Abuse

Question 1

Signs of child abuse

Answer 1

“<ul><li><h3><span><strong>6 B’s – Bruises, Breaks, Bonks, Burns, Bites, Baby blues</strong></span></h3></li><li>Injuries at different stages of healing</li><li>Multiple Injuries</li><li>Patterned Injuries</li><li>Any injury in a young infant.</li><li>Poor child hygiene</li><li>A child who appears, anxious, withdrawn or fearful of a person in the room</li></ul>”

Question 2

Bruises suspicious of abuse

Answer 2

“<div>Any bruise found in any of the following locations should trigger the possibility of pediatric physical abuse:</div><div><span><strong>T</strong></span><strong>orso</strong></div><div><span><strong>E</strong></span><strong>ars</strong></div><div><span><strong>N</strong></span><strong>eck</strong></div><div><strong>Any bruise in a child younger than</strong><span><strong>4</strong></span><strong>months old</strong></div><div><span><strong>FACES</strong></span></div><div><span><strong>F</strong></span><strong>renulum</strong></div><div><span><strong>A</strong></span><strong>ngle of Jaw</strong></div><div><span><strong>C</strong></span><strong>heek</strong></div><div><span><strong>E</strong></span><strong>yelid</strong></div><div><span><strong>S</strong></span><strong>ubconjunctival Hemorrhage</strong></div>”

Question 3

<strong>Patterned Bruises</strong>

Answer 3

<ul><li>Linear bruises to buttock (whipping, spanking, paddling)</li><li>Linear bruising to the pinna</li><li>Retinal bleeding</li><li>Hand prints or oval marks</li><li>Belt Marks – U-shaped end or associated buckle inflicted puncture wounds</li><li>Loop marks (rope, wire, electric cord)</li><li>Ligature marks, circumferential rope burns to neck, wrists, ankles and gag marks to comers of the mouth</li></ul>

Question 4

Fractures highly suspicious of abuse

Answer 4

<div>1.<strong>Any fracture in a nonambulatory infant or child</strong></div>

<div>2.<strong>Femur fracture in an infant < 12-18 months of age</strong></div>

<div>3.<strong>Humerus fractures in an infant < 18 months of age (</strong>Location: Proximal and mid shaft humeral fractures are more likely due to abuse whereas distal humerus/supracondylar fractures are less likely to be due to abuse).</div>

<div>4.<strong>Multiple fractures and/or an unexpected healing fracture</strong></div>

<div>5.<strong>Skull fractures, especially if complex or bilateral</strong></div>

<div><div><strong>6. Classical metaphyseal fractures</strong>(bucket handle fractures) from being shaken violently back and forth<strong></strong></div><div><strong>7. Rib fractures,</strong>especially posterior rib fractures (<b>highest probability for abuse)</b></div></div>

<div><b>8. Skull fractures</b> are complex, bilateral, depressed, open, presenting with suture diathesis or occipital fractures.</div>

Question 5

Mimics of child abuse

Answer 5

<ol> <li>Mongolian spots</li> <li>Hemangiomas</li> <li>Bruising due to blood dis (HSP, ITP, hemophilia)</li> <li>Osteogenesis imperfecta and rickets (multiple fractures with min force)</li> </ol>

Question 6

Skeletal survey for Abuse

Answer 6

<p><strong>Appendicular skeleton </strong></p>

<ol> <li>Arms (AP)</li> <li>Forearms (AP)</li> <li>Hands (PA)</li> <li>Thighs (AP)</li> <li>Legs (AP)</li> <li>Feet (PA or AP)</li> </ol>

<p></p>

<p><strong>Axial skeleton </strong></p>

<ol> <li>Thorax (AP and lateral), to include thoracic spine and ribs</li> <li>AP abdomen,</li> <li>lumbosacral spine, and bony pelvis</li> <li>Lumbar spine (lateral)</li> <li>Cervical spine (AP and lateral)</li> <li>Skull (frontal and lateral)</li> </ol>

Question 7

<p>Historical data that would raise suspicion for child abuse? (5)</p>

Answer 7

<ul> <li>Injury inconsistent with developmental stage or MOI <ul> <li>eg: non-ambulatory child</li> </ul> </li> <li>Discrepancy between child/caregivers stories</li> <li>Changing story over time</li> <li>Delay in presentation without reasonable explanation</li> <li>Substance abuse or intoxicated caregiver</li> <li>Lack of parental concern or appreciation of significance of injury</li> <li>History of previous trauma/repeat visits</li> <li>History of domestic violence in other family members</li> </ul>

