Non-accidental trauma Kelly Gettig, RN, MSN, CPNP-PC/ACTCH Advanced Practice Provider ConferenceFebruary 7, 2014

Objectives

• Increase awareness of the prevalence and signs and symptoms of NAT in children.

• Review epidemiology and clinical manifestations of NAT.

• Discuss the importance of non-biased screening for NAT using an objective algorithm.

• Review radiologic findings in skeletal injuries and abusive head trauma.

• Review multiple case scenarios of abuse with a focus on abusive head trauma.

• Illustrate the importance of a high index of suspicion for AHT with non-specific presenting symptoms.

EPIDEMIOLOGY

• 1 million cases substantiated annually• 7% children experience physical abuse• 2500 deaths annually in US• Texas leads nation in child abuse deaths• 50% deaths – families with previous CPS history

• Past history of abuse – 50% chance repeat abuse; 10% chance of death

US Dept. Health & Human Services, 2007Rajaram et al, 2011Gilbert et al, 2009Clarke et al, 2011

Clinical manifestations

• Soft tissue injury – most common type of injury• Bruising, bites, burns, pattern injuries• Face, neck, ears, torso, buttocks• Intraoral trauma

Case scenario #1

• 2 yo male s/p scald burns to bilat hands• Sustained at daycare - “washing hands in the sink”• IVF, morphine x 1, hands wrapped in sterile towels• Transported to ED

CLINICAL MANIFESTATIONS

• Fractures – 2nd most common type of injury• 55% of abused children• Multiple fractures more common with abuse• Ribs, radius/ulna, tib/fib, humerus, femur, clavicle, skull • Transverse, spiral, oblique• Metaphyseal fractures

Scherl et al 2011Leventhal et al 2008Kemp et al 2008

0–11 mo 12–23 mo 24–35 mo 0–36 mo

No. of Fractures

Proportion From Abuse,

%No. of

Fractures

Proportion From Abuse,

%No. of

Fractures

Proportion From Abuse,

%No. of

Fractures

Proportion From Abuse,

%

Ribs 809 69.4 96 28.5 96 27.6 1001 61.4Radius/ulna 261 62.1 103 19.8 293 4.7 657 29.8

Tibia/fibula 493 58.0 192 16.1 384 4.7 1069 31.1

Humerus 518 43.1 545 6.8 2108 1.6 3172 9.3

Femur 1257 30.5 761 4.8 2008 2.5 4026 11.7Clavicle 227 28.1 65 16.7 95 6.0 388 20.7

Skull 3363 17.1 948 8.6 1575 3.7 5886 12.1

Incidence of Fractures Attributable to Abuse in Young Hospitalized Children: Results From Analysis of a United States Database

CORNER FRACTURE

“BUCKET HANDLE” FRACTURE

HEALING POSTERIOR RIB FRACTURES

Case scenario #2

• 3 mo male, 30 wk preemie• Admitted to PICU in resp distress• Viral illness, high flow NC oxygen, nebs• Exam shows multiple small/mild bruises, abrasions –

forehead, trunk, penis/scrotum• Linear pattern bruise to abdomen• Hematologic and metabolic workups started

RED FLAGS

• Injury inconsistent with mechanism• Vague/varying history, delay in care• Developmentally incompatible history

• Epidemiological factors cannot guide decision making

CASE SCENARIO #3

• 5 wk old male brought in for URI symptoms-Flu A+ • RN noted bruising to abdomen

NAT work-up completedSkeletal Survey:

2 right parietal skull fxsBilateral distal tibial metaphyseal fxL proximal tibia metaphyseal fx2 additional lucencies on tibias bilaterallyRight fibula lucency

CT head: negCT abdomen: bilat posterior 6th/7th rib fxs

NAT ALGORITHM

• Pre-ambulatory infants and/or <12 mos. with skeletal fracture or other concern for abuse:• Thorough history• Head to toe physical assessment• Skeletal survey• UA, ALT/AST• Social work consult

NAT ALGORITHM

• Head CT• Neuro deficits or evidence of trauma above the clavicle• Infants <6 months

• Abdominal CT with contrast for:• Abnormal abdominal exam• UA with >10 RBCs per HPF• AST/ALT >200mg/dl

NAT ALGORITHM

• Further workup based on findings:• Child abuse team consultation• PT/PTT, platelet function assay• Ophthalmology consult • Urine toxicology• MRI brain

CASE SCENARIO #4• 4 mo infant presents with scalp swelling following a fall

off the changing table onto tile a few hours ago. She is alert and neuro intact and tolerating PO well.

