Apnea: Absence of respiration.
Contusion: A tissue injury with diffuse bleeding into subcutaneous tissue, causing discoloration under unbroken skin. Also known as a bruise.
Diffuse Axonal Injury: A widespread injury in the cynderlike extension of a neuron that conducts impulses away from the neuron.
Differential Diagnosis: Any condition having similar signs and symptoms that must be considered during patient evaluation.
Extensor Surfaces: The outside of the body or an organ.
Pinna: The largely cartilaginous projecting portion of the external ear.
Subdural Hematoma: A pooling of blood beneath the dura mater and arachnoid. Acquire a better understanding of child abuse;
EMS is called to the residence of a 2-month-old child who’s lethargic and hasn’t eaten well for several days. On arrival, the grandmother of the patient states she’s concerned because the child isn’t acting right. During your assessment, you notice the child isn’t acting age appropriate. Initial vital signs after placing the patient in the ambulance reveal: blood pressure 82/46, pulse 146 bpm, respirations 32 and a blood-glucose level of 134 mg/dL. Further assessment reveals bruising to the pinna of the right ear.
On arrival at the emergency department (ED), the child begins to have periods of apnea, and the hospital healthcare providers intubate the patient. A post-intubation chest X-ray reveals multiple acute and sub-acute rib fractures. The ED staff exposed the patient during their assessment and noted bruising to the left ear and the jaw. There’s also bruising found in different stages of healing to the anterior and posterior chest wall. The ED staff suspects this patient is a victim of child maltreatment, so the proper authorities are notified. During the investigation, the mother admits to abusing the child.
Statistics from the Centers for Disease Control and Prevention in 2010 show that one in 100 U.S. children were victims of maltreatment in 2008.1 Our nation has an epidemic of child maltreatment, and healthcare professionals aren’t detecting it quickly enough. More than one million substantiated cases of child abuse occur each year in the U.S.2,3 Unfortunately, for every substantiated case of child abuse, there are an estimated four to five suspected cases.
Child maltreatment is the number one killer of children 4 years of age and less in the U.S.1 It’s an epidemic that’s detectable and has to be stopped. Through proper assessments, healthcare professionals can discover the subtle signs that may indicate that a child’s life is in danger and prevent further maltreatment.
Defining the Problem
According to the National Children’s Alliance, child maltreatment can be physical, mental or sexual abuse.2 Child neglect is also a form of child maltreatment because it endangers the child through the lack of physical or emotional needs from the parent or caregiver.
In short, child maltreatment is the failure to provide their basic needs for life. Child abuse occurs most commonly with children 3 years or younger; however, child abuse, neglect or sexual abuse can occur at any age up to the age of 18. As a result of child maltreatment, approximately four children die each day in the U.S.2
The EMS professional holds a key position in not only assessing the child, but also their environment. There are some key questions and observations that you should note:
1. What are the living conditions of the child? Do they appear to be in an unsafe or unsanitary environment?
2. How does the family relate to the child in the current situation?
3. How does the caregiver interact with the EMS professionals?
4. Are the injuries consistent with the mechanism of injury?
5. Does the story being told change over time?
EMS can play a big role in helping properly identify abused patients. In a study out of Denver published in JAMA, 31% of abuse patients were evaluated by a physician after their injury and were misdiagnosed.4 The average number of hospital visits before the proper diagnosis was made was 2.8. Unfortunately, 27% of these patients were re-injured when their diagnosis was missed in the initial visit.
It takes a team effort and everyone being aware of the possibility for abuse to make the right diagnosis. Vector Vieth, director of the National Child Protection Training Center, says, “The problem doesn’t cease to exist because we choose to ignore it. If you don’t ask, you’ll never know.”
The following risk factors are commonly associated with child maltreatment:
>> Children aged 3 years and younger;
>> Children separated from their parents at birth;
>> Adopted children;
>> Children living in a foster home;
>> Children with chronic medical problems; and
>> Children with behavioral or developmental problems.1
The ugly truth of child maltreatment is that it happens regardless of ethnicity, culture, religion, or financial or social status.
Two of the more common complaints in the ED that led to the missed diagnosis of abuse were vomiting and irritability.4 These children were discharged home with the diagnosis of viral gastroenteritis or influenza. Such factors as the patients being in a younger age group, being Caucasian and having an intact family were associated with these misses.
Pediatric patient assessment can be challenging for many reasons, including concerned parents, bystanders on scene, a chaotic scene, fear among all parties involved and the child’s anxiety toward the emergency responder. These challenges can be summed up with one word: distractions. Most EMS services have low pediatric call volumes and encounter a critical pediatric patient even less. Too often the healthcare provider misses key components of the pediatric assessment, which leads to overlooking significant injuries, and this problem is especially true when dealing with a suspected abuse case.
The provider must first assess every patient’s airway, breathing and circulation (ABCs). Once they ensure the ABCs are properly managed, they should proceed on to D and E. “D” stands for disability and helps establish the neurologic status of the patient. For patients with significant head injuries or trauma, tracking the patient’s neurologic status can be helpful over time and assist the providers in deciding whether the patient needs an emergent airway.
When assessing “E,” or exposure, the emergency provider must fully examine the patient, anteriorly and posteriorly. Exposure is part of the assessment that’s most commonly skipped or missed by EMS providers. You may think, “I didn’t have enough time to unclothe the patient.” But if you don’t, then you didn’t complete your primary survey.
When caring for a suspected abuse patient who’s critical, such undergarments, as a diaper can hide the key piece of the puzzle that clues providers in to suspect non-accidental trauma (NAT). Remember that the only way to become proficient at pediatric patient assessment is to do an assessment the same way every time, regardless of whether it’s an adult or pediatric patient.
