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Child Abuse Jeff Erdner D.O.

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Child Abuse Jeff Erdner D.O. Management Diagnosing child abuse is a team approach Released to a safe place Duty to report A person having cause to believe that a ... – PowerPoint PPT presentation

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Title: Child Abuse Jeff Erdner D.O.


1
Child Abuse Jeff Erdner D.O.
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Case 1
  • 17 month old boy brought by mom for evaluation.
  • Mom states boy has 2 bruises to head from running
    into the table and the wall. just want to make
    sure hes ok

4
Case 1
  • PMH none
  • Exam healthy smiling baby
  • Vital signs normal
  • 2cm x 1cm purple bruise (linear) above left eye
  • 2cm x 2cm yellow bruise on right forehead
  • 1cm x .5cm abrasion to right groin
  • Otherwise exam normal

5
Case 1
  • Child abuse?
  • Does the injury fit the story?
  • Does the injury fit the age?

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Child Abuse
  • Definition
  • Mental or emotional injury affecting growth,
    development, or psychological function
  • Causing or permitting the child to be in a
    situation in which the child sustains injury or
    increases the risk for injury
  • Failure to make a reasonable effort to prevent
    harm
  • Harmful sexual conduct
  • Failure to prevent harmful sexual conduct
  • Encouraging the child to engage in such conduct

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Child abuse
  • Definition
  • Placing a child or failing to remove a child from
    a harmful environment
  • Failure to seek appropriate care
  • Failure to provide appropriate care
  • Failure to arrange appropriate care when
    returning home

9
Child Abuse
  • 1998 National Institute of Child Abuse
  • 3 million referrals
  • 1/3 substantiated
  • 53 neglect
  • 23 physical
  • 12 sexual
  • 1100 deaths (1.6/100,000)

10
Child Abuse
  • Victimization rates are highest in the 0-3 yrs
    age group
  • African American -gt American Indian -gt Hispanic
    -gt Caucasians -gt Pacific Islanders
  • Overall perpetrators are female
  • Sexual and physical tend to be male

11
Child Abuse
  • Risk Factors
  • Prematurity
  • Chronic illness
  • Mental retardation
  • Difficult temperament

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Child Abuse
  • Characteristics of abusers
  • Young parents
  • Abuse of the caretaker as a child
  • Previous removal of a child by CPS
  • Substance abuse
  • Mental illness
  • Lack of family support
  • Low socioeconomic status

13
Child Abuse
  • Stranger Danger
  • The vast majority of abuse (all types) occur by
    family, relatives, or family friends/neighbors.

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Child Abuse
  • Clues to history
  • Inconsistency with history and injury or
    developmental milestones
  • Delay in seeking treatment
  • Projection of blame to a third party

15
Child Abuse
  • Key is high index of suspicion
  • Jenny et al. reported that young age of the
    child, white race, less severe symptoms, and an
    intact family were key features that led to
    missed diagnoses of abusive head trauma

16
History and Physical keys
  • Overall health of child
  • History keys
  • Bed wetting
  • Soiling pants
  • Difficulty urinating

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History and Physical keys
  • Complete physical may need to sedate
  • Particular attention to mouth (frenulum), nose,
    genitalia, rectum
  • Irritation, pain, redness, bruises, burns, tears
  • Hymen age 0-2 under estrogen influences
  • Start thick, pliable, elastic until age two, then
    becomes thin and delicate
  • Intrusion without tear

18
History and Physical keys
  • Exam must correlate with the parents story
  • Story must correlate with the childs age
  • Child must fit the developmental milestones

19
Case 2
  • 18 month girl brought in by EMS for burns to
    bilateral feet.

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Early motor milestones
  • 4 mos raises head
  • 5-6 mos rolls over
  • 8-9 mos sits alone
  • 15 mos walks alone
  • 18 mos climbs stairs
  • 22 mos throws ball overhand
  • 2-3 years pedals tricycle
  • 3 years alternates feet up stairs5 years catches
    ball bounced

21
History and Physical keys
  • Normal exam does not exclude child abuse

22
Head Trauma
  • Leading cause of non-accidental death in child
    abuse is head trauma.

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Head Trauma Shaken Baby Syndrome
  • Shaken Baby Syndrome
  • Classically describe as occurring in infants less
    than 6 months. Classic triad edema, subdural
    hematoma, retinal hemorrhages
  • AKA Shaken Impact syndrome
  • Duhaime et al 1987 J Neurosurgery concluded that
    severe head injury require impact, not just
    shaking
  • However, significant other literature states
    shaking in all that is required.

