e1 26 Holmes JF, Brant WE, Bond WF, et al Emergency department ultra sonography in the evaluation of hypotensive and normotensive chil dren with blunt abdominal trauma J Pediatr Surg 2001;36 968 973 2[.]
e1 References Bleyer A The major causes of death in children N Engl J Med 2019;380(14):1383-1384 Wegner S, Colletti JE, Van Wie D Pediatric blunt abdominal trauma Pediatr Clin North Am 2006;53:243-256 Dokucu AI, Otcu S, Ozturk H, et al Characteristics of penetrating abdominal firearm injuries in children Eur J Pediatr Surg 2000;10: 242-247 Chiu WC, Shanmuganathan K, Mirvis SE, et al Determining the need for laparotomy in penetrating torso trauma: a prospective study using triple-contrast enhanced abdominopelvic computed tomography J Trauma 2001;51:860-868 Hayes JR, Groner JI The increasing incidence of snowboard-related trauma J Pediatr Surg 2008;43:928-930 McCrone AB, Lillis K, Shaha SH Snowboarding-related abdominal trauma in children Pediatr Emerg Care 2012;28:251-253 Williams BG, Hlaing T, Aaland MO Ten-year retrospective study of delayed diagnosis of injury in pediatric trauma patients at a level II trauma center Pediatr Emerg Care 2009;25:489-493 Coppola CP, Leininger BE, Rasmussen TE, Smith DL Children treated at an expeditionary military hospital in Iraq Arch Pediatr Adolesc Med 2006;160:972-976 Leininger BE, Rasmussen TE, Smith DL, et al Experience with wound VAC and delayed primary closure of contaminated soft tissue injuries in Iraq J Trauma 2006;61:1207-1211 10 Committee on Trauma Advanced Trauma Life Support 10th ed Chicago: American College of Surgeons; 2018 11 Arbra CA, Vogel AM, Zhang J, et al Acute procedural interventions after pediatric blunt abdominal trauma: a prospective multicenter evaluation J Trauma Acute Care Surg 2017;83(4):597-602 12 Tyroch AH, McGuire EL, McLean SF, et al The association between Chance fractures and intra-abdominal injuries revisited: a multicenter review Am Surg 2005;71:434-438 13 Vogel AM, Zhang J, Mauldin PD, et al Variability in the evaluation of pediatric blunt abdominal trauma Pediatr Surg Int 2019;35(4):479-485 14 Capraro AJ, Mooney D, Waltzman ML The use of routine laboratory studies as screening tools in pediatric abdominal trauma Pediatr Emerg Care 2006;22(7):480-484 15 Keller MS, Coln CE, Trimble JA, et al The utility of routine trauma laboratories in pediatric trauma resuscitations Am J Surg 2004; 188(6):671-678 16 Thorp AW, Young TP, Brown L Test characteristics of urinalysis to predict urologic injury in children West J Emerg Med 2011;12(2):168-172 17 Buckley J The diagnosis, management, and outcomes of pediatric renal injuries Urol Clin North Am 2006;33(1):33-40 18 Killeen KL, Shanmuganathan K, Poletti PA, et al Helical computed tomography of bowel and mesenteric injuries J Trauma 2001;51:26-36 19 Christiano JG, Tummers M, Kennedy A Clinical significance of isolated intraperitoneal fluid on computed tomography in pediatric blunt abdominal trauma J Pediatr Surg 2009;44:1242-1248 20 Moore EE, Cogbill TH, Malangoni MA, et al Organ injury scaling, II: pancreas, duodenum, small bowel, colon, and rectum J Trauma 1990;30:1427-1429 21 Moore EE, Shackford SR, Pachter HL, et al Organ injury scaling: spleen, liver, and kidney J Trauma 1989;29:1664-1666 22 Hynick NH, Brennan M, Schmit P, et al Identification of blunt abdominal injuries in children J Trauma Acute Care Surg 2013;76:95-100 23 Petrosoniak A, Engels PT, Hamilton P, Tien HC Detection of significant bowel and mesenteric injuries in blunt abdominal trauma with 64 slice computed tomography J Trauma Acute Care Surg 2013;74:1081-1086 24 Holmes J: Identifying children at very low risk of clinically important blunt abdominal injuries Ann Emerg Med 2013;62(2):107-116.e2 25 Streck CJ, Vogel AM, Zhang J, et al Identifying children at very low risk for blunt intra-abdominal injury in whom CT of the abdomen can be avoided safely J Am Coll Surg 2017;224(4):449-458.e3 26 Holmes JF, Brant WE, Bond WF, et al Emergency department ultrasonography in the evaluation of hypotensive and normotensive children with blunt abdominal trauma J Pediatr Surg 2001;36:968-973 27 Calder BW, Vogel AM, Zhang J, et al Focused assessment with sonography for trauma in children after blunt abdominal trauma: a multi-institutional analysis J Trauma Acute Care Surg 2017;83(2): 218-224 28 Holmes JF, Kelley KM, Wootton-Gorges SL, et al Effect of abdominal ultrasound on clinical care, outcomes, and resource use among children with blunt torso trauma: a randomized clinical trial JAMA 2017;317(22):2290-2296 29 Dolich MO, McKenney