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Peds Rotation > Child Abuse 🥺 > Flashcards

Child Abuse 🥺 Flashcards

1
Q

What is the most common cause of lethal child abuse?

A

Abusive head trauma **!!! Must know*

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2
Q

What ethnic groups have disproportionately higher child deaths in Arizona?

A

African American

American Indian

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3
Q

What are the leading causes of death in childern ages 1-4

A
  1. Accidents
  2. Congenital malformation, chromosomal abnormalities
  3. Assault (Homicide)***
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4
Q

Who are the main perpetrators of child abuse?

A

Parents 81%

Step-parent/mom’s new boyfriend: 12%

Other adult 7%

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5
Q

What are the parental risk factors that make them more likely to become abusers?

A

Young age/single parent

Low education

Poverty

Drug/alcohol abuse

Domestic violence in household

Unrealistic expectations of baby/kid

Unrelated adult male in household (mom’s new boyfriend)

Social isolation

Hx of animal cruelty

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6
Q

What are the risk factors for babies and children that makes them more likely to get abused?

A

Medical conditions- learning disability, prematurity (fussier), ADHD (talkative/energetic), etc

Non-biologic caregiver- adopted child, step-parent

Age- most common in children <3 years!!**

Prior abuse

Unplanned pregnancy, unwanted child

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7
Q

Who usually reports child abuse?

A

Teachers

Law enforcement

Social services

Medical personnel

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8
Q

What are the 4 types of abuse?

A

Neglect (75%)

Physical (44%)

Sexual (8.5%)

Emotional (7%)

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9
Q

Where are the normal places for a little kid to have bruises?

A

Bony prominences:

Forehead

Knees

Front of body

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10
Q

What are some characteristics of bruising that are suspicious for child abuse?

A

Central bruising- buttocks, back, trunk, genitals, inner thighs, neck, EARS**👂🏻👂🏻

Bruising in babies that aren’t mobile on their own or <6 months

Clustered bruises

Human bite marks

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11
Q

Are ear bruises ever normal?

A

NO

She said this soooo many times

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12
Q

What kind of shapes would bruises appear if they were caused by abuse?

A

Handprints/oval finger marks

Loop marks- rope, wire, cords

Linear- whipping, paddling

Belt marks- may end in horse shoe shape

Ligature marks- neck, wrists, ankles, corners of mouth if baby was gagged

Bruising over the pinna of the ear- blow to ear or side of head

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13
Q

You notice bite marks on your pediatric patient. Their dad claims it was from his 4 year old brother. How would you tell if this was true?

A

Measure the distance between the maxillary inter-canines. (2.5-3cm in an adult)

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14
Q

Should you swab a bite mark for DNA

A

Yes

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15
Q

What kind of abuse are bite marks associated with

A

Sexual abuse

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16
Q

What kind of pattern would make you think that a baby burned itself on accident?

A

Irregular, top-down pattern like if a baby pulled a hot pot of soup down on themselves

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17
Q

What are some suspicious burns?

A

Brands- imprint from an object

Immersion- stocking glove, buttocks, leg

Cigarette burns

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18
Q

Cigarette burns tend to be _____ degree and heal (fast/slow) with ______

A

Third degree**

Slowly with scarring**

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19
Q

Where are cigarette burns usually located on a baby

A

Back of hands/feet

Face

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20
Q

What should a frenulum tear make you think?

A

Force feeding

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21
Q

Is it common to see orofacial injuries in abused children?

A

Yes, occurs in up to 50% of abused kids

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22
Q

What are some examples of orofacial injuries that were caused by abuse?

A

Frenulum tears

Lip lacerations

Missing/broken teeth

Tongue injuries

Burns from scalding foods

Facial fractures, basilar skull fractures, perioribtal ecchymosis

Ear bruising

Traumatic alopecia (missing clumps of hair)

Bruising/lichenificatino at corners of mouth

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23
Q

What can cause bruising/lichenification at corners of mouth

A

Being gagged

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24
Q

What is the second most common injury in physical abuse after bruises?

