CYPT Flashcards
When should an investigation for AHT be done?
- evidence of acute or chronic trauma with inconsistent, evolving or no explanation
- severe HI after alleged short fall or minor trauma
- unexplained HI in child who was well when last seen
- subdural hemorrhage, retinal hemorrhage, rib or skull fracture or metaphyseal fracture
What is included in the assessment of AHI?
complete physical exam retinal exam by optho CBC, lytes, glu renal function coags metabolic screen, tox screen and microbiology skeletal survey, then 10-14d later CT head for acute cases MRI for additional info re presence or location of injury
what is strongly suggestive of AHT?
Traumatic retioscisis
Who is involved in investigation of AHT?
medical physician Child proteiction agency police psychosocial professionalas (SW, psychologist) Coroner (if death) neurosurgery neurology optho radiologist
What are the risk factors for shaking a baby?
Social isolation substance abuse psychiatric problems parent having been abused themselves family violence poor parental attachment to the child
What is in the ddx for bruises?
congenital dermal melanocytosis (Mongolian spot) erythema multiforme incontinentia pigmenti cupping and coining practices discolouration from dyes hemangioma photophytodermatitis
What are the characteristics of accidental bruising?
small
oval to round shape with nondistinct borders
no recognizable pattern to shape of bruise
front of body
on or above bony prominence (forehead, knees, shins)
makes sense in context of developmental ability of child
what are the red flags for inflicted injury?
Bruises in babies not yet cruising
bruises on back of neck, ears, chest, back, abdo, buttock, genitalia, feet
bruises not on front of body or overlying a bone
patterned bruises
numerous or unusually large bruises
bruising not fitting with causal mechanism described
Should babies not cruising be bruising?
No,
Is colour a reliable indicator for aging bruises?
No; colour or progressive changes in colour is NOT a reliable indicator of the age of bruise
what is the most common ACQUIRED disorder of coagulation?
ITP
Most common inherited coagulation disorder
vWD>hemophilia A> hemophilia B
BUT hemophilia A more commonly dx in pediatric population
Other than hematoloic disorders, what medical conditions are associated with bruising?
Infections (meningococcemia) Severe systemic illness (DIC) Malignancies (leukemia, neuroblastoma) connective tissue disorders (ED, OI) autoimmune/inflammatory (ITP, HUS) Nutritional deficiency (vit K, vit C def)
What hematologic disorders are associated with bruising?
ITP, vWD, Hemophilia A, Hemophilia B
What is important on hx in pt with bruising in infancy?
post circumcision bleeding
cephalohematoma
IV site bleeding
bruising at pressure sites (car seat fastener)
bruising at clothing pressure sites
macroscopic hematuria
bleeding with separation of umbilical stump
What is important on hx in family and index child?
spontaneous, easy or excessive bruising gingival bleeding epistaxis lasting more than 10min or needing medical attention GI or GU bleeding excessive bleeding after surgery menorhhagia hx of blood transfusion joint swelling after minor trauma hx of unexplained anemia bleeding from minor wounds FHx: bleeding d/o, d/or predisposing to bleeding (ED), consanguinity, moms periods, postpartum bleeding, need for transfussions, recurrent severe epsistaxis SHx: family disciplinary methods and childs behaviour
What is important on physical exam?
injury to frenulum dental health full skin exam dysmorphisma HSM, LN joint hypermobility and skin laxity
What lab tests to order if bleeding and suspected child abuse?
CBC
peripheral blood smeat
PTT/INR
aPTT
liver function (for secondary plt dysfunction)
kidney function (for secondary plt dysfunction)
factor 8
factor 9
fibrinogen
vWD studies
blood group (for interpretation of vWD studies)
What tests need to be done in all children under 2 with bleeding and suspected abuse?
skeletal survey
consider head imaging
optho eval
when are parents more likely to use physical punishment?
if they experienced it themselves
if they approve of it
hx of depression or other stress
if they feel anger in response to child’s behaviour