MG, Varela JE, et al 2,576 ultrasounds for blunt abdominal trauma J Trauma 2001;50:108-112 30 Coley BD, Mutabagani KH, Martin LC, et al Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma J Trauma 2000;48:902-906 31 Fang JF, Chen RJ, Lin BC, et al Small bowel perforation: is urgent surgery necessary? J Trauma 1999;47:515-520 32 Meyer G, Huttl TP, Hatz RA, Schildberg FW Laparoscopic repair of traumatic diaphragmatic hernias Surg Endosc 2000;14:1010-1014 33 Gates RL, Price M, Cameron DB, et al Non-operative management of solid organ injuries in children: an American Pediatric Surgical Association outcomes and evidence based practice committee systematic review J Pediatr Surg 2019;54(8):1519-1526 34 Swendiman RA, Goldshore MA, Fenton SJ, Nance ML Defining the role of angioembolization in pediatric isolated blunt solid organ injury J Pediatr Surg 2020;55(4):688-692 35 Carlotti AP, Carvalho WB Abdominal compartment syndrome: a review Pediatr Crit Care Med 2009;10:115-120 36 Stylianos S APSA Trauma Committee Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury J Pediatr Surg 2000;35:164-169 37 Bowman SM, Sharar SR, Quan L Impact of a statewide quality improvement initiative in improving the management of pediatric splenic injuries in Washington state J Trauma 2008;64:1478-1483 38 Gauer JM, Gerber-Paulet S, Seiler C, Schweizer WP Twenty years of splenic preservation in trauma: lower early infection rate than in splenectomy World J Surg 2008;32:2730-2735 39 Naik-Mathuria BJ, Rosenfeld EH, Gosain A, et al Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis: a pediatric trauma society collaborative J Trauma Acute Care Surg 2017;83(4):589-596 40 Rosenfeld EH, Vogel AM, Jafri M, et al Management and outcomes of peripancreatic fluid collections and pseudocysts following nonoperative management of pancreatic injuries in children Pediatr Surg Int 2019;35(8):861-867 41 Peter SD, Keckler SJ, Spilde TL, et al Justification for an abbreviated protocol in the management of blunt spleen and liver injury in children J Pediatr Surg 2008;43:191-194 42 Holmes JF, Sokolove PE, Land C, Kuppermann N Identification of intra-abdominal injuries in children hospitalized following blunt torso trauma Acad Emerg Med 1999;6:799-806 43 Nance ML, Keller MS, Stafford PW Predicting hollow visceral injury in the pediatric blunt trauma patient with solid visceral injury J Pediatr Surg 2000;35:1300-1303 44 Strouse PJ, Close BJ, Marshall KW, Cywes R CT of bowel and mesenteric trauma in children Radiographics 1999;19:1237-1250 45 Kim HS, Lee DK, Kim IW, et al The role of endoscopic retrograde pancreatography in the treatment of traumatic pancreatic duct injury Gastrointest Endosc 2001;54:49-55 46 Burjonrappa S, Vinocur C, Smergel E, et al Pediatric blunt abdominal aortic trauma J Trauma 2008;65:E10-E12 47 Anderson SA, Day M, Chen MK, et al Traumatic aortic injuries in the pediatric population J Pediatr Surg 2008;43:1077-1081 48 Hamner CE, Groner JI, Caniano DA, et al Blunt intraabdominal arterial injury in pediatric trauma patients: injury distribution and markers of outcome J Pediatr Surg 2008;43:916-923 e2 Abstract: Trauma is the leading cause of morbidity and mortality in the pediatric age group An estimated 1.5 million pediatric injuries occur each year, resulting in 500,000 hospitalizations and 20,000 deaths, exceeding all other causes of death combined Abdominal injuries are a marker of severe trauma Management of pediatric trauma requires a multidisciplinary approach with emergency department physicians, critical care specialists, anesthesiologists, and surgeons working as a team to provide prompt stabilization, assessment, and treatment Performing the primary and secondary survey, ensuring a stable airway, instituting fluid resuscitation, and arriving at a decision as to the most appropriate management plan are the principal goals of the trauma team leader but must be understood as well by the critical care provider Key words: trauma, solid-organ injury, intestinal injury, child abuse, hepatic injury, splenic injury 121 Child Abuse TOM KALLAY AND CAROL BERKOWITZ PEARLS • • • Infants and children with inflicted head or other traumatic injuries often appear in emergency departments with signs and symptoms of trauma or conditions suspicious of being of medical origin While children who suffer abuse experience a wide range of injuries, the minority require critical care Early consultation is recommended so that the appropriate forensic history and a complete physical examination, including photographs, are obtained early in the course