When treating children/adolescents who have been physically abused, evaluate the social, emotional, and physical status. Ensuring the safety of the child/adolescent is critical to treatment and should be a priority.
Outpatient Evaluation and Treatment
Victims of physical abuse often initially present to Emergency Departments. These injuries should be treated in the same way as in a patient with accidental injury except for possibly collecting forensic data. If the case has not already been reported, report any suspicious injuries to the State Central Register (1-800-635-1522) or local hotline.
In a private practice setting, after completing the initial physical exam, decide whether the injury can be treated in the office. The primary care provider may not have direct access to the ancillary services needed to fully evaluate the physical abuse. In these instances, it may be necessary to refer the child to a diagnostic center for radiographic studies, refer the child for specialist care, or have the child hospitalized for further evaluation. For more detailed information, see TRIAGE: Steps. When appropriate, take photographs promptly to document the injuries because many of them heal quickly. In children under two years of age, based upon the presenting injury, a skeletal survey; indirect ophthalmologic examination, preferably by a skilled pediatric ophthalmologist; and CT of the head may be recommended to ascertain the presence of old or concurrent trauma.
For more information, see RADIOLOGY: Injuries Associated with Abuse.
Information regarding the circumstances of an injury will need to be corroborated by an investigative agency, such as law enforcement or Child Protective Services. This includes inspecting the site where the injury occurred regarding water temperature and proximity of radiators and wall heaters to beds for burns; height of tables, types of floor coverings, and window guards for falls; and access to medicines and poisons.
Inpatient Evaluation and Treatment
Victims of physical abuse may need hospitalization based on the severity of their injuries. In addition, many children are hospitalized to ensure their safety when it is unsafe to send them back into their homes. If the case has not already been reported, report any suspicious injuries to the State Central Register (1-800-635-1522) or local hotline.
Head injuries are the most common cause of death in abused children. If severe head injury is present with symptoms of vomiting, lethargy, irritability, increasing head circumference, or obvious external head trauma, aggressive intervention may be required. This is most appropriately treated in an intensive care setting with neurosurgical evaluation and possible intervention. A CT and/or MRI are necessary to search for intracranial injury (i.e., epidural, subarachnoid, and subdural hemorrhages). An indirect ophthalmoscopic examination, preferably by a skilled pediatric ophthalmologist, can determine the presence of concurrent retinal hemorrhages, their location, and severity (i.e., single versus multi-layered). For more information, see RADIOLOGY: Head Trauma.
Abdominal injuries are the second most common cause of death in abused children. These injuries may result in blood loss, infection, and obstruction. Appropriate diagnostic tests include AP and lateral abdominal X-rays, CT scan of the abdomen and pelvis, and/or abdominal ultrasound to identify the injury when necessary. For more information, see RADIOLOGY: Abdominal Injury. Helpful laboratory tests include a complete blood count (CBC), amylase, lipase, and liver functions. A stool guaiac will reveal occult blood. For more information, see LABORATORY: Evaluation of Visceral Injury. Based on the above test results and the aggressive progression of abdominal injuries, surgical intervention may be necessary.
Burn treatment requires sufficient rehydration and wound care, often in a burn or surgical intensive care unit. Treat bruises and fractures no differently than if they were caused by accidental injury. The appropriate referral to a burn specialist or orthopedist is necessary when injuries are severe.
All the above injuries also require the radiographic inspection of the skeleton to detect old or concurrent fractures. In some cases, a bone scan may be necessary to determine occult fractures that are not visualized in a skeletal survey. Since fractures may not be evident early in the course of healing, repeat radiographic testing is recommended one to two weeks after the injury. For more information, see RADIOLOGY: Injuries Associated with Abuse.
Follow-Up
The ultimate goal is to assure that the child suffers no further harm. Unfortunately, this task is difficult to accomplish. A helpful parameter is to have close continuity of care with the child/adolescent and family. After making a report to the State Central Register, remain a strong advocate for the child and family. This includes offering or referring for supportive services, ongoing mental health intervention, and further medical follow-up.