24
Head Trauma
  • Accidental vs inflicted
  • Short vertical falls less than 4 feet (regardless
    of the landing surface) usually result in minimal
    or no injury.
  • May cause small linear skull fractures (thus a
    few case reports of epidural hematomas)
  • Much more significant force is required for
    depressed, stellate, complex, bilateral, or
    basilar skull fractures

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S- Sagittal L- Lambdoidal P - Parietomastoid
(squamosal) O - Occipitomastoid C- Coronal
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Head Injury
  • Most common head trauma in abuse is subdural
    bleeds and parenchymal injury (including DIA)
  • Increased risk of cervical cord injury because of
    the large head to body ratio
  • Spinal cord contusions, subdural hematomas at the
    cervicomedullary junction

30
Retinal hemorrhages Evidence of abuse or abuse
of evidence?
  • Extraordinary force
  • Unilateral or bilateral hemorrhages are present
    in 75-95 of abusive head trauma
  • Common with birth trauma but resolve within 4
    weeks
  • Other causes of retinal hemorrhages include
    hematologic abnormalities, central nervous system
    vascular malformations, infections, high-altitude
    mountain climbing, during normal deliveries of
    newborns, and as a complication of general
    anesthesia

31
Head Injury Retinal Hemorrhages
  • Odom A et al. Prevalence of retinal hemorrhages
    in pediatric patients after in-hospital
    cardiopulmonary resuscitation a prospective
    study. 1997- Divisions of Critical Care, Le
    Bonheur Children's Medical Center, University of
    Tennessee, Memphis
  • Prospective study with 43 pediatric patients
    undergoing CPR for greater than 1 minute. Not
    included if child abuse is suspected, trauma,
    near drowning or seizures. All patients survived
    recessitation. Afterward, 2 pedi opthomologist
    examined the retina and found only one case of
    retinal hemorrhage. Conclusion- retinal
    hemorrhage is very uncommon in CPR

32
Abdominal and Thoracic Injury
  • 2nd most common cause of death from child abuse
  • Duodenal Injury common
  • Spleen, liver
  • Accidental vs Non-accidental
  • Suspect in non-walking children

33
Skeletal Manifestations
  • 80 of abusive fractures are under age 18 months
  • Clavicle most common fracture of childhood most
    common is the middle third
  • Lateral third more suspect
  • Buckethandle fractures of the metaphysis

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Skeletal Manifestations
  • Rib fractures highly suggestive
  • Multiple posterior fractures result from shaking
  • Femur fracture highly suggestive
  • Tibial fracture
  • Toddlers fracture non displaced oblique
  • Normal
  • Spiral fractures highly suggestive

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Skeletal Manifestations
  • Vertebral fractures- occur from severe
    hyperflexation
  • Facial, sternal, scapular, pelvic
  • High force
  • Highly suggestive

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Skin Marking
  • Normal Trauma
  • Extensor surfaces to arms and legs
  • Protruding bony surfaces of face
  • Protected areas
  • Inner arms
  • Throat
  • Abdomen
  • Lower back
  • Inner thighs

44
Skin Marking
  • Dating Bruises?
  • Depth, skin color, location, amount of bleeding
    in the tissue
  • Fresh red/purple -gt blue -gt brown -gt
    yellow/green
  • Cannot effectively date bruises.
  • Document location, size, shape, color

45
Skin Marking
  • Pattern injuries
  • Central clearing
  • Hand
  • Iron
  • Belt
  • Baseball bat
  • Fingers

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Oral lesions
  • Upper frenulum and upper lip from external forces
  • Frenulum under tongue internal force

51
Burns
  • Accidental- irregular, indistinct margins,
    satellite splash lesions, v-shape
  • Suspected burns
  • Stocking/glovelike
  • Bilateral
  • Uniform degree of the burn
  • Multiple burns
  • Coexistent with trauma
  • Cigar burns 8mm

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Bite Wounds
  • Animal vs human
  • Animal sharp canine teeth
  • Human uniform
  • Child vs adult
  • Canine to canine measurment 3cm adult
  • Oval vs arch
  • Suck would
  • Swab wounds- 80 have ABO blood group identifiers

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Neglect
  • Major needs of the child are not met
  • Major needs food, shelter, protection, clothing,
    health care, education, emotional support
  • Most common cause of abuse
  • Underdiagnosed and underreported

59
Neglect
  • Clues
  • Poor hygiene, inappropriate clothing, fatigue,
    medical/physical problems unattended to, failure
    to thrive
  • Risk for potential harm
  • Unattended

60
Munchausen by Proxy
  • DSM IV facticious disorder
  • Uncommon
  • Usually mother
  • Medically educated
  • Two types
  • Simulated
  • Produced
  • Poisoned
  • Scratch (look like rash)
  • Treatment

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Conditions that Mimic Child Abuse
  • Bruising
  • Mongolian spots
  • Congenital coagulopathy
  • Birth trauma
  • Accidental trauma
  • Fractures
  • Osteogenisis Imperfecta
  • Rickets
  • Scurvy
  • Syphilis
  • Copper Deficiency- Menkes kinky hair syndrome

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Cultural healing
  • Cupping- Mexican/ Eastern European
  • Coining- Southeast Asia, Vietnam
  • Spooning- China
  • Moxibustion
  • Maquas- Arabs, Jews, Russian
  • Salting
  • sunken fontanel Mexican American Communities

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Management
  • Diagnosing child abuse is a team approach
  • Released to a safe place
  • Duty to report
  • A person having cause to believe that a childs
    physical or mental health or welfare has been
    adversely affected by abuse or neglect by any
    person must immediately make a report.
  • Any state or local law agency
  • Texas department of protective and regulatory
    services

69
Documentation
  • Extremely important to document correctly
  • Use diagrams
  • Measure with a ruler
  • Document what you see, not what it implies
  • Vaginal tears consistent with abuse

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Conclusion
  • Its the EPs job to become educated about abuse
    and how to evaluate the possible abused so that
    we do not, 1) miss and abused child and 2) accuse
    innocent people of abuse
  • Correlate the age, story, milestones

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The End
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