A

Fractures

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25
Q

What are fractures of high suspicion?

A

Rib fractures in babies

Long bone fractures in non-walking children

Sternum/scapula or spinal fractures (HIGH impact required)

Multiple fractures in various stages of healing

Depressed skull fractures

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26
Q

What causes depressed skull fractures?

A

Being struck by something (not from falling down)

🔨🏌️‍♂️⚱️

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27
Q

What are the 2 most comon types of fractures in abuse?

A

Metaphysical lesions of long bones (pulling baby out of crib with leg stuck in grates)

Rib fractures due to forceful compression while shaking (usually posterior ribs near the spine)

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28
Q

What are some behavioral changes that a child who is being sexually abused may exhibit?

A

Regress with toileting (suddenly starts pooping pants)

Personality changes- depressed, angry, reserved

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29
Q

Are boys or girls more likely to be sexually abused?

A

Girls, but boys are less likely to report so this is prob skewed

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30
Q

Is it OK to ask a kid if they’re being sexually abused if their mom is sitting right there?

A

Yes, you want the child to be as comfortable as possible

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31
Q

What do you need to look for during your exam if you suspect sexual abuse?

A

Vaginal, penile, anal trauma

Oral exam for forced oral sex

STI screening

Pregnancy testing in adolescents

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32
Q

What do you NEED to do if you suspect sexual abuse?

A

Collect forensic evidence, especially if the abuse occurred in the last 24 hrs

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33
Q

All neglect encompasses _____ and _____ harm

A

Actual

Potential

(Potential harm, like if the deprivation of medical care went on for awhile, that would be actual harm)

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34
Q

What is neglect?

A

Failure to provide a child basic needs

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35
Q

What are some examples of neglect?

A

Physical- food, shelter, hygiene, supervision

Psychological/emotional

Educational- enrollment at school, addressing special needs

Medical- timely medical/dental care

36
Q

What are some ways a child can be emotionally neglected?

A

Rejection

Isolation

Terrorizing- setting unrealistic expectation, threatening to hurt child, pets, or loved ones

Ignoring

Corrupting- encouraging bad behavior

Verbal assault- name calling, sarcasm, humiliating

Over-pressuring- overly advanced expectations

37
Q

When do you need to report neglect to CPS?

A

If there is malicious intent or potential for harm:

  • child has no supervision
  • Medical/dental neglect despite offered assistance
  • failure to proved adequate food, shelter, clothing, protection and education
  • domestic abuse
38
Q

Does CPS take the child out of the home 100% of the time?

A

No, sometimes it may involve counseling for parent and child

39
Q

What is induced illness?

A

Forced ingestion by children

Overlaps with fictitious disorder imposed on another aka Munchausen by proxy

40
Q

What are some ways a parent can cause induced illness

A

Salt poisoning

Water intoxication

Prescription/illicit drugs

41
Q

Is it common to miss head traumas at the initial evaluation of the child?

A

Yes up to 30%

42
Q

What are some reasons that caretakers bring children to the hospital after a head injury that was truly an accident?

A

Localized swelling following injury

Lethargy

Concern for children who are asymptomatic

43
Q

What are the reasons caretakers will take a child to the ER after the child had an abusive head injury?

A

Breathing difficulties

Apnea

Seizures

Lifelessness

(Aka they wait until things look really grim)

44
Q

Which kind of intracranial bleed happens more frequently with accidental head trauma?

A

Epidural hemorrhage

45
Q

What kind of force is necessary to cause a subdural hemorrhage?

A

Significant force, such as MVA or drop from significant height.
They are not typically accidental.

46
Q

A significant amount of infants with subdural hemorrhage will show evidence of ______

A

Past subdural hemorrhage

47
Q

What kind of intracranial bleed is present in nearly ALL fatal inflicted head traumas?

