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Highlight doc Day 2 - maltx
#ir #peds
  1. MALTREATMENT: phys/emo/sex/neglect/exploitationàactual/potential harm to child’s health/survival/development/dignity within relationship of responsibility/trust/power
  • Child isn't walking, but XR shows spiral fracture in femur. What's next?
  • MCQ: full body XR
  • Suspected child abuse: when are you suspicious, what to ask on Hx, and what is Tx?
  • Red Flags: inj inconsistent w/ hx (mechanism, force, age/developmental stage), hx inconsistent/changes, medical attn delay, multiple inj, different age inj, bruises (non-amb bruises, well-cushioned, patterned), # (non-amb, different ages, location)
    • Fractures: metaphyseal/ribs/scapula/vertebrae/sternum/mult skull #s
  • Hx: events leading up to injury
    • Location & time, who present, detailed events, child’s response, caregiver’s response, other children at risk, relevant PHx
  • Thorough O/E (completely undress): head, skin (ears, genitalia, buttocks), neuro (fontanelle, HC, fundi), mouth (frenulum), abdo, msk (swelling, pain), g/u (by specialized team)
    • Palpate everywhere
  • Document all injuries on a body diagram: type, location, size, shape, colour, pattern
  • Photography of skin injuries is ideal (police or hospital camera)
  • Ix (suspected non-accidental in non-ambulating children/infants): skeletal survey (all <2yo if NAI suspected), CT head, direct ophthalmoscopy, labs for occult trauma (AST, ALT, lipase, UA)
    • Fractures: bone density on XR, Ca2+, Mg2+, Phos, ALP, PTH, VIT D
      • Ddx: accidental inj, osteogenesis imperfecta, Menkes dz, osteopenia (rickets, prematurity, meds), osteomyelitis, bone tumours
  • Bruising: CBC, diff, smear, INR, PTT, von Willebrand, clotting factors VII, IX, X, XIII.
    • Ddx: accidental inj, bleeding d/o (ITP, thrombocytopenia, hemophilia), connective tissue d/o (Ehlers Danlos), Mongolian spots, folk healing practices, phytophotodermatitis, ink/paint
  • Intracranial bleed: bruising workup + urine organic acids
    • head trauma often missed b/c: non-specific sx’s (vomiting, crying, irritable)
  • Sexual abuse: STIs
  • r/o other causes (ddx)
  • CAS duties: 1) report (reasonable grounds to suspect needs protection) 2) ongoing report (additional reasonable grounds) 3) no delegation
    • àinvestigation (CAS (safety) + police (criminal charges))
  • How to report
    • Provide basis for suspicion, address, religion, relationship w/ offender, other children
  • A father is known to hit his son for discipline. The child says his dad hits him with a ruler. Father says he hits his son only with a hand. How can you tell O/E how the child was hit? Is this discipline or child abuse?
  • O/E: shape of imprint/bruise, type of injury
  • Abuse: potentially meets definition (depends on injury)
  • Child abuse (2 MCQ questions, what tests would you do; can't remember scenario)
  • (See above)
  • You "see bruises on infant" and also that the mother says infant "fell from a table" (the question stem does not make it clear at first that this is abuse, as is typical of all abuse stems), and it is highly likely that this is child abuse (however there is still a chance that I'm wrong and this is just simple knee fracture). 5 marks for Tx.
  • (See above)
  • 5mo ♀ brought into ER. Bruise on cheek and CT reveals subdural hemorrhage. Assume Hx + O/E already done. What steps in Ix and Tx do you perform?
  • (See above)
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