Nonaccidental Trauma Evaluation Research Articles

Investigating the Determinants of Nonaccidental Trauma Evaluation in Pediatric Femur Fractures.

Femoral fractures in children have the highest probability for abuse after skull fractures and humeral shaft fractures. However, the reported proportion of pediatric femur fractures that result from nonaccidental trauma (NAT) varies in the literature from 2% to 60%. The purpose of this study was to determine the patient characteristics associated with a physician's decision to conduct a NAT workup and challenge universal clinical practice guidelines stating that all children younger than 3 years with a diaphyseal femur fracture be evaluated for NAT. A retrospective review was conducted on patients aged 0 to 36 months diagnosed with a femur fracture between January 1, 2004, and April 9, 2019, at our institution. NAT was defined as a diagnosis of trauma that was nonaccidental in the medical chart after a positive workup by skeletal survey, ophthalmological examination, or other appropriate referral made by the institution's child abuse and neglect team. Patients with incomplete medical records were excluded. A total of 299 patients were identified, and 22 were excluded. 71% (197/277) were screened for NAT. Patients younger than 1 year were significantly more likely to undergo a NAT workup (P = 0.009; Odds Ratio [OR], 2.3; 95% CI, 1.2 to 4.4) and receive a positive result from the NAT workup (P < 0.0005; OR, 11.3; 95% CI, 4.6 to 27.4). Additional injuries were also a significant predictor of a positive NAT workup (P < 0.001; OR, 5.3; 95% CI, 2.4 to 11.9). Patient race/ethnicity, sex, and fracture type were not markedly associated with the physician's decision to conduct a NAT workup. Infants younger than 1 year with a femur fracture and children younger than 3 years presenting with a femur fracture and another injury are at increased risk of possible NAT. While clinical practice guidelines may minimize racial bias in NAT evaluation, this study demonstrates that universal NAT workups for walking-age children in the absence of other evidence of abuse may be unnecessary. This is a Level III retrospective cohort study.

Providers Assessing Child Abuse and Neglect

Providers Assessing Child Abuse and Neglect

Predictive value of non-ocular findings for retinal haemorrhage in children evaluated for non-accidental trauma.

To determine non-ocular examination findings in non-accidental trauma (NAT) patients that are associated with retinal haemorrhage and warrant urgent examination by an ophthalmologist. A hospital- and clinic-based retrospective cross-sectional and cohort study of children age 0-12 years who underwent workup for NAT over a span of nine years in a level I trauma and tertiary referral centre. Details of ocular and non-ocular examination and imaging findings at the time of NAT evaluation were collected by chart review. Univariate and logistic regression analysis for association between retinal haemorrhage and non-ocular examination findings was performed. A total of 557 patients with ophthalmology evaluation and 425 without were included in this study. All ages combined, none of the cutaneous signs of trauma or non-skull fractures were associated with retinal haemorrhage on univariate analysis (p > 0.05). By logistic regression, subdural or extra-axial haemorrhage (OR = 16.2; 95% CI [5.11-51.3]), occipital lobe insult (OR = 6.2; 95% CI [1.77-21.6]) and Glasgow coma score (GCS) <15 (OR = 5.8; 95% CI [1.96-17.4]) were significant predictors of retinal haemorrhage. Subdural or undistinguished extra-axial haemorrhage, GCS <15, and occipital lobe insult are risk factors for the presence of retinal haemorrhage in patients with suspected NAT and their presence warrant urgent dilated fundus examination by an ophthalmologist. The presence of cutaneous trauma or non-skull bone fractures without the aforementioned risk factors does not warrant ophthalmology evaluation.