Question 8

<p>Name two long bone fracture patterns that are highly suggestive of non-accidental trauma (NAT). What is the typical mechanism of injury for each?</p>

Answer 8

“<p>1) Metaphyseal corner or “bucket handle” fractures</p> <ul> <li>usually secondary to ‘shaking’ MOI</li> <li>femur, humerus, and tibia</li> </ul><img></img><br></br> <p>2)Two long bone fracture patterns highly suggestive of NAT?</p> <ul> <li>Spiral fractures (secondary to ‘twisting’ MOI)</li> </ul><img></img><br></br>”

Question 9

<p>Other fractures that are suggestive of NAT?</p>

Answer 9

<ul> <li>Ribs</li> <li>Sternum</li> <li>Scapula fractures</li> <li>Skull fractures</li> <li>Clavicle</li> <li>Mandible</li> <li>Vertebral</li> <li>Multiple fractures at different stages of healing</li> </ul>

Question 10

<p>Other physical signs that are specific for NAT?</p>

Answer 10

<ul> <li><strong>Bruises</strong>: <ul> <li>Anatomic location: ears, intraoral, posterior neck, anogenital, inner thigh, inner arms, back, etc</li> <li>Suspicious bruise shape: hand print, object marks</li> <li>Multiple bruises, bruises at different stages of healing</li> </ul> </li> <li><strong>Bite</strong> marks</li> <li>Immersion <strong>burns</strong>, marked burns</li> <li>Subtle signs of head injury (<strong>bonks</strong>) <ul> <li>Hemotympanum, retinal hemorrhages</li> </ul> </li> <li>Fractures/<strong>breaks</strong> (especially youngest children)</li> <li>Irritability (baby <strong>blues</strong>)</li> <li>Ligature marks</li> <li>Frenulum injuries</li> </ul>

Question 11

<p>What other means can assist you to confirm your suspicions?</p>

Answer 11

<ul> <li>Old charts (review previous presentations for possible missed clues)</li> <li>Further collateral from other parties (grandparents, other caregivers, family physician)</li> <li>Skeletal Survey</li> <li>CT head (when indicated)</li> </ul>

Question 12

<p>List 4 other risk factors associated with domestic violence that may be present in this case.</p>

Answer 12

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Question 13

Mandatory police notification in domestic abuse

Answer 13

<ul> <li>Children witnessing abuse, suspected child neglect in home</li> <li>Cognitively disabled</li> <li>Abuse of elderly (without full capacity)</li> <li>Injury from firearm/ stab wounds</li> </ul>

Question 14

<p>Aside from physical assessment and treatment, what other assessment and management steps should be addressed?</p>

Answer 14

<ul> <li>Screening for suicidal/homicidal ideation</li> <li>Assessing for safety of children in household</li> <li>Referral/information for intimate violence experts in community</li> <li>Safety plan</li> <li>Clear documentation</li> </ul>

Question 15

<p>What historical information is important to gather for a patient presenting with sexual assault?</p>

Answer 15

<ul> <li>Age of victim and assailant</li> <li>Time of assault</li> <li>Activities since assault (eg. washing, brushing teeth)</li> <li>Oral/anal/vaginal penetration</li> <li>Use of condom or weapon</li> <li>Physical trauma</li> <li>Last regular sexual activity</li> <li>Use of drugs or alcohol</li> <li>Birth control use</li> </ul>

Question 16

<p>Describe the steps on how to collect evidence for sexual assault. Be specific</p>

Answer 16

“<ul> <li>Consent</li> <li>Secure/safe environment</li> <li>Chaperone (gender specific, when possible)</li> <li>Collect patient’s clothing in secure bags/ kits</li> <li>Full physical exam</li> <li>Detailed documentation of any findings</li> <li>Collect samples from any areas of penetration</li> <li>Colposcopy +/- toluidine blue dye for signs of cervical/vaginal trauma</li> <li>Wood’s lamp to identify and collect samples of stains or secretions</li> </ul>”

Question 17

<p>What are important steps in the treatment of sexual assault victims?</p>

Answer 17

<ul> <li>Treat all physical injuries</li> <li>Consider and discuss prophylaxis for: <ul> <li>GC/Chlamydia</li> <li>Hep B</li> <li>Tetanus</li> <li>Pregnancy</li> <li>HIV, syphilis, trichomonas, etc</li> </ul> </li> <li>Provide counselling and arrange for follow up: <ul> <li>Crisis/Social workers, specialized counsellors</li> <li>Sexual assault team</li> <li>GP</li> <li>Psychiatry</li> </ul> </li> </ul>

Question 18

“<span>Name 5 risk factors that may lead to child abuse</span>”

