When You Suspect Abuse or Neglect

Work-up Guidelines
Fall 2003

Health care providers can share this protocol with radiologists, and request that it be used whenever child abuse or neglect is suspected.

A physical abuse work-up should include:

� Humeri - antero-posterior (AP)
� Forearms - APbr
� Hands - oblique, AP
� Femurs - AP
� Lower legs - AP
� Feet - AP
� Thorax - AP and lateral; oblique views to help detect rib fractures
� Pelvis - AP, including mid and lower lumbar spine
� Lumbar spine - lateral
� Cervical spine - lateral
� Skull - frontal and lateral; oblique views to determine extent of fractures

In suspicious spots of injury, repeat film with coning and restriction to the specific area. Depending on what is learned, additional assessment may need to include:

�   Bone scintigraphy -  The patient is injected with small amounts of radioactive tracers that are attracted to bone. A special camera takes pictures of the bones; the images show any damage.

Use when suspicion is high for skeletal injury but initial skeletal survey is negative
Or
Repeat skeletal survey in two weeks

�   CT scan of the chest and abdomen with intravenous contrast

Use when trauma of the chest or stomach is suspected, or when child is comatose and has shaking impact injuries

• Platelet count (PLT)

• Prothrombin time (PT)

• Partial thromboplastin time (PTT)

• Von Willebrand panel
  (Von Willebrand disease, the most common inherited bleeding disorder, produces symptoms that include easy bruising, nosebleeds, prolonged bleeding following injury or surgery)

Use when bruises or intra-cranial or retinal bleeding are present

� Electrolytes

�  Liver function tests (AST, ALT, total bilirubin)

� Amylase, lipase
� Creatine phosphokinase (CPK)

�   Urinalysis and urine toxicology

Use when intracranial, abdominal, or muscular trauma are indicated or suspected

and

when intoxication or the presence of drugs is suspected

�  Ophthalmology consult for fundoscopy after pupil dilatation

Use when:

• Intra-cranial injury, including shaken impact syndrome, is suspected
• Spiral fracture, metaphyseal fracture, or rib fracture are found in child younger than two
• Suspicious injury found in an infant younger than six months

Use when a fresh adult bite is present, if skin hasn’t been washed. Clean with moistened sterile gauze; after air-drying, place it in a paper envelope and send it to CPS for saliva analysis.

� Gonorrhea	Girls, prepubertal	Throat, anus, vagina/vestibule
	Girls, postpubertal	Throat, anus, uterine cervix
	Boys	Throat, anus, urethra
� Chlamydia (send on ice)	Girls, prepubertal	Anus, vagina/vestibule
	Girls, postpubertal	Throat, anus, cervix
	Boys	Throat, anus, urethra
� Herpes simplex virus (HSV)	All	Scraping of vesicles or ulcers for culturing
� Syphilis � Hepatitis B, C � HIV	All	Blood sample for serology (after counseling the parents/child)
�  Trichomonas �  Bacterial vaginosis (clue cells)	All	Wet preparation of discharge
�  Pregnancy	Girls, postpubertal	Urine test Pap smear, if speculum exam is done
�  Sexual assault (acute)	All	Forensic evidence collection, using kit
�  Drug abuse	As indicated	Urine screening

You will find more detailed information on screening for child sexual abuse in the summer 2003 issue of this newsletter.