Emergency Department Management of Sentinel Injuries in Infants (Trauma CME and Child Abuse CME)

Table of Contents

 

About This Issue

Recognizing sentinel injuries is critical, since these subtle findings may not only represent current child physical abuse but often precede more severe forms of child physical abuse. Failure to recognize these findings may result in devastating outcomes. This issue reviews the most common sentinel injuries in infants and provides an evidence-based approach for the workup and management of infants with sentinel injuries in the emergency department (ED). In this issue, you will learn:

The most common sentinel injuries (bruises, subconjunctival hemorrhages, oral injuries, and burns)

Guidance for differentiating between accidental and nonaccidental injuries

Recommendations for obtaining the history that will maintain objectivity and enhance documentation clarity and reliability

Guidance for physical examination of infants who present to the ED

Recommendations for which laboratory and imaging studies to obtain for the evaluation of infants with an injury concerning for child physical abuse

When reporting to Child Protective Services and/or law enforcement is warranted

Recommendations for collaboration with Child Protective Services and child abuse pediatricians to ensure safe disposition and follow-up for infants with sentinel injuries

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
   1. Bruises
   2. Subconjunctival Hemorrhages
   3. Oral Injuries
   4. Burns
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
10. Diagnostic Studies
    1. Laboratory Studies
    2. Imaging Studies
11. Management Considerations
    1. Reporting
    2. Cost
12. Special Populations
13. Controversies and Cutting Edge
14. Disposition
15. Summary
16. 5 Things That Will Change Your Practice
17. Risk Management Pitfalls for Emergency Department Management of Infants With Sentinel Injuries
18. Time- and Cost-Effective Strategies
19. Case Conclusions
20. Clinical Pathway for Emergency Department Management of Infants With Sentinel Injuries
21. Tables and Figures
22. References

Abstract

Sentinel injuries are often found incidentally on infants presenting with medical concerns or minor trauma as the chief complaint. Failure to recognize these findings as a potential indicator of child physical abuse may result in devastating outcomes including disability and death. This issue reviews the most common sentinel injuries including bruises, subconjunctival hemorrhages, oral injuries, and burns. Evidenced-based strategies are provided for evaluation and management of infants presenting to the emergency department with sentinel injuries.

Case Presentations

A 9-week-old girl presents with constipation and fussiness...

• On examination, she is found to have a subconjunctival hemorrhage. The girl’s parents state that this appeared earlier that day due to excessive crying and straining to stool.
• What workup, if any, is warranted at this time?

A 4-month-old boy presents with fever and fussiness...

• The boy’s parents say they believe these symptoms are due to teething.
• On examination, he is found to have an upper labial frenulum tear. The parents tell you that it is a self-inflicted injury from a teething toy. His mother says that he has had bleeding from the mouth before.
• How should you further evaluate this patient? Should you consider calling Child Protective Services?

A 7-week-old girl presents with fussiness…

• On physical examination, she is found to have a bruise on her abdomen. Her parents say they believe it is from the mother accidentally rolling onto her while co-sleeping. The girl’s parents also say that the infant rolled off the bed onto carpeted flooring, and this may have caused the injury.
• What are the next steps in the management of this infant?

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Clinical Pathway for Managing Patients Presenting with Acute Diarrhea in Urgent Care

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

2. * Sheets LK, Leach ME, Koszewski IJ, et al. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics. 2013;131(4):701-707. (Retrospective case-control; 200 patients) DOI: 10.1542/peds.2012-2780

10. * Sugar NF, Taylor JA, Feldman KW. Bruises in infants and toddlers: those who don’t cruise rarely bruise. Puget Sound Pediatric Research Network. Arch Pediatr Adolesc Med. 1999;153(4):399-403. (Cross-sectional survey; 973 patients) DOI: 10.1001/archpedi.153.4.399

31. * Anderst JD, Carpenter SL, Abshire TC, et al. Evaluation for bleeding disorders in suspected child abuse. Pediatrics. 2013;131(4):e1314-e1322. (AAP clinical report) DOI: 10.1542/peds.2013-0195

82. * Kleinman PK, Nimkin K, Spevak MR, et al. Follow-up skeletal surveys in suspected child abuse. AJR Am J Roentgenol. 1996;167(4):893-896. (Prospective diagnostic; 181 patients) DOI: 10.2214/ajr.167.4.8819377

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Keywords: infants, sentinel injury, sentinel injuries, child physical abuse, nonaccidental trauma, bruise, bruises, bruising, TEN-4-FACESp, subconjunctival hemorrhage, subconjunctival hemorrhages, oral injury, oral injuries, frenulum, frenulum tear, torn frenulum, burn, burns, scald burn, immersion burn, contact burn, occult injury, occult injuries, incidental injury, incidental injuries, documentation, reporting, nonambulatory