What is TEN-4-FACESp rule for child abuse
T: Torso
E: Ears
N: Neck
F: Frenulum (the tissue under the tongue)
A: Angle of the jaw
C: Cheeks
E: Eyelids
S: Subconjunctivae (the area under the conjunctiva of the eye)
4: Represents infants 4 months and younger with any bruise, anywhere on their body
p: Indicates the presence of patterned bruising, which may suggest abuse.
Hx suggestive of Child abuse
-No history to account for the injury
-History of unwitnessed trauma
-History of family violence
-Mechanism incompatible with the child’s age or developmental capabilities
-History does not easily account for the findings
-Inconsistent or changing histories without reasonable explanation
-Unreasonable delay in seeking medical attention
-Any injury in a non-ambulatory infant
-History of another child causing significant injury
-Certain injuries with high specificity for abuse eg ear bruising, posteromedial rib fractures, scald pattern suggesting immersion, injury to genitalia
-An infant with an unexplained encephalopathy (suspect abusive head injury and/or poisoning)
-Child or young person has problematic or harmful sexual behaviors
Examination findings in Child abuse ?
Skin or soft tissue injury:
-Any bruise or soft tissue injury in child <6 mo
-Frenulum injury
-Subconjunctival haemorrhages after the newborn period
-Bruises in TEN-4 FACES P areas
-Abnormally large, multiple, patterned or clustered bruises
-Bruising with petechiae
-Unexplained mouth bleeding
-