A

Subarachnoid hemorrhage

48
Q

What are you looking for in the eye exam if a child has suffered a head trauam?

A

Retinal hemorrhage

49
Q

Which has more severe retinal hemorrhage: abusive trauma or accidental injury

A

Abusive trauma

50
Q

What kind of skull fractures should make you suspect abuse?

A

Complex, depressed*** skull fractures

51
Q

What are 4 other possible causes of bruising that should be on your DDx (other than abuse)

A

Salicylate injection (aspirin poisoning)

Mongolian spots

Coagulopathy

Vasculitis

52
Q

If a child comes in with bruises, what plasma test do you NEED to run?

A

Salicylate concentration ****

EATING ASPIRIN CAN CAUSE BRUISES
💊💊💊💊💊💊

53
Q

What kind of symptoms occur with salicylate ingestion?

A

Diffuse bruising

Tachypnea, hyperthermia, tachycardia, hypotension

Vomiting

54
Q

What ethnicities more commonly get Mongolian spots?

A

African American

Asian

Hispanic

55
Q

Where do Mongolian spots typically appear?

A

Lower back

Buttocks

Might extend to upper back and extremities

56
Q

How long does it take for Mongolian spots to fade?

A

Months to years

Unlike actual bruises that fade in a few days

57
Q

How will a child with henoch-schonlein purpura present?

A

Purpura on lower extremities

Arthralgia (knees and ankles)

Abdominal pain

58
Q

When do you need to do coagulation studies to r/o a coagulopathy?

A

If there was NO witnessed abuse

mom says “Idk what happened these bruises just appeared”

If abuse was witnessed, bleeding/coagulation studies may not be necessary

59
Q

What are 3 possible explanations for suspicious fractures that should be on your ddx?

A

Osteogenesis imperfecta

Nutritional deficiency- Vitamin D

Neoplasm- Pathologic fractures

60
Q

What is something that can cuase lesions that look A LOT like cigarette burns?

A

Impetigo**

61
Q

How can you tell a cigarette burn apart from impetigo?

A

Impetigo: superficial layers only**

Cigarette burn: typically 3rd degree and heal with scarring***

62
Q

What is a totally innocent cause of burn-like lesions that Ms. Sears said happened to her kid?

A

Phytophotodermatitis ***

Kid spills lemon/orange/celery/fig juice on their skin and then plays in the sun= burn-like lesions
🍊☀️🍋🌞🔥🔥🔥

63
Q

What is a super rare genetic condition that could explain why a kid looks like it was beaten?

A

Congenital pain insensitivity

Kid doesn’t feel pain/temperature and walks around burning, bruising, fracturing, etc and doesn’t ever complain. Wounds end up getting infected

64
Q

What are 3 cultural practices that can result in wounds that look suspicious

A

Cupping- middle eastern, Asian, Latin America, Eastern European people people

Coining- SE Asian peopel rub oiled coin on skin

Spooning- Chinese people rub skin with a spoon

65
Q

What is important when you are talking to parents/caregivers when there is possible abuse?

A

Use non-accusatory language when speaking with them

66
Q

Let’s look at a list of 6 injuries with a high association with abuse

A

Bruises of trunk, EAR, and neck

Bruises in infants who are not cruising

Long bone fractures in non-walking babies

Rib fractures in babies <1 yr

Subdural hematoma in baby <1yr

Hollow Viscous injury in children <4 yrs (like a ruptured bladder/bowel)

67
Q

What are some things that should raise suspicion when a parent is telling the story of how the child got hurt?

A

History inconsistent with injury

Mechanism of injury changes (ex told triage nurse something else)

History is vague or not offered (“I have no idea what happened”

Injury is blamed on younger siblings or self-inflicted

Implausible history

History of bruising or orofacial injury in non-cruising infant

Injury attributed to in-home resuscitation efforts- “i did CPR on him that why he has rib fractures”

68
Q

What kind of parent behavior is suspicious when they bring their kid in to the ER?

