A Case of Tot Maltreatment
A.N. is a previously healthy 2-year-old African American girl who was admitted to a pediatric trauma center after being evaluated in the emergency department at an outside hospital and transferred for an acute abdomen. Her mother reported she had a 1-day history of bilious emesis, a green stool with bloody flecks, and abdominal pain at the outside hospital. Her mother and mother's paramour reported that she fell over several times while sitting in her "time-out" chair as she kicked the wall until the chair fell over backwards. There was no report of any other trauma. At the outside hospital, an episode of bilious emesis and bright red rectal bleeding occurred. In route to the pediatric trauma center, A.N. received a 60 mL/kg fluid bolus with normal saline solution and a dose of ampicillin and gentamicin to cover a possible "abdominal catastrophe."
A.N. is a previously healthy toddler with no medical or surgical history. She has no known medication or dietary allergies. Her family history is noncontributory to her current illness. Her immunizations are reported to be up to date per her mother's verbal report. A.N.'s review of systems revealed no recent respiratory or gastrointestinal illnesses, with no previous bowel issues.
A.N.'s weight is 10 kg (5th to 10th percentile), her height is 82 cm (10th percentile), and her temperature is 37.3° Celsius tympanic. Her heart rate is 143 beats per minute, her respiratory rate is 26 breaths per minute, and her blood pressure initially was 84/palpation, and 30 minutes after a fluid bolus, her blood pressure was 95/44 mm Hg. The general impression is of a lethargic, grunting toddler lying supine; no family members are present at the bedside at the time of the examination.
Results of a head, ears, eyes, nose, and throat examination reveal a hematoma measuring 1 by 1.5 cm on her right forehead and a 2-mm laceration on her nasal bridge. An examination of tympanic membranes is normal, and no ear or nasal discharge is appreciated. Her oral mucous membranes are moist and clear, with intact dentition.
A cardiopulmonary examination reveals no murmur; she is tachypneic, although her breath sounds are clear and equal. She has no retractions or accessory muscle use. Her extremities are cool peripherally, with a capillary refill time of 5 seconds. Her radial and pedal pulses are easily palpable bilaterally.
Examination of her abdominal reveals a distended, firm abdomen with hypoactive bowel sounds. There is diffuse rebound tenderness; however, no bruising or discoloration is appreciated. Bright red blood is present in her diaper, and a rectal examination was deferred. A neurologic examination reveals a lethargic, fearful toddler with a Glasgow Coma Scale score of 14. She moves all extremities symmetrically, and motor strength is 5/5 in all extremities.
Case Study
History of Present Illness
A.N. is a previously healthy 2-year-old African American girl who was admitted to a pediatric trauma center after being evaluated in the emergency department at an outside hospital and transferred for an acute abdomen. Her mother reported she had a 1-day history of bilious emesis, a green stool with bloody flecks, and abdominal pain at the outside hospital. Her mother and mother's paramour reported that she fell over several times while sitting in her "time-out" chair as she kicked the wall until the chair fell over backwards. There was no report of any other trauma. At the outside hospital, an episode of bilious emesis and bright red rectal bleeding occurred. In route to the pediatric trauma center, A.N. received a 60 mL/kg fluid bolus with normal saline solution and a dose of ampicillin and gentamicin to cover a possible "abdominal catastrophe."
History
A.N. is a previously healthy toddler with no medical or surgical history. She has no known medication or dietary allergies. Her family history is noncontributory to her current illness. Her immunizations are reported to be up to date per her mother's verbal report. A.N.'s review of systems revealed no recent respiratory or gastrointestinal illnesses, with no previous bowel issues.
Physical Examination in the Emergency Department
A.N.'s weight is 10 kg (5th to 10th percentile), her height is 82 cm (10th percentile), and her temperature is 37.3° Celsius tympanic. Her heart rate is 143 beats per minute, her respiratory rate is 26 breaths per minute, and her blood pressure initially was 84/palpation, and 30 minutes after a fluid bolus, her blood pressure was 95/44 mm Hg. The general impression is of a lethargic, grunting toddler lying supine; no family members are present at the bedside at the time of the examination.
Results of a head, ears, eyes, nose, and throat examination reveal a hematoma measuring 1 by 1.5 cm on her right forehead and a 2-mm laceration on her nasal bridge. An examination of tympanic membranes is normal, and no ear or nasal discharge is appreciated. Her oral mucous membranes are moist and clear, with intact dentition.
A cardiopulmonary examination reveals no murmur; she is tachypneic, although her breath sounds are clear and equal. She has no retractions or accessory muscle use. Her extremities are cool peripherally, with a capillary refill time of 5 seconds. Her radial and pedal pulses are easily palpable bilaterally.
Examination of her abdominal reveals a distended, firm abdomen with hypoactive bowel sounds. There is diffuse rebound tenderness; however, no bruising or discoloration is appreciated. Bright red blood is present in her diaper, and a rectal examination was deferred. A neurologic examination reveals a lethargic, fearful toddler with a Glasgow Coma Scale score of 14. She moves all extremities symmetrically, and motor strength is 5/5 in all extremities.
Case Study Questions
What laboratory tests are ordered initially, and what is your interpretation of the laboratory results?
What are the most appropriate radiographic studies to order for a child suspected of sustaining an abdominal trauma?
What common abdominal injuries occur with nonaccidental trauma, and what is the usual treatment?
What risk factors for child abuse were identified? Who was the perpetrator of this injury?
What are considerations for follow-up, and what initiatives exist for the prevention of child maltreatment?
Source...