A Case of Tot Maltreatment
Sarah A. Martin, RN, MS, CPNP-PC/AC, CCRN; Terea Giannetta, MSN, RN, CPNP; Karin Reuter-Rice, PhD, RN, CPNP
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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.”
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
Questions and Answers
What Laboratory Tests Are Ordered Initially, and What is Your Interpretation of the Laboratory Results?
In the emergency department, the following laboratory tests were ordered: a comprehensive metabolic panel (electrolytes, liver transaminases, blood urea nitrogen, and a creatinine level), amylase, lipase, complete blood cell count (CBC), type and cross for packed red blood cells, and urinalysis. A.N.’s electrolytes were within reference range except for a CO2 level of 16 mEq/L (reference range, 24-30 mEq/L). This depletion of carbon dioxide reflects a metabolic acidosis and may indicate some degree of dehydration, hydrogen chloride loss from vomiting, and ischemic and or necrotic bowel.
Her hemoglobin in the emergency room was 7.2 g/dL (reference range, 12-16), and this reading, with a previous measure of 8.2 g/dL at the outside hospital, raised concern for internal bleeding. A type and cross for packed red blood cells was ordered. A.N. has a leukocytosis of 27 thou/µL (reference range, 5-20), and this elevation can reflect stress, infection, or inflammation. Her liver transaminases were elevated with an alanine aminotransferase of 628 IU/L and an aspartate aminotransferase of 1,227 IU/L, which indicates some trauma to the liver. Her amylase and lipase values were normal. Her urinalysis was unremarkable.
A.N.’s physical examination and laboratory values support an intra-abdominal injury with signs of diffuse peritonitis. It is interesting to note that in a quarter of children with abdominal injuries from nonaccidental trauma, there is no sign of external bruising (Vandeven & Newton, 2006). Because she is showing signs of hypovolemic shock (tachycardia, hypotension, and poor perfusion) and fluid boluses of greater than 60 mL/Kg have been administered, packed red blood cells are ordered to be transfused.
What are the Most Appropriate Radiographic Studies to Order for A Child Suspected of Sustaining an Abdominal Trauma?
When an intra-abdominal injury is suspected, radiographic evaluation includes a cervical spine, chest x-ray, and pelvic radiograph to evaluate for concomitant injuries. A flat plate of A.N.’s abdomen revealed a pneumoperitoneum (with right subphrenic air present), which is suggestive of a hollow organ injury with presumed perforation. Although an abdominal computed axial tomography (CAT) scan is highly sensitive and specific for solid organ injuries, the study has not been shown to be diagnostic for hollow viscus injuries. Given her instability and existing x-ray findings, a CAT scan was not done because urgent operative intervention was needed.
Although the majority of pediatric abdominal traumatic injuries are managed nonoperatively, because a viscus perforation was suspected, A.N. was prepared for an exploratory laparotomy. Consent was obtained from her mother. Because the specific injury or injuries were not known, the consent was comprehensive and included exploration, possible bowel resection, possible bowel diversion, and central line placement. Harris and Stylianos (2001) describe the operative procedure for an exploratory laparotomy for a child in detail.
Case Update With Operative Findings. Operative findings included a duodenal hematoma, small bowel perforation, avulsion of the small bowel mesentery, and a right kidney contusion. An exploratory laparotomy was performed with repair of the ileal perforation, repair of the small bowel mesentery, exploration of the duodenum and right kidney, and drainage of a hematoma. The ileum was noted to be blue to purple in color; however, Doppler pulses were present, and the intestine was not resected. There was a hematoma in the duodenal wall and a serosal tear and a hematoma in the right colon.
At the time of this initial operation, a decision was made to bring the child back to the operating room in 24 hours to assess bowel viability; therefore, the abdomen was left open and packed with moist sponges, and a drain was placed. The child was transferred to the pediatric intensive care unit on mechanical ventilation with sedation and neuromuscular blockade. A Protective Services Team (PST) consult was initiated for presumed child maltreatment.
What Common Abdominal Injuries Occur with Nonaccidental Trauma, and What is the Usual Treatment?
For the pediatric trauma victim, blunt trauma occurs in 90% of the cases versus 10% for penetrating injuries (Gaines & Ford, 2002). Blunt abdominal trauma is the etiology for most abdominal injuries, and the most commonly injured organs are the spleen, liver, and kidneys. The most common mechanisms for injury are motor vehicle collisions, falls, and child abuse. Unfortunately, in 2004, child maltreatment was the etiology for as many as 1,490 fatalities (Child Welfare Information Gateway, 2006).
The injuries this child sustained could not be explained by the history offered by her family, and inconsistencies between the history and physical findings are key in diagnosing physical abuse. Injury to the gastrointestinal tract in a child who sustains blunt trauma is uncommon and occurs in less than 1% of the cases (Canty, Canty, & Brown, 1999). Roaten et al. (2005) reported that in children sustaining nonaccidental trauma, 50% of the children in their series had hollow viscus injuries. Roaten et al. found in 265 cases of nonaccidental trauma that the most frequently injured solid organ was the liver (33%), followed by the spleen (21%), and for hollow organs, the jejunum and ileum (29%) were most frequently injured, followed by the duodenum (25%) and the stomach (4%).