Non-accidental trauma presenting with nasal septal hematoma or abscess

ObjectivesFailure to diagnose non-accidental trauma (NAT) leaves the victim at risk of further injury or even death. It is incumbent upon physicians and other health care personnel to identify trauma patterns that have a high likelihood of being caused by NAT. The objective of this study is to discuss the presentation of nasal septal hematoma (NSH) or nasal septal abscess (NSA) as a sign of NAT. MethodsThis is a retrospective case series of patients presenting with nasal septal hematoma or abscess between 2010 and 2019. The primary endpoint was the etiology of the injury. Secondary endpoints included demographics, concomitant injuries and treatments rendered. ResultsThere were 28 patients who presented with septal hematoma or abscess. The etiologies included 20 (71.4%) due to accidental trauma, four (13.8%) with NAT, one infectious, and three unknown. All four NAT patients were male and infants with an average age of 5.4 months (SD 4.6) significantly (p = 0.0069) younger than 10.3 years (SD 5.1) in the accidental trauma group. There was a delayed time to presentation for the NAT patients compared to other etiologies. Two of four NAT patients were initially thought to have a congenital midline nasal dermoid, yet surgical intervention revealed a hematoma. Further NAT evaluation noted concomitant injuries including rib fractures and intracranial injuries in 75% of the NAT patients. ConclusionsPresentation of a child with NSH/NSA prior to the onset of ambulation or with a delayed time to presentation should prompt suspicion and further workup for NAT.

Nonaccidental trauma in pediatric patients: evidence-based screening criteria for ophthalmologic examination

Ophthalmologic examination is included in the work-up for pediatric nonaccidental trauma (NAT) when there is concern for retinal hemorrhage. However, dilated fundus examination entails patient discomfort and prohibition of assessment of pupillary response. Previous studies have suggested that patients without neuroimaging abnormalities are unlikely to have retinal hemorrhage. The purpose of the current study was to analyze the findings in patients who received NAT evaluation with eye examination at our institution, and to propose screening criteria for inclusion of ophthalmologic examination in NAT evaluation. The medical records of patients who received NAT evaluation with ophthalmologic examination at The Johns Hopkins Children's Center Pediatric Emergency Department from August 2014 to July 2018 were reviewed retrospectively. Data collected included demographics, presenting symptoms, imaging findings, and ophthalmologic examination findings. The main outcome measure was presence of retinal hemorrhage. A total of 192 evaluations with ophthalmologic examination were included, representing 190 unique individuals of mean age 8.4±9.5months at presentation. In approximately half (54%) of the evaluations, there were abnormal findings on neuroimaging. Fifteen children (8%) had retinal hemorrhage, all of whom also had abnormal neuroimaging. Abnormal neuroimaging was associated with presence of retinal hemorrhage, with an odds ratio of 21.0 (95% CI, 3.47-∞; P<0.001). Of the 15 children with retinal hemorrhage, 14 had subdural hemorrhage. When neuroimaging abnormalities are present, ophthalmologic examination should be performed as part of the pediatric NAT evaluation. When there is no evidence of head injury on neuroimaging, ophthalmologic examination should not be routine.

The Implementation of a Pediatric Nonaccidental Trauma Evaluation Protocol: A Quality Improvement Analysis.

Pediatric nonaccidental trauma (NAT) accounts for more than 1500 deaths annually and is a source of incalculable lifelong morbidity. Evidence-based NAT evaluation protocols are available; however, compliance studies are lacking. Here, we analyze the quality of implementation of a new NAT evaluation protocol. A review of registry data from a level 3 trauma center was performed for patients with a suspicion of NAT from September 2014 to May 2016. Compliance rates and results of 2 new age-based evaluation protocols were examined before (phase 1) and after (phase 2) a multidisciplinary conference was initiated to improve performance. Seventy-five children underwent evaluation for NAT during the study period. In phase 1, median compliance rates with all of the protocol elements were low (63%). After a bimonthly multidisciplinary conference was initiated, compliance rates improved to 75%. Some elements, which were often missed, were found to be clinically irrelevant. If only clinically relevant elements were included, median compliance in phase 2 is 86%. Compliance with a new protocol for NAT was improved with the institution of a multidisciplinary conference. Protocol elements, which are shown to be clinically unnecessary, have also been identified and will be eliminated.

Improving Follow-up Skeletal Survey Compliance in Suspected Nonaccidental Trauma Patients: What's the FUSS About?