of management Evaluating and managing cases involving child maltreatment in the intensive care setting is challenging from many aspects Beyond identifying and treating life-threatening conditions, the intensivist must be aware of the many components involved in nonaccidental trauma (NAT) Although the intensivist may be involved with cases of neglect (including medical neglect), psychological abuse, and sexual abuse, this chapter will focus on child physical abuse and the importance of its recognition as a potential etiology for the injuries As a mandated reporter, the intensivist is expected to initiate a report of child abuse based on a reasonable suspicion that such abuse occurred This chapter provides a broad overview of the important components of a child abuse case The intensivist should be knowledgeable about the difference between a medical and forensic evaluation, the significance of sentinel injuries, the scope of findings as related to accidental versus abusive trauma, and the importance of a multidisciplinary approach when developing a comprehensive assessment of critically ill and injured children This chapter also reviews common abuse syndromes, provides guidance on recognizing signs or patterns of abuse, and reviews obligations for information sharing Case Example An 8-month-old male is transported by private car to the emergency department of a children’s hospital after allegedly falling feet from a bed to the floor The fall was not witnessed In the emergency department, his Glasgow Coma Scale is 8, he is moaning and responding to noxious stimuli, and his eyes are deviated to the right He has a bruise on the pinna of his right ear He is • • • • The term sentinel injuries denotes injuries that, by themselves, appeared to be minor but have been associated with subsequent more severe trauma, including death Trauma secondary to abuse typically is more severe than that from accidental injury Abusive head trauma is the leading cause of fatal head injuries in children The death of a child with suspected abusive injuries mandates notification of the coroner intubated A computed tomography (CT) scan reveals an occipital skull fracture extending into the parietal bone and a right subdural hematoma with a small midline shift A subsequent CT scan of the abdomen and chest reveals a healing posterior fracture of the left seventh rib An ophthalmologic examination reveals bilateral multilayered retinal hemorrhages Abuse vs Accident? Infants and children with inflicted head or other traumatic injuries often appear in emergency departments with signs and symptoms of trauma or conditions suspicious of being of medical origin The approach to these children involves the basic ABCs of management during which the patient is stabilized and then transferred to an inpatient setting to continue the evaluation and care The history may not disclose the true nature of the traumatic event; the evaluating physician must be knowledgeable about child development and the biomechanics of injuries to make an informed assessment that the injuries are consistent with the story The potential that injuries are secondary to inflicted trauma is always present It is also important to be aware that some injuries, such as head and abdominal trauma, may present with nonspecific symptoms, such as vomiting, lethargy, apnea, and altered mental status Physical findings—such as the presence of bruises, especially in certain areas of the body (sentinel injuries)—may provide the clue to the etiology of the symptoms There is currently a high degree of medical consensus that shaking alone can cause significant traumatic brain injury (TBI), retinal hemorrhages, and death.1 In 2009, the American Academy of Pediatrics Committee on Child Abuse and Neglect issued a 1417 1418 S E C T I O N X I I Pediatric Critical Care: Environmental Injury and Trauma statement supporting the medical use of the term abusive head trauma (AHT).2 Despite the significant amount of evidence supporting this as a diagnosis, there remains speculative theories unsupported by medical evidence designed to cast doubt on current consensus Reports in the media and legal counsels promulgate these fringe theories However, they exist only to effect the outcome of a legal case rather than contribute to the science Lindberg et al provide an excellent review examining these concepts and illustrate how they fail to provide evidence to refute the reality that shaking alone can cause significant brain damage.3 Epidemiology Statistics about child maltreatment have been gathered since 