Escalation Injuries: Pediatric Trauma Series 2017

Trauma is the number one killer for children and 48% of child fatalities each year are a result of physical abuse.

Approximately 12% of child fatalities from abuse involve families that had some sort of CPS intervention in the last 5 years prior to the fatality, with the majority of these children being less than 4 years of age.

At one level 1 trauma center, only about a little over half of the kids being evaluated for NAT were seen by a pediatric surgeon.

In the retrospective cohort, 89% of NAT cases had inconsistent or missing history.

79% of NAT cases in the retrospective study involved unwitnessed injuries.

Almost 40% of NAT patients had a prior ED visit and 60% of those were less than a year of age.

Between 41% and 73% of patients were missing social history data in the retrospective review.

Perineal bruising or injury was found in a small number of patients, with the majority being less than 4 years of age, and was associated with significantly increased risk of mortality and increased morbidity.

Implementation of the standardized NAT screening tool did not result in a significant increase in the number of NATs diagnosed.

After protocol implementation, there was an increase in referrals to pediatric surgeons for NAT cases.

60% of NAT patients less than a year of age had fractures, with a fraction having undiagnosed healing fractures in other sites.

The use of head CT did not change after implementation of the NAT screening protocol.

A third of NAT patients had rib fractures, which were significantly associated with injury and other undiagnosed healing fractures, with half having an injury severity score greater than or equal to 16.

ED length of stay did not change after implementation of the screening tool.

The number of admissions went down after protocol implementation, possibly because more standardized screening in the ER led to safer disposition planning from the start and fewer medical holds.

Of the 9 patients who died in the retrospective cohort, 2/3 had had a prior ED visit and 5 had prior contact with CPS.

The PD Burn clinical prediction rule and the PREDAHT clinical prediction rule are the two clinical prediction rules with the largest amount of evidence for identifying abusive head trauma.

High risk long bone injuries for NAT include proximal and mid humeral fractures, femur fractures, and especially rib fractures in infants without a preceding history of major trauma.

Greater than 95% of patients presenting with intentional burns were aged less than 5 years.

Hollow viscous injuries, specifically duodenal injuries in children less than 4 years of age, are highly suggestive of abuse.

Abusive abdominal injury can occur without external signs such as bruising.

In mobile children, the incidence of lip injuries and oral injuries including frenulum injuries are equivalent between accidental trauma and non-accidental trauma mechanisms, so frenulum tears alone are not sufficient evidence to recommend a child abuse workup in this population.

An infant with an oral injury should raise a red flag, and if there is another finding, it is recommended to proceed with NAT workup.

Nearly one-third of NAT patients in the Mary Bridge retrospective study had undiagnosed healing fractures.

Anecdotally, there was more comfort discussing NAT workup with parents from both physicians and staff once the screening language was standardized.

For hospitals without pediatric radiologists or child abuse specialists, Mary Bridge recommends that concerning cases be sent to the regional pediatric trauma center for evaluation.