Introduction:Nonaccidental trauma (NAT) victims account for a significant percentage of our pediatric trauma population. The skeletal survey (SS) and follow-up skeletal survey (FUSS) are essential in the evaluation of selected NAT patients. We identified that our clinically indicated FUSS completion rate was suboptimal. We hypothesized that implementing an intervention of postdischarge follow-up in our pediatric surgery clinic would improve FUSS completion rates.Methods:A follow-up clinic for NAT patients was established in July 2013. A retrospective review was performed of all suspected NAT cases younger than 2 years old seen at Kentucky Children’s Hospital between November 2012 and February 2014. The study population was divided into pre (Group 1) and postintervention (Group 2). Bivariate analysis was performed.Results:Group 1 consisted of 50 patients (58% male; median age, 9 months). Forty-7 (94%) had an SS; fractures were identified in 37 (74%) patients. Only 20 patients (40%) had FUSS; of those, 4 had newly identified fractures. Group 2 consisted of 52 patients (54% male; median age, 7 months). All 52 children (100%) had an SS; fractures were identified in 35 (67%) patients. Forty-seven patients (90%) had FUSS. Of those, 6 had new radiographic findings. Thirty-five patients (67%) were seen in our clinic. This improvement in FUSS (40% versus 90%) was statistically significant, P < 0.001.Conclusion:The decision to follow NAT patients in our clinic had significantly increased our rates of FUSS completion. This additional clinic follow-up also provided more evidence for NAT evaluation.

Factors Associated with Non-Accidental Trauma Evaluation Among Patients &amp;lt;36 Months Old Presenting with Femur Fractures

Factors Associated with Non-Accidental Trauma Evaluation Among Patients &amp;lt;36 Months Old Presenting with Femur Fractures

Impact on Hospital Resources of Systematic Evaluation and Management of Suspected Nonaccidental Trauma in Patients Less Than 4 Years of Age

There has been an increasing movement worldwide to create systematic screening and management procedures for atypical injury patterns in children with the hope of better detecting and evaluating nonaccidental trauma (NAT). A legitimate concern for any hospital considering implementation of a systematic evaluation process is the impact on already burdened hospital resources. We hypothesized that implementation of a guideline that uses red flags related to history, physical, or radiologic findings to trigger a standardized NAT evaluation of patients <4 years would not negatively affect resource utilization at our level II pediatric trauma center. NAT cases were evaluated retrospectively before and prospectively after implementation of the NAT guideline (n = 117 cases before implementation, n = 72 cases postimplementation). Multiple linear and logistic regression, χ2, and Wilcoxon rank-sum tests were used to evaluate human, laboratory, technology, and hospital resource usage between cohorts. Human (child abuse intervention department, ophthalmology, and evaluation by a pediatric surgeon for admitted patients), laboratory (urine toxicology and liver function tests), and imaging (skeletal survey and head or abdominal computed tomography) resource use did not differ significantly between cohorts (all P > .05). Emergency department and hospital lengths of stays also did not differ between cohorts. A significant 13% decrease in the percentage of patients admitted to the hospital was observed (P = .01). Structured evaluation and management of pediatric patients with injuries atypical for their age does not confer an added burden on hospital resources and may reduce the percentage of such patients who are hospitalized.

Children presenting in delayed fashion after minor head trauma with scalp swelling: do they require further workup?

It is common to evaluate children who have sustained minor head trauma with computed tomography (CT) of the head. Scalp swelling, in particular, has been associated with intracranial injury. A subset of patients, however, present in delayed fashion, often days after the head trauma, as soft tissue edema progresses and their caregiver notices scalp swelling. We explore the value of further workup in this setting. We conducted a retrospective review of a prospectively collected cohort of children ≤24months of age presenting to the Texas Children's Hospital with scalp swelling more than 24h following a head trauma. Cases were collected over a 2-year study period from June 1, 2014 to May 31, 2016. Seventy-six patients comprising 78 patient encounters were included in our study. The mean age at presentation was 8.8months (range 3days-24months). All patients had noncontrast CT of the head as part of their evaluation by emergency medicine, as well as screening for nonaccidental trauma (NAT) by the Child Protection Team. The most common finding on CT head was a linear/nondisplaced skull fracture (SF) with associated extra-axial hemorrhage (epidural or subdural hematoma), which was found in 31/78 patient encounters (40%). Of all 78 patient encounters, 43 patients (55%) were discharged from the emergency room (ER), 17 patients (22%) were admitted for neurologic monitoring, and 18 patients (23%) were admitted solely to allow further NAT evaluation. Of those patients admitted, none experienced a neurologic decline and all had nonfocal neurologic exams on discharge. No patient returned to the ER in delayed fashion for a neurologic decline. Of all the patient encounters, no patient required surgery. Pediatric patients ≤24months of age presenting to the ER in delayed fashion with scalp swelling after minor head trauma-who were otherwise nonfocal on examination-did not require surgical intervention and did not experience any neurologic decline. Further radiographic investigation did not alter neurosurgical management in these patients; however, it should be noted that workup for child abuse and social care may have been influenced by CT findings, suggesting the need for the future development of a clinical decision-making tool to help safely avoid CT imaging in this setting.

