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Blunt trauma

Penetr. heart

Child abuse


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These pages are excerpted from the Trauma Resident Handbook, Rhode Island Hospital Department of Surgery, Division of Trauma - updated 2001. The policies herein are intended to serve as guidelines only. Individual circumstances need to be considered as there may be times when it is appropriate or desirable to deviate from these guidelines. These educational guidelines will be reviewed and updated routinely.

When to suspect child abuse or neglect:

Historical Findings

  • Inconsistent history
  • History that does not match the physical findings
  • Injuries that do not match the developmental stage of the child

High-Risk Presentations

  • Unexplained or poorly explained death of an infant
  • Unexplained apnea
  • Ingestion or toxin exposure with suspicious history
  • Repeated drug or toxin exposure


  • Abandonment
  • Children <8 years old left unattended
  • Delay in seeking care for a serious injury
  • Serious noncompliance with medical care
  • Failure to thrive with no medical explanation
  • Cold injury
  • Parent refusal of medically necessary care (despite medical/cultural/religious differences)

Physical Abuse

Head injury

  • Unexplained CNS insults resulting in coma, seizures or obtundation
  • Skull fracture with suspicious or no history of significant trauma, especially:
  • Depressed skull fracture
  • Diastatic fracture
  • Fracture >3 mm wide
  • Complex or multiple skull fractures
  • Bilateral skull fractures
  • Fracture with associated intracranial injuries
  • Evidence of Shaken Infant Syndrome (altered level of consciousness, closed head injury, CNS or retinal hemorrhage)
  • Catastrophic injury explained by routine falling
  • Subdural hematoma without history of significant trauma

Thermal Injury

  • Suspicious pattern or unexplained burns
  • Cigarette burns, multiple or in various stages of healing
  • Burns that imprint the shape of an object
  • Glove and sock pattern liquid burn
  • Burns on the back of the hand, on the back, or on the buttock (especially if patterned)
  • Diaper area burns or doughnut shape burns
  • Bilateral burns
  • Burns that involve neglect


  • Rupture of the costovertebral junction
  • Posterior rib fracture
  • Metaphyseal avulsion fracture (bucket handle or corner fracture)
  • Two or more fractures in a different stage of healing
  • Long bone fracture in a nonambulatory child
  • Spiral fracture in a nonambulatory child
  • Uncommon fractures without a history of significant trauma (e.g., vertebrae, sternum, pelvis, or scapulae)
  • Unexplained fractures


  • Blunt trauma to the abdomen or chest without history of significant trauma (may not be bruises), especially:
    · Duodenal hematoma
    · Pancreatic pseudocyst
    · Bowel, spleen or liver laceration
    · Mesenteric or retroperitoneal hematoma
  • Suspicious or unexplained oral, facial or dental trauma
  • Bruises
  • Any injury resulting from discipline in a child
  • Patterned bruises (e.g., bruising of pinna or genitalia; loop, strap, buckle or rope marks; fist, slap, bite impression)
  • Bilateral black eyes without nasal injury
  • Circumferential injuries of the extremities
  • Multiple bruises without medical explanation in inaccessible places or at different stages of healing
  • Injuries that suggest the use of an instrument
  • Munchausen by Proxy
  • Recurrent illnesses or findings not explained by medical diagnosis
  • Unexplained metabolic derangement suspicious for nonaccidental poisoning

Emotional abuse

  • Suicidal gestures in children without known history of psychiatric illness
  • Anorexia nervosa in patients <10 years old
  • Chemical addiction in children <12 years old
  • Hair loss without medical explanation
  • Runaways

Sexual Abuse

  • Credible disclosure of abuse by a child
  • Suspicious genital or anal injuries:
    · Hymenal or vaginal tears
    · Hymenal scars (usually are retracted, mounded linear avascular areas)
    · Hymenal synechiae between 3 and 9 o'clock
    · Large horizontal diameter of hymenal opening during traction (>10 mm, average diameter 1 mm)
    · Irregular anal orifice with dilation, reflex anal dilation in absence of stool in antrum >20 mm
  • Presence of STD in children <12 years old (exclude neonatal infection); N. gonorrhea, T. pallidium, HPV (especially in children >2 years old), HIV, Chlamydia, Herpes II, Trichomonas vaginalis
  • Presence of sperm and/or seminal fluid
  • Pregnancy in a child <12 years old

All suspected cases of child abuse and all of the medical problems listed above require immediate social work intervention.
If child abuse is suspected during the medical or social service evaluation, it is the treating physician's responsibility (the primary physician in the ED or in the subspecialty consult) to file a Physician's Report of Examination (PRE) with the Department of Children, Youth and Families (DCYF). The Pediatric ED Attending will assume responsibility for a filed PRE on behalf of the child suspected of having been abused and is identified in the Pediatric ED. The Child will not be discharged from the ED or admitted to the Pediatric ward until a PRE is in process.
If a pediatric social worker is unavailable for immediate consult and abuse is suspected, a PRE should be filed immediately. If the patient is admitted to the hospital, a social service consult should be ordered on the ward.
The physician filing a PRE should inform the parent(s) of the action taken on behalf of the child.
Documentation is critical. Always include the history of the injury, witnesses to the event, time of injury, past history of injuries, medical problems, and a complete physical examination. When appropriate, photographs and diagrams should be added to the medical record.
Always notify the primary care physician (or coverage) when his or her patient is suspected of being a victim of child abuse.

When and how to refer to the Child Protection Service:

The Child Protection Program will be contacted at 4-3996 from 8:00 a.m. to 5:00 p.m. and through the page operator at 4-5611 from 5:00 p.m. to 8:00 a.m. in all of the following cases:

  1. Head injuries All unexplained head injuries to children, especially in children <2 years of age.
  2. Fractures
    a) All unexplained fractures, particularly in nonambulatory children and in children <1 year of age.
    b) Any child with more than one fracture who has not experienced major trauma
  3. Burns
    a) All immersion burns (not all scald burns)
    b) All "pattern" injury burns (e.g., cigarette, lighter, etc.)
    c) All questionable burns in nonambulatory children
    d) All unexplained burns
  4. All unexplained abdominal injuries in children.
  5. Sexual Assaults
    All acute sexual assaults in children and adolescents (within 72 hours) that require immediate documentation of physical trauma by colposcopy. (Most sexual abuse cases >72 hours post-assault can be referred to the Child Safe Clinic).
  6. Other
    a) All drownings in children <5 years of age
    b) All cases presenting to the hospital where the child is suffering from exposure or starvation
    c) All cases admitted to the hospital because a child's medical care has been significantly delayed or neglected
    d) Ingestion of drugs or alcohol suspected to be "nonvoluntary" or suspected to have been caused by parental neglect, especially ingestion of illegal drugs in children
    e) All cases of suspected Munchausen syndrome by proxy
    f) All other cases where injuries have been purposefully inflicted on a child (e.g., "pattern" bruising such as slap marks, strap marks, or ligature marks)
    g) Chronic failure-to-thrive cases where no medical cause explains the child's growth failure
    h) Cases of repeated episodes of infantile apnea where the child has been previously admitted to the hospital and whose medical work-up was negative. Also, cases of previously healthy children who experience apnea after nine months of age
    i) All falls > 3ft. in children < 1 year of age
    j) Repeated admissions for trauma in children < 2 years of age.


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