PTS Newsletter
Spring, 2017

Lee Ann Wurster, RN
Lee Ann Wurster, RN
Nationwide Children's Hospital

Terri Elsbernd, MS, RN, CEN, CPEN
Terri Elsbernd
Mayo Clinic Hospital

Guidelines Committee Update
Tony Escobar, MD
NAT Lead

Marc Auerbach, MD
Guidelines Committee Chair

Tony Escobar, MD Tony Escobar, MD
NAT Lead
Marc Auerbach, MD Marc Auerbach, MD

The Pediatric Trauma Society (PTS) Guidelines Committee Non-Accidental Trauma (NAT) Working Group recently had the manuscript "The association of non-accidental trauma with historical factors, exam findings and diagnostic testing during the initial trauma evaluation" accepted for publication in The Journal of Trauma and Acute Care Surgery. The Guideline Committee identified screening for NAT as a key area for guideline development during the first annual PTS meeting when a number of presentations on guidelines where noted to have significant variations across centers. A multi-disciplinary working group was created including PTS members and international experts in NAT from outside of PTS. Subgroups were developed to summarize and assess the quality of the evidence describing the correlation between NAT and the following: bruising, burns, abusive head trauma [AHT], abdominal injuries, fractures, historical factors, and oral trauma. The groups approach was novel in that it focused on these seven specific findings and the likelihood that each alone might be a harbinger of NAT. Over the subsequent two years the group synthesized the highest-quality evidence for each of these findings. The associations with NAT are summarized in a Table within the article and included below. The authors believe that this table provides a one page resource for use by ED, traumatologists, and emergency personnel that encapsulate key findings or "satchel knowledge". The next steps for this group include dissemination of these data and collaborative research to provide further validity evidence. The group will start this work with a bruising screening tool.

Please contact or if you are interested in getting involved in this work. PLEASE share this with your colleagues on social media with the following link:

Tweet: #PTSguideline The association of NAT with hx, exam and testing during ED trauma evaluations-evidence review

Marc Auerbach, MD

Table 4. A summary of features associated with non-accidental trauma (NAT) and recommendations based on specific findings including bruising, burns, intracranial injury, abdominal injury, skeletal injuries, historical factors, and oral injuries.

Category Features associated with NAT, compared to non-abused children Summary Recommendations
Bruising TEN-4 clinical prediction rule: bruising in children <4 years on trunk, ears, neck; or any bruising in infants <4 months (19)

Patterned, petechiae, large size, cheeks, ear, neck, head, truck, buttocks, arms (17)

Less likely from abuse: Front of body, bony prominences, however “expected” bruising depends on developmental age/disability of the child (17)
TEN-4 bruising 97% sensitive, 84% specific for NAT à child abuse workup

“When you don’t cruise, you don’t bruise.”
Burns Independent associations with confirmed abuse – age (2.1 vs. 5.0 years); chemical burn; contact burn; scald burn; feet; buttocks; perineum (22)

Less likely from abuse: beverages, spill injuries with irregular margins, burns to chest and head (spills) (21)
Up to 25% children admitted to burn centers have been abused (20)

Most intentional burn injury is from scalds to buttocks, perineum, bilateral lower limbs, feet, unilateral limbs, multiple contact burns, or clearly demarcated edges à child abuse workup.(21)

Any burn in age <5 years à child abuse workup. (22)
Intracranial injury Subdural hemorrhage, hypoxic-ischemic injury, diffuse axonal injury, metaphyseal fractures, rib fractures, retinal hemorrhages, apnea, seizures PEDIBIRN clinical prediction rule 96% sensitive, 43% specific for abusive head trauma (AHT)
1+ feature* in child <3 years à child abuse workup (41-43)

PredAHT clinical prediction rule 72% sensitive, 86% specific for AHT 3+ features** in child < 3 years à child abuse workup (32)
Abdominal injury Children with NAT and abdominal injury have a higher ISS, higher mortality, and often need an operation. It is important to note that intraabdominal injury may be found without bruising but in the presence of elevated LFTs. Hollow viscus injury, particularly duodenal injury, in children <4 years, combined hollow viscus + solid organ injury à child abuse workup (48)
Skeletal injury Fractures in children < 3 years and/or non-ambulating child

Fractures proximal and mid-shaft humerus, femur fractures + non-ambulating child

Rib fractures in absence of major trauma
Fracture patterns inconsistent with degree of mobility and child age à child abuse work up (65)

Skeletal survey to screen for occult fractures is indicated for any child < 2 years with suspected NAT (71)
Oral injury Frena injury + non-ambulating child Lip injury is extremely common in accidental trauma and does not justify a child abuse work up (79)
Historical factors Delay in care, inconsistent or implausible history, a history that changes or is developmentally incompatible, a report or concern for harm to the child, domestic violence Children who present with a change in behavior + skeletal injuries, subdural hemorrhage with suspicious history, injury inconsistent with history, and delay in seeking care à child abuse workup

*Acute respiratory compromise before admission; bruising of the torso, ears, or neck; bilateral or interhemispheric subdural hemorrhages or collections; and any skull fractures other than an isolated, unilateral, nondiastatic, linear, parietal fracture.

** Retinal hemorrhage, rib and long-bone fractures, apnea, seizures, and head or neck bruising


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