Injury to the duodenum is unusual and occurs in less than 5% of pediatric trauma victims, because the organ in children is protected in the retroperitoneal space (Gaines, Shultz, Morrison, & Ford, 2004). In a series of children who had sustained duodenal injuries, the most common etiology was found to be motor vehicle crashes, followed by child abuse (Gaines et al.). Clendenon, Meyers, Nance, and Scaife (2004) reported on duodenal injuries from two pediatric trauma centers over a 10-year period and found the most common etiology of these injuries to be child abuse. In addition, it was found that for children younger than 4 years, all of the duodenal injuries could be attributed to child abuse (Gaines et al.). Other injuries found in children who had duodenal injuries from child abuse included multiple contusions, rib fractures, other intestinal injuries, long bone fracture, pancreatic injury, and head injury (Gaines et al.).
Because nonaccidental trauma was presumed in this case, additional diagnostic testing was done and included a head CAT scan, skeletal survey, and an ophthalmology consult. Results of the head CAT scan were reported as normal, no abnormalities were noted on the skeletal survey, and the ophthalmology examination revealed no retinal hemorrhages. According to the American Academy of Pediatrics (2000), an initial negative skeletal survey should be repeated in 2 weeks for an increased diagnostic yield and may allow for a more precise age of individual injuries and may determine initial findings to be normal anatomic variants.
Management of duodenal injuries involving intestine rupture is operative with primary repair, and for hematomas, observation with the administration of parenteral nutrition is appropriate. Unfortunately, duodenal hematomas can contribute to a significant gastric outlet obstruction, and often lengthy hospitalizations of a month or longer for parenteral nutrition is necessary because enteral nutrition is not tolerated.
The Second Look Operation. A.N. remained mechanically ventilated and hemodynamically stable following her first operation. She was tachycardic, with a heart rate of 140 beats per minute, and she was febrile (38.8° Celsius rectal). Fresh frozen plasma and vitamin K was administered for a presumed consumptive coagulopathy. Total parenteral nutrition was started as a prolonged “nothing by mouth” status was anticipated. Upon return to the operating room a segment of her small bowel was necrotic and 20 cm of the ileum was resected. Her abdomen was closed, and she was readmitted to the PICU.
What Risk Factors for Child Abuse Were Identified? Who Was the Perpetrator of This Injury?
An extensive interview with the social worker and the mother and a separate interview with the mother’s boyfriend revealed several parental risk factors for abuse. In addition to the PST consult, detectives from the police department and, in accordance with mandated reporting, the Department of Children and Family Services were notified and involved. Identified risk factors included single parenthood, substance abuse, mental illness (maternal depression), and a history of neglect for the mother when she was a child.
Pediatric nurse practitioners are mandated reporters; however, there often is reluctance to report, and additional education and research is needed. Flaherty (2006) reported that physicians have expressed fears related to reporting, including losing families as patients, subsequent litigation for reporting suspected abuse, and concern they will have to testify in court. Prior to reporting a family, consider conferring with the child’s attending physician and parent(s) prior to making a report. The PST fulfilled the mandated reporting obligation of child abuse to the Department of Children and Family Services.
The history ascertained from PST included a detailed timeline of events surrounding the time frame the injury was thought to have occurred. This child’s family sought care after the mother had completed a work shift, and the history reflects that mother had been working and that the mother’s boyfriend had been caring for the child. Although no confession was obtained, the injuries were consistent with child maltreatment, and the Department of Children and Family Services took protective custody of A.N. Efforts to identify foster care for A.N.’s discharge was initiated by the PST.
What Are Considerations for Follow-up, and What Initiatives Exist for the Prevention of Child Maltreatment?
A number of programs have been developed to aid with the prevention of child abuse. The National Association of Pediatric Nurse Practitioners (2007) Position Statement contends that pediatric nurse practitioners are in a strategic position to assess for risk and protective factors as well as provide primary prevention. It is known that if it happens once and is not diagnosed, it will happen again, with the increased likelihood of more severe injury.
A number of programs exist for the prevention of child abuse. Because crying is known to be the number one trigger, the National Center on Shaken Baby Syndrome has a program Period of PURPLE crying, with the goal of educating parents about infant crying. Readers are referred to Vandeven and Newton (2006) and Walls (2006) for additional educational resources.
On hospital day 64, A.N. was discharged to a foster mother; she was tolerating enteral feeds after having her ileostomy taken down. Fortunately, this child had recovered from her injuries, and despite some morbidity, was discharged with a functional gastrointestinal tract. This child was seen in the pediatric surgery clinic 10 days after discharge and was doing well. A.N. was to be followed by the multidisciplinary PST on an ongoing basis. At the time of her discharge from the pediatric surgery clinic, there were no specific recommendations for long-term follow-up. As with any child who undergoes an abdominal surgery, A.N. is at lifelong risk for a bowel obstruction. Symptoms of concern that would warrant evaluation include abdominal distension, abdominal pain, and bilious emesis.
Fortunately, no deaths from intra-abdominal injury due to nonaccidental trauma were reported in the literature, with all deaths related to concomitant head injuries. A confession for this injury was never obtained, and thus there was no criminal prosecution. This case supports further investigation when there is suspicion for child maltreatment or when the history is inconsistent with the injury.