A

Inappropriate delay in seeking medical care

Lack of appropriate concern for severityof injury

Aloofness, lack of emotional attachment to child (ex: playing on phone )

Argumentative, aggressive, violent with staff

Partial confession: “I hit him, but NOT hard”

69
Q

What kind of questions should you NOT ask children when you’re interviewing them?

A

Yes or No questions

70
Q

If a child is too young to recall timing, what is something you can ask them instead?

A

Use historical details. Ex: “Was this before or after Christmas?”

71
Q

What kinds of questions should you ask children when you’re interviewing them?

A

Open-ended. Who, What, Where When

72
Q

Why do you need to look at a child’s clothing when you’re examining them?

A

Make sure it’s weather appropriate and clean

73
Q

What do you need to do during your physical exam of a child you suspect may be abused?

A

Palpate EVERYWHERE and look for tenderness: kid might be afraid to tell you when something hurts

Ask them to walk/jump around and look for a reluctance to use an extremity

74
Q

What labs do you need to do if you suspect abuse?

A

Coagulation studies if abuse was NOT witnessed**

CBC w diff

CMP including ALT,AST for Hepatic Injury

Amylase, lipase for pancreatic injury

UA

Toxicology (serum and urine)

Stool guaiac (abdominal/sexual trauma)

75
Q

What kind of imaging needs to be done for skull fractures?

A

NON-contrast CT

X-ray

76
Q

What kind of imaging needs to be done for spinal fractires?

A

CT WITH Contrast***

MRI for nerve/spinal cord injury***

X ray

77
Q

What kind of imaging needs to be done for a thoracic injury’?

A

CT WITH contrast**

CR with oblique views

78
Q

What kind of imaging needs to be done for an abdominal injury?

A

CT with IV contrast** (not oral)

Plain flat AND upright X-ray (looking for free air)

79
Q

If you suspect an occult fracture, but X-ray has not shown anything, what other kind of imaging study can be done?

A

Bone scan***

80
Q

What to you need to do EVERY time you suspect child abuse

A

Call CPS and law enforcement **

Consult with other healthcare providers

Documentation

81
Q

Are PAs mandated reporters

A

Yes

82
Q

When do you need to admit a child?

A

If not considered safe to go home with parent/caregiver

If CPS response will be delayed

83
Q

Why do you need to find out if a child has siblings?

A

You need to identify if any OTHER children are at risk*******

84
Q

What should your medical records include if you see a child with abuse?

A

Hx of any known previous injuries (call their PCP)

Procedures you performed and why

Labs/studies

Statements from parents *IN QUOTATIONS**

Descriptive findings including a sketch outlining injuries ✏️

Photographs if possible 📸

Final disposition of child

85
Q

What are the 6 questions you need to consider when screening for child abuse in the ER?

A
  1. Is the history consistent with what you’re seeing?
  2. Was seeking care unnecessarily delayed?
  3. Does the injury fit with the developmental level of the child?
  4. Is the behavior of the child, the parents, and their interaction appropriate?
  5. Are findings of the head-to-toe exam in accordance with the history?
  6. Are there any other signals that make you doubt the safety of the child or other family members?

if yes to any of these= CPS now

86
Q

When a child has suffered abuse, what kinds of behaviors are they more likely to exhibit as they grow up?

A

NINE TIMES more likely to be involved in criminal activity 👮🏼‍♀️*****

Teen pregnancy 🤰🏻

1/3 will abuse their own children and are at risk of domestic partner abuse

Psychological disorders

More than 1/3 will develop a substance abuse disorder 💉💊

87
Q

Why do abused children need psychotherapy?

A

To learn how to trust

To teach what normal behaviors and relationships are

To learn conflict management

Boost self esteem

Peds Rotation (13 decks)

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