Ep 108 Pediatric Physical Abuse Recognition and Management

This is EM Cases main episode podcast on Pediatric Physical Abuse Recognition and Management Just one case of missed pediatric physical abuse I consider a travesty. The sad state of affairs is that thousands of cases of pediatric physical abuse are missed on initial presentation to EDs across North America. And a small but significant minority of these children die. In fact, 20-30% of children who died from abuse and neglect had previously been evaluated by medical providers for abusive injuries that were not recognized as abuse. Every child that presents to the ED with a suspicious injury gives the treating physician an opportunity to intervene. We have to get better at identifying these kids when there’s still something we can do to protect them, before it’s too late. In this EM Cases main episode podcast on Pediatric Physical Abuse Recognition and Management Dr. Carmen Coombs and Dr. Alyson Holland discuss the 6 B's of child abuse, the TEN-4 FACE decision rule, the Pittsburgh Infant Brain Injury Score, disclosure tips, screening tests, reporting responsibilities and more... Podcast production by Anton Helman. Editing and sound design by Richard Hoang & Anton Helman Written Summary and blog post by Shaun Mehta & Alex Hart, edited by Anton Helman February, 2018 Cite this podcast as: Helman, A, Coombs, C, Holland, A. Pediatric Physical Abuse Recognition and Management. Emergency Medicine Cases. March, 2018. https://emergencymedicinecases.com/pediatric-physical-abuse/. Accessed [date]. Why pediatric physical abuse matters For those children who survive their physical trauma, there are both short term and long term effects. Short term effects include risk of escalating abuse with increased risk of morbidity and mortality. Long term effects include developmental delays, mental health issues, chronic disease and substance abuse according to the ACEs Study. Emergency providers' responsibility in suspected pediatric physical abuse The unfortunate truth is, if we don’t think about abuse, we’ll definitely miss it. So, the most important first step is always simply to think about it. Then our responsibility turns to reporting it, considering the differential diagnosis, investigating what is medically necessary and ensuring appropriate follow up or admission if necessary. Sentinel injuries are minor injuries with major significance Much as with sentinel bleeds of subarachnoid hemorrhages, even seemingly trivial injuries of abuse can be viewed as “sentinel events” for much worse outcomes in the future. According to Sheets et al in 2013, as many as 25% of abused infants had prior sentinel injuries. One reason we miss physical abuse in these kids is that most sentinel injuries are minor injuries such as bruises, intraoral injuries, or simple fractures and we overlook the real significance of these injuries, which is that they provide an opportunity for us to intervene before more serious injury occurs. As EM providers, recognizing and responding appropriately to sentinel injuries protects kids. Failure to do so can result in repeated abuse and subsequent morbidity and mortality. Historical Indicators of Pediatric Physical Abuse * No/vague explanation for a significant injury * Important detail of the explanation changes dramatically * Explanation given is inconsistent with the child’s physical and/or developmental capabilities * Different witnesses provide different explanations