Factors Associated With Nonaccidental Trauma Evaluation Among Patients Below 36 Months Old Presenting With Femur Fractures at a Level-1 Pediatric Trauma Center.

In 2009, the American Academy of Orthopedic Surgeons published clinical practice guidelines (CPGs) on the treatment of pediatric diaphyseal femur fractures, which recommended a nonaccidental trauma (NAT) evaluation for all patients below 36 months of age. A recent study of these guidelines found <50% clinical compliance with this treatment recommendation. We aimed to identify areas for improvement in compliance with this guideline. A retrospective review was performed of all patients presenting to a single pediatric tertiary care hospital with a diaphyseal femur fracture from January 2007 to June 2013 who were below 36 months old. Medical records were reviewed for documentation of a NAT evaluation, patient characteristics, presence of other fractures or injuries, and hospital of presentation. Radiographs were reviewed for fracture pattern. Statistical analysis was performed to assess for differences overall and before and after CPG publication. During the study period, 281 children below 36 months presented with femur fractures; 41% were evaluated for NAT. Overall, the following factors were significantly associated with receipt of a NAT evaluation: younger age (P<0.001), transfer from an outside facility (P=0.027), and identification of another fracture (P=0.004). Before publication of the CPG, nonwhite patients were much more likely to undergo NAT evaluation compared with white patients (43% vs. 19%; P=0.014). After publication of the CPGs, this differential disappeared (43% vs. 47%; P=0.685). Fracture pattern and patient sex did not influence receipt of NAT evaluation. We found poor utilization of NAT evaluation for patients below 36 months old presenting with femur fracture. Despite CPG publication, only modest improvements in this evaluation occurred over the study period, with less than half of all patients being evaluated. Younger children, patients transferred from other institutions, and patients presenting with concomitant fractures were more likely to undergo NAT evaluation. Compliance with the CPG may be improved by focusing on older children, patients who initially present to tertiary care centers, and those with an isolated femur fracture. Level III-retrospective comparative study.

A Rare But Important Entity: Epistaxis in Infants

BackgroundEpistaxis is a common emergency department (ED) complaint; however, this entity is rare among children younger than 2 years of age. In this age group, epistaxis may be a presenting sign of a bleeding disorder or nonaccidental trauma. Case ReportWe present a case of a 2-month-old infant who was evaluated in the pediatric ED for epistaxis and discharged home. The infant returned 2 days later with facial swelling and irritability, and was found to have significant head trauma. In this article we review the epidemiology and differential diagnoses for epistaxis among infants, as well as the initial approach to the evaluation of this uncommon clinical entity in this age group. Why Should an Emergency Physician Be Aware of This?Potential etiologies for epistaxis among infants and young children include severe systemic disease and nonaccidental trauma. Given its rarity and possible clinical significance, the approach to epistaxis differs in this age group. Emergency physicians should screen for and exclude a bleeding disorder while also having a very low threshold for a nonaccidental trauma evaluation.

Factors Associated with Non-Accidental Trauma Evaluation Among Patients &lt;36 Months Old Presenting with Femur Fractures

Factors Associated with Non-Accidental Trauma Evaluation Among Patients &lt;36 Months Old Presenting with Femur Fractures