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NONACCIDENTAL TRAUMA*

(Photo contributors: Smita Kumar, MD, Earl R. Hartwig, MD, Jonathan Thackeray, MD, and Binita R. Shah, MD)

*The author acknowledges the special contributions of Konstantinos Agoritsas, MD, and Mary Birmingham, MD, to prior edition.

CHILD ABUSE

Clinical Summary

In the United States, child abuse is defined as “any act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation” or “an act or failure to act which presents an imminent risk of serious harm.” The key aspect of child abuse is maltreatment by someone who at the time of the incident has a duty to supervise and provide a safe environment for the child or an obligation to provide for the child’s well-being. Risk factors for child abuse include families with a history of substance abuse, single-parent households, young parental age, lack of parental education, previous incidents of domestic violence, socioeconomic constraints, and mental health problems. Mechanisms of inflicted injuries include direct impact (eg, punch, slap, kick, or strike with or against an object), violent shaking, penetrating injuries, and injuries related to asphyxiation. Abused children can have variable presentations; some may be completely asymptomatic while others have a range of signs and symptoms spanning minor bruises and contusions, to critically ill manifestations including respiratory distress, seizures, coma, or death, with the latter usually being associated with abusive head or blunt abdominal trauma. While inflicted abdominal injuries may present early with minimal findings such as vomiting alone, some children may progress to hypovolemic or even septic shock secondary to solid organ injury or a perforated viscus. Skeletal injuries, burns, poisoning, and Munchausen syndrome by proxy are all possible presentations for child abuse. Abused children are also often subject to a variety of forms of neglect, such as nutritional neglect, medical neglect, and lack of appropriate clothing, proper hygiene, or supervision, which may lead to injuries as well.

FIGURE 1.1

“Loop Marks”; Inflicted Bruises and Abrasions. (A, B) An extension cord is a common instrument used to inflict injury. Such a whipping or beating can cause “loop marks,” which commonly have a “U” or “C” shape, often with parallel “train track” linear marks. With greater force, deeper abrasions are seen. This 12-year-old boy was struck by his mother over 50 times in the head, trunk, and extremities after allegedly molesting his 5-year-old sister. (Photo contributor: Earl R. Hartwig, MD.)

Emergency Department Treatment and Disposition

The approach to a child who has been abused or neglected is not significantly different from the standard evaluation and ...

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