Physical abuse is the most commonly reported type of abuse and is manifested through bruises, burns, ligature marks, fractures and disorders involving the central nervous system (e.g., seizures). Eye injuries, such as retinal hemorrhages, can be signs of abuse as well. The most common signs of abuse are the three Bs: burns, breaks and bruises.
Bruises in the pre-ambulatory child are especially concerning. During your patient assessment, look for unusual patterns and locations of bruises. Ambulatory children will normally have bruises over extensor surfaces, such as their elbows, knees and forehead. Bruises that may cause you to suspect abuse are often discovered in locations typically covered up by clothing or are in strange places other than where children would land if they fell. These places include the back, upper arms, upper legs, abdomen, buttocks and the pinna of the ear.
It’s imperative for the EMS professional to thoroughly assess and examine every child the same way every time so you don’t miss any areas. A “sicker” child, or a call with a higher index of suspicion, is all the more reason to fully expose the patient.
Central nervous system injuries are most commonly manifested with subdural hematomas, contusions or diffuse axonal injuries. Seizures, coma and even death may occur. However, of head injury related deaths in children younger than 2 years old, 80% are due to abuse.5,6 Have you ever been called to the residence of a child having a seizure? If the child is afebrile and has no history of seizures, then child abuse should at least be on your differential diagnosis. You should be thorough in your assessment and ensure your documentation of the patient’s physical exam is accurate.
For this reason, a thorough assessment is paramount. Exposure in the primary assessment is not only critical, but it should also be required. Here’s one medic’s realization of why exposure is important.
On a nice fall afternoon, my partner and I were watching the football game when the tones went off. We responded to a call for “a child not acting right.” We arrived at the scene to find a young mentally and physically challenged girl withdrawn and tearful. Her neighbor insisted that this child was always happy and always had a smile on her face.
Obtaining a neuro assessment was going to be challenging to say the least. The only reliable source at the time was the girl’s neighbor, who called 9-1-1.
My assessment in the back of the ambulance was fairly unremarkable. There were no visible wounds or signs of trauma, except the patient had a small smear of blood on her thigh. (She was wearing shorts and a T-shirt.)
Instantly, there was a wave of nausea as intuition told me I’d have to further expose this young girl. I requested a female police officer join me as we proceeded to remove her shorts and diaper. My heart sank at the horrifying sight of blood that filled this young girl’s diaper. We transported the child to the hospital, where she spent several hours of surgery to repair the tears to her vaginal wall.
In a recent study, a new rule was devised to help better identify victims of physical abuse called the TEN-4 rule.7 The TEN-4 rule is used to help healthcare providers better differentiate between bruises caused by non-accidental trauma and accidental trauma. The TEN-4 regions consist of the torso, ears, and the neck in children younger than 4 years. Bruising in these areas of this age group and any bruising to a child younger than 4 months old should alert the provider to the high probability of child maltreatment.
Many providers reading this article may have never been to court in front of jury reading a patient care record (PCR) that they wrote five years prior. If you have, I’m sure the experience changed the way you document. If you haven’t, save yourself lots of anxiety and carefully document in the future.
The reality is that all PCRs should be written to paint the entire picture of the event. Because documentation mostly happens after the event, it’s important to remember key pieces of information so the documentation can be accurate.
When documenting a suspected non-accidental trauma case, remember that your job isn’t to assume; it’s to be as descriptive as possible in presenting the facts. The provider’s opinion doesn’t count for these cases. In fact, it may give the defense attorney ammunition against the hospital provider who documents something differently. The information should be objective, not subjective.
An excellent example would be the provider who documents bruises but then states that they’re in different stages of healing. The EMS provider may suspect this, but instead of writing that the bruises are in different stages, providers should note the size and color of each bruise.
Another important part of documentation is not to use “within normal limits” or “WNL” when describing vital signs. Remember, our job is to be objective with our documentation. Another common error providers make is to document “no obvious trauma” when a thorough assessment wasn’t performed. If you don’t look at it, you shouldn’t be documenting it. Hopefully, however, you’re looking everywhere you should be and documenting it appropriately.
Providers must document important information about the scene and the patient’s position. This is especially true when a patient is found in cardiac arrest. It’s also vital to document what you see, hear and smell, and what you’re told about the incident. Statements made by caregivers or others at the scene should be documented in quotation marks, so those statements can be attributed to the right person. This helps the police investigators check the stories of everyone involved.
If you suspect non-accidental trauma and think the caretaker’s story is changing, don’t keep asking the same questions and clue the person in to their changing story. Also be careful not to validate the caregiver’s concern about how an injury occurred or suggest possible mechanisms for the patient’s injuries.
Duty to Report
Remember that everyone who cares for children has a legal duty to report any suspicion of abuse. This includes physicians, nurses, respiratory therapists, EMS professionals, police and day-care workers. You don’t have to be able to prove the case to report it. You only have to suspect it. Unfortunately, many children are abused and treated for other complaints besides NAT. In fact, pediatric patients may be transported by EMS to the hospital and later discharged with other injuries or illnesses that are due to child abuse.
Although the goal is to stop the epidemic of child maltreatment, the goal of EMS should be to properly treat, document and report suspected cases of child abuse. The EMS professional should be aware of the signs and concerned with any child presenting with unusual bruises, breaks or burns to their body that don’t match the mechanism of injury, the story or the environment.
EMS professionals who suspect any type of child maltreatment must report their suspicions to the proper authorities and other healthcare providers to whom they’re relinquishing care of the patient. We all play an important role in this process and have to work together on this important issue. JEMS
Take Home Points
This article originally appeared in October 2011 JEMS as “Child Abuse: Discovering the horrifying truth.”