable for children up to 60 months

Imaging

The role of imaging in non-accidental trauma is to identify both medically treatable and forensically significant injuries. Child abuse can result in a variety of identifiable injuries, which are discussed below:

  • Neuroimaging: CT scans are preferred over skull x rays due to improved non-accidental trauma sensitivity. Multifocal trauma and subdural hematomas are both suggestive of abuse
  • Retinal Imaging: The presence of retinal hemorrhages is strongly suggestive of abuse and a possible coinciding traumatic brain injury. However, the lack of retinal hemorrhages does not rule out a TBI
  • Skeletal Survey: Always look for classic metaphyseal lesions (bucket handle fractures), which are specific for abuse.​2​ Furthermore, pay attention for posterior rib fractures, long bone fractures in non-ambulating children, and multiple fractures in various healing stages
  • Abdominal Imaging: Consider a CT Abdomen if AST or ALT is above 80 IU/L. Ultrasound may be helpful for identifying injuries, but use cautiously as it lacks sensitivity

Management

There are a few key differences to managing abusive injuries compared to non-abusive. Firstly, abusive head trauma has a higher morbidity and mortality than non-abusive head trauma. Furthermore, it has a 30% incidence of non-convulsive seizures, so EEG monitoring should be considered. However, the management of other abusive traumatic injuries is similar to managing non-abusive injuries.

Secondly, emergency physicians must report all reasonable concerns of abuse to Child Protective Services or their country’s equivalent agency. This allows for the situation to be further investigated, and does not automatically remove the child from their home. Lastly, before discharging a child with potential abusive injuries, ensure that: the patient’s injuries are treated and stabilized, you have reported the situation to the proper agency, and the child has a safe environment to return to.

Thanks for tuning in! Keep your eye out in the future for more PEM Pearls Infographics!

References

  1. 1.
    Lindberg D. Child Abuse. In: Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Elsevier; 2017:2224-2235.
  2. 2.
    Adamsbaum C, De B, Teglas J, Rey-Salmon C. Classic Metaphyseal Lesions among Victims of Abuse. J Pediatr. 2019;209:154-159.e2. doi:10.1016/j.jpeds.2019.02.013

Expert Review

This infographic details important information on the clinical management/investigation of a child with suspected non-accidental trauma/injury in the ED. It is part 2 of a 2 in a series on NAT. The infographic provides appropriate and well organized information that is relevant and appropriate for clinicians responsible for caring for this vulnerable population. Included are important medical expert content, as well as practical documentation and bedside tips for consideration.

Dr. James S Leung
MD, FRCPC (Pediatrics, Pediatric Emergency Medicine)
Andrew Tolmie

Andrew Tolmie

Andrew is a PGY-1 at the University of Saskatchewan Emergency Medicine Program. He is also a Graphic Design Lead for the CanadiEM Infographics team. Outside of medicine, Andrew enjoys pour-over coffee, downhill skiing, and mountain biking.
Alvin Chin

Alvin Chin

Alvin is currently a PGY5 in the FRCP EM program at McMaster University. He serves as Director of Design for CanadiEM and has interests in knowledge translation and health innovation.