1988, when the Child Abuse Prevention and Treatment Act (CAPTA) was amended This amendment created the National Child Abuse and Data System On average, 700,000 cases of child abuse and neglect are reported annually In 2016, the number of child deaths due to abuse or neglect was 1750.4 Physical abuse accounts for about 15% of all cases of reported abuse While children who suffer abuse experience a wide range of injuries, the minority require critical care A 5-year review of 188 trauma cases of suspected NAT found that 24% required pediatric intensive care services and 48% had multiple injuries.5 Medical vs Forensic Assessment While there is often overlap between a medical and forensic assessment, the purpose of a forensic assessment is to detect the presence of injuries that not necessarily require medical intervention but whose presence helps establish inflicted trauma as the etiology While the intensivist should be aware of the recommendations about the components of a forensic assessment, it is appropriate for the intensivist to consult with child abuse experts if such individuals are available at one’s institution Early consultation is recommended so that the appropriate forensic history and a complete physical examination, including photographs, are obtained early in the course of management The physical examination should be performed with the child completely unclothed, and the skin carefully examined for evidence of bruises, burns, or scars Depending on the age of the patient, a skeletal survey is recommended even if there are no apparent fractures As noted in the opening case, rib fractures are not uncommon in physically abused infants.6 Rib fractures are commonly noted involving the posterior ribs and are often healing, indicative of prior trauma Classic metaphyseal lesions (CML) are felt to be pathognomonic for inflicted trauma Other fractures, especially earlier ones, would indicate physical abuse over a period of time Long-bone fractures are particularly suspect in premobile children Some skull fractures are also worrisome because of the nature of the skull bone in that area of the head and the biomechanics of children’s falls For instance, parietal skull fractures can be seen with simple falls in young infants, but frontal and occipital skull fractures are uncommon It is not unusual for adults to sustain an occipital skull fracture The usual scenario involves an inebriated individual missing a curb and striking the head against the edge of the sidewalk Children, particularly infants, have short necks; during a fall backwards, the occiput is protected by the upper back Occipital fractures are more indicative of a forceful impact to the skull rather than a simple fall Liver enzyme studies should be performed to assess for occult injury Levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) over 80 U/L are correlated with significant abdominal trauma that, in general, should be further evaluated with an abdominal CT scan with intravenous (IV) contrast Ultrasound has not reached a level of sensitivity in which it can replace CT for evaluation of abdominal trauma Coagulation studies are obtained to be certain that a child with bruises does not have an underlying coagulopathy Children with significant trauma may have evidence of a consumptive coagulopathy from internal bleeding Sentinel Injuries Case Example A 3-week-old male infant was seen by his primary care physician for a routine check and was noted to have a torn frenulum (lip to maxilla) The mother had no explanation but said that the infant was a fussy feeder She was advised by her pediatrician to return if feeding became difficult The mother returned to the emergency department the next day reporting that the infant had vomited blood The hemoglobin was g/dL and the infant’s heart rate was 174 beats/min The infant had a chest radiograph, which revealed six acute posterior rib fractures The term sentinel injuries was first introduced by Sheets et al to indicate injuries that, by themselves, appeared to be minor but have been associated with subsequent more severe trauma, including death.7 There are a number of mnemonics that are used to identify these injuries TEN-4 refers to bruising or injuries to the torso, ear, or neck in infants months old or younger that, if noted, should prompt concern for abuse FACES (bruising to the frenulum, auricle, cheek, eyelid, subconjunctival hemorrhage) is another such mnemonic for areas classically involved in inflicted trauma cases There is also an adage, “Those who don’t cruise rarely bruise” to