By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Key Feature 12: In children with traumatic injury, rule out abuse. (Carefully assess the reported mechanism of injury to ensure it corresponds with the actual injury.)
Skill: Clinical Reasoning, Selectivity
Phase: Diagnosis, Hypothesis generation
In my last post on trauma, I mentioned how it is important to consider abuse as being a reason patients may present with trauma. Depending on the trauma that has occurred, this may not be obvious, and when you see a loved one who seems legitimately worried about a patient at the bedside, it may seem downright counterintuitive. But victims of abuse are commonly brought in for medical care by the perpetrator, particularly when it comes to children and their primary caregivers. Assessing for abuse in children can be particularly tricky when it comes to physical trauma: children are clumsy and take chances exploring in sometimes dangerous ways. Getting injured is one of the ways we learn that things can harm us.
UpToDate offers up some signs and symptoms that may help you pick up on a child with trauma secondary to abuse:
Whenever you have more than a wisp of worry about abuse as a factor in a child's presentation for traumatic injuries, it warrants reporting the situation to the local child protection agency. Some physicians may hesitate to do this for fear of accusing caregivers who actually have not done any harm, which could have serious and unforgiving repercussions such as removing children from a home with caregivers who in fact provide good care. But reporting a situation that is questionable for child abuse does not mean you are charging the parents with abuse. It simply means the child protection agency will perform a thorough assessment to look for evidence that confirms or refutes child abuse. Given the prevalence of child abuse that is always too high (Statistics Canada), and the fact that, according to UpToDate, "Children returned to their families after an event of maltreatment have an 11 to nearly 50 percent chance of a second event," I think most people would agree that it is worth being overcautious at the risk of over-investigating cases and finding that many of them were in fact unintentional injuries.