• CT head - left parietal non-displaced linear skull fracture with no underlying hemorrhage.

• H & P – unremarkable• Skeletal survey – otherwise negative• UA – negative for blood• ALT/AST – normal• SW consult – no concerns• Neurosurgery consult – follow up in clinic in 2 weeks

CASE SCENARIO #5

• 9 month female presents to ED with mother• Cc: right leg swelling & pain s/p fall from bed• Displaced femur fx identified• NAT protocol followed• Skeletal survey: multiple metaphyseal fxs • Chest CT: right scapula fx & 6th rib fx• Discharged with foster family

Abusive head trauma

Most common cause of traumatic death in infancy Most common cause of neurotrauma <2 yrs 29.7 in 100,000 children < 1 yr For every identified case, 152 go undiagnosed 5.6% of parents of 6 mo. olds report shaking

Keenan et al (2003)Theordore et al (2005)Reijneveld et al (2004)

Abusive head trauma

13-35% victims die Survivors

› >60% significant neuro impairment› Considerably worse outcomes than non-inflicted

Parks et al (2011)Sieswerda-Hoogendoorn et al (2011)

Risk factors

• Prematurity• Physical/mental disability• Male• Age 2-6 months • Young parents, lower SE status• Unstable family situation, military service• Substance abuse, mental disorders• Unreasonable developmental expectations

Perpetrators

#1 - Father #2 - Mother’s boyfriend #3 - Female babysitter #4 – Mother

Herman et al (2011)

Pathophysiology

• Rotation-acceleration forces• Tearing of bridging veins across subdural spaces• Bleeding and subdural hematoma (SDH)• Diffuse brain dysfunction • Cerebral edema, hypoxic-ischemic injury• Retinal hemorrhages

Clinical presentation

History of minor trauma or no trauma No trauma – 92% PPV

Neurological impairment Altered LOC (77%) Seizures (43-50%) Vomiting (15%)

Hettler et al (2003)Sieswerda-Hoogendoorn et al (2011)

Presentation

• Apnea - critical distinguishing factor 93% PPV Respiratory insufficiency complicated by delayed

care Repeated trauma to respiratory centers

• Out of hospital CPR• Hypoxic-ischemic brain injury

Sieswerda-Hoogendoorn et al (2011)Kemp et al (2011)

Abusive head trauma

• AHT should be considered in ALL children presenting with neurotrauma*

Case scenario #6

• 4 yo female presents to ED with Cc: vomiting. No diarrhea or fever.

• Petechiae noted around eyes. • Dx with UTI and sent home. • 48 hrs later, found unresponsive by caregiver. • EMS to scene - GCS 4, posturing, blown right pupil• Extensive abdominal bruising; facial and extremity

bruising.• 100% BVM, spine immobilized, transported to ED

Case scenario #6

• CT head with diffuse edema, loss of gray-white differentiation, SDH, and extensive herniation. CT abd/pelvis with mesenteric hematoma.

• To OR for evacuation and hemicraniectomy, ventriculostomy, ICP monitor; exploratory laparotomy.

Case scenario #7

• 5 month old male - fall off bed 3-4 ft. onto hard floor• No LOC, but fussy, vomited• Brought to ED by parents later in day• Presented alert but very quickly deteriorated• Minor bruising to left cheek/FH

Case scenario #8

• EMS to scene of 2 month old who “fell off the couch” at babysitter’s.

• Found cyanotic and responsive only to pain• Hematoma to temporal-parietal area• 100% BVM with color improved• C-collar applied• Posturing en route, right pupil dilated, deviated gaze• IO placed, valium given

Case scenario #8

• Arrived in the ED; intubated and to CT scanner• Left parietal skull fracture, SDH with herniation• 3% NaCl, phenobarb, PRBCs• To OR for decompressive craniectomy, ICP monitor• ICPs 50s despite maximum medical management• Parents decide to withdraw care on HD# 7

Case scenario #9

• 4 mo infant “found down” at apartment by maternal boyfriend

• Pulseless, apneic/cyanotic, unresponsive• CPR by EMS with return of pulse after 5th dose epi