denote the unlikelihood of bruises in very young infants, particularly those who are premobile.8 Facial bruising is always concerning, as are bruises to the pinna of the ear, subconjunctival hemorrhages, and intraoral lesions, such as torn frenula There are three frenula: lip to maxilla, sublingual, and lip to mandible by the two central incisors Intraoral tears may be secondary to forced feeding to quiet a fussy infant or to occlude the mouth in efforts to silence loud crying Infants with injuries to the head or torso, even if the infant appears to be well, warrant a further evaluation for occult injuries Recognition requires a high level of suspicion, a detailed history, and thorough trauma workup The intensivist must be knowledgeable about the important signs specific to NAT Though they may not present an immediate risk of death, these signs may be precursors to life-threatening inflicted trauma (Figs 121.1 to 121.4) Specific Syndromes Trauma secondary to abuse typically is more severe than that from accidental injury Deans et al performed a review of 2782 pediatric TBI patients; 315 (11%) were due to NAT In comparison with patients with TBI secondary to accidental mechanisms, patients with NAT were younger (mean, year vs years), had longer intensive care unit (ICU) stays (mean, days vs day), and had higher rates of gastrostomy tube placement (4% vs 1%; P , 0001) Similarly, in the subgroup of severe TBI, patients with AHT required gastrostomy tubes more often than those with TBI due to accidents (5% vs 2%; P 014) Factors CHAPTER 121 Child Abuse 1419 • Fig 121.1 Bruising on the pinna of the ear (Courtesy Alex Rodriguez, MD.) • Fig 121.4 Three-dimensional computed tomography scan reconstruc- tion revealing shattered occiput The history proffered was that while the caretaker was carrying the baby down a staircase, the baby slipped out of the arms and struck the edge of the stair The extent of comminution is not consistent with the history provided • Fig 121.2 Bruising on the pinna of the ear (Courtesy Alex Rodriguez, MD.) independently associated with mortality were presence of nonaccidental mechanism, higher injury scores, and younger age.9 Regarding mortality, inflicted abuse typically portends worse outcomes than accidental trauma (AT) A study performed at Children’s Medical Center in Dallas examined the differences in incidence, severity, and outcome between AT and NAT in children.10 NAT victims had a greater severity of injury and a sixfold higher mortality rate Delay in recognition occurred in nearly 20% of the cases, contributing to the worse outcome Patients requiring critical care admission typically have head injury The second most common type of critical injury in NAT is abdominal trauma While this chapter focuses on these injuries, it is important to keep in mind that abusive injuries can be wide ranging Abusive Head Trauma • Fig 121.3 Temporal bruise in a premobile infant (Courtesy Alex Rodriguez, MD.) Appreciation of the injuries that occur in AHT requires knowledge of the anatomy and development of the head and neck after birth The skull of a neonate is relatively soft and malleable to enable passage through the birth canal The relative softness of the skull and the presence of sutures allows forces applied to the skull to propagate directly into maturing brain tissue The lack of myelination and the brain’s higher water content creates a fragile environment more susceptible to damage from shearing forces, which can occur when being shaken.11 The young child’s head is approximately 15% to 20% of total body weight, as opposed to 2% to 3% in adults A relatively heavier head with a lack of nuchal muscular strength predisposes to significant injury in infants and toddlers as opposed to older children Furthermore, young children may not have the ability to control and coordinate head and body motion, which increases vulnerability, as they are not able to protect themselves ... involved with cases of neglect (including medical neglect), psychological abuse, and sexual abuse, this chapter will focus on child physical abuse and the importance of its recognition as a potential... expected to initiate a report of child abuse based on a reasonable suspicion that such abuse occurred This chapter provides a broad overview of the important components of a child abuse case The intensivist... multidisciplinary approach when developing a comprehensive assessment of critically ill and injured children This chapter also reviews common abuse syndromes, provides guidance on recognizing signs or patterns