Answer 18

-Violence in the family<br></br>-Parental drug abuse and dependency<br></br>-Parental mental health diagnoses<br></br>-Parental abuse as a child<br></br>-Multiple caregivers<br></br>-Poor family socioeconomic status<br></br>-Financial strain<br></br>-Inadequate child care<br></br>-Physical or mental health problems in the child

Question 19

“<span>Name 4 historical characteristics that may be suggestive for child abuse:</span>”

Answer 19

-Unexplained or poorly explained injuries<br></br>-Injuries incompatible with the stated history<br></br>-A changing history<br></br>-Discrepancy between the story provided by child and caregiver<br></br>-Inappropriate delay in care<br></br>-Repeated ‘accidental’ ingestions

Question 20

“<span>Name 8 findings on physical exam that may be suggestive of physical abuse:</span>”

Answer 20

-Bruises in non-mobile children<br></br>-Multiple bruises in various stages of healing<br></br>-Concerning bruise location (away from bony prominences: inner aspect of the arms or under chin, ears, eyes, neck, hands, feet, upper arms, abdomen, back, genitals, buttocks)<br></br>-Patterned bruising - with characteristic appearance of a hand slap, cord loop, etc<br></br>-Ligature marks (especially wrist, ankle, neck)<br></br>-Bites with an intercanine diameter >3cm (adult bite)<br></br>-Lacerations of frenulum / oral mucosa<br></br>-Burn patterns suggestive of immersion<br></br>-Cigarette burns<br></br>-Contact or caustic burns (especially in a protected area of the body with uniform depth of injury)<br></br>-Retinal hemorrhages

Question 21

“<span>Describe the abnormality on the following radiograph and its clinical relevance (2)<br></br></span><img></img><span><br></br></span>”

Answer 21

-Metaphyseal chip fracture of the tibia (also known as corner or bucket handle fractures)<br></br>-Mechanism: forcible pulling or twisting<br></br>-Highly specific for non-accidental trauma

Question 22

“<span>Name 3 additional findings on X-ray that would be consistent with physical abuse:</span>”

Answer 22

-Spiral fractures (twisting of long bones, especially in a pre-mobile child)<br></br>-Periosteal elevation (from new bone formation at sites of previous microfractures)<br></br>-Fractures at unusual sites (ribs, sternum, scapula, spinous process)<br></br>-Multiple fractures at different stages of healing<br></br>-Bilateral fractures

Question 23

“<span>You are working in a minor procedures clinic and notice your colleague has just arrived to complete some cases. They appear well-dressed and professional, yet as you are greeting them, you notice the smell of alcohol on their breath. You also note their gait is unsteady and they appear moderately intoxicated.<br></br></span><span>What is the main priority in this situation?</span><span><br></br></span>”

Answer 23

“-Patient safety<br></br>-Prevent your colleague from performing the procedure<br></br>-““Do no harm”””

Question 24

What to do in case of unsuccessful attempt to talk to an intoxicated doctor?

Answer 24

-Speak to your local chief of staff/ department head<br></br>-Notify your provincial college/ licensing body<br></br>-Discussion with the patient about rescheduling/ postponing the procedure<br></br>-Offer to take over the procedure for your colleague (if appropriate)

Question 25

“<span>What steps can be taken by physicians to avoid medication administration errors?</span>”

Answer 25

-Clear, legible charting<br></br>-Avoiding ambiguous abbreviations, symbols or dose designations (ie. ug vs mg, QD vs QID)<br></br>-Avoid trailing zeros, include zeros before a decimal (ie. 5 mg, not 5.0 mg and 0.5 mg, not .5 mg)<br></br>-Verify/ confirming allergies<br></br>-Reviewing home medications/ medication reconciliation

Question 26

“<span>What steps can be taken by nursing staff to avoid medication errors?</span>”

Answer 26

-Clear handovers<br></br>-Legible, accurate charting of medication given, including time administered<br></br>-Verify/ confirming allergies<br></br>-Reviewing home medications/ medication reconciliation<br></br>-Confirming patient identifiers<br></br>-Double checking high risk medications with a colleague<br></br>-Separate problematic drugs (avoid storing those with look-alike names or similar packaging beside each other)

Question 27

What steps to take in wrongly administered drug?

Answer 27

-Inform the patient that the error has occurred<br></br>-Consider an apology<br></br>-Explain to the patient/family the possible effects and sequela of the medication error<br></br>-Explain what is being done to avoid a similar error in the future<br></br>-Document the error and patient conversation in the chart<br></br>-Report the error within your institution (ie. incident report or similar)