Case scenario #8

• ED - Intubated, epi & milrinone gtts• Pupils fixed and dilated, no cough, no gag• Mother requested withdrawal of care• NAT workup revealed• Extensive cerebral edema• Left lateral 6th, right lateral 4th & 5th & 7th rib fxs in

various stages of healing• Numerous acute and healing retinal hemorrhages

Case scenario #10

• 19 mo reported to be seizing at home• Transported via EMS with posturing en route• Pupils unequal (left pupil “extremely dilated”)• Intubated on arrival to ED• Loaded with fosphenytoin, 3%NaCl bolus• Physical exam • U shaped bruise/bite mark noted to back• Abrasion to forehead

• To CT scanner

Case scenario #10

• Left SDH with midline shift, early herniation• To OR for craniotomy, evacuation, ICP monitor• TBI protocol with encouraging neuro exam and well

controlled ICPs• 9 day hospital stay • Right hemiparesis, outpatient therapies• Home with aunt

The TRIAD

• Bilateral thin-film SDH• Retinal hemorrhages• Encephalopathy

Abusive head trauma

• High index of suspicion:• Vomiting• Change in mental status• Seizures• Apnea, resp distress/arrest

References

Higginbotham, H, Lawson, KA, Gettig, K. Utility of a child abuse screening guideline in an urban pediatric emergency department. J Trauma Acute Care Surg 2013;00:00-00.

Herman, BE, Makoroff, KL & Croneli, HM. Abusive head trauma. Pediatric Emergency Care. 2011;27:1, 65-69.

Keenan, HT, Runyan, DK, Marshall, SW. A population-based study of inflicted head injury in young children. JAMA. 2003; 290:621-626.

Kemp, AM. Abusive head trauma: recognition and the essential investigation. Arch Dis Child Educ Pract Ed. 2011; 96, 202-208.

Kemp, AM, Jaspan, T, Griffiths, J, Stoodley, N, Mann, MK, Tempest, V & Maguire, SA. Neuroimaging: what neuroradiological features distinguish abusive from non-abusive head trauma? A systematic review. Group.bmj.com, 2011.

Parks, SE, Kegler, SR, Annest, JL, Mercy, JA. Characteristics of fatal abusive head trauma among children in the USA: 2003-2007: an application of the CDC operational case definition to national vital statistics data. Injuryprev.bmj.com, 2011.

Kemp, AM, Dunstan, F. et al. Patterns of skeletal fractures in child abuse: systematic review. BMJ, 2008; 337.

References

Reijneveld, SA, van der Wal, MF, Brugman, E. Infant crying and abuse. Lancet, 2004; 364:1340-1342.

Sieswerda-Hoogendoorna, T, Boos, S, Spivack, B, Bilo, RAC & van Rijn, RR. Abusive head trauma part II: radiological aspects. Eur J Pediatrics, 2011.

Sieswerda-Hoogendoorna, T, Boos, S, Spivack, B, Bilo, RAC & van Rijn, RR. Abusive head trauma part I: clinical aspects. Eur J Pediatrics, 2011.

Squier, W. The “Shaken Baby” syndrome: pathology and mechanisms. Acta Neuropathologica, 2011.

Theordore, AD, Chang, JJ, Runyan, DK, et al. Epidemiologic features of the physical and sexual maltreatment of children in the Carolinas. Pediatrics, 2005; 115:e331-e337.

Leventhal, JM, Martin, KD, Mphil, AG, Asnes, MD. Incidence of fractures attributable to abuse in young hospitalized children: results from analysis of a US database. Pediatrics, 2008; 122:3.

References

• Harris, TS. Bruises in children: normal or child abuse? Journal of pediatric health care. 2009, 24:4, 216-220.

• Scherl, SA, Endom, EE, Phillips, W & Lindberg, DM. Orthopedic aspects of child abuse. Retrieved 12/1/2011 from www.uptodate.com.

• Lane, WG, Rubin, DM, Ragin, M & Christian, CW. Racial differences in the evaluation of pediatric fractures for physical abuse. JAMA. 2002, 288:13, 1603-1609.

• Clarke, NMP, Shelton, F, Taylor, CC, Khan, T & Needhirajan, S. The incidence of fractures in children under the age of 24 months – In relation to non-accidental injury. Journal of Injury. 2011.08.024.

• Rajaram, S, Batty, R, Rittey, CDC, Griffiths, PD & Connolly DJA. Neuroimaging in non-accidental head injury in children: an important element of assessment. Postgrad Med J. 2011, 87:355-361.

• Lindberg, DM, et al. Utility of Hepatic Transaminases in Children With Concern for Abuse. Pediatrics. 2013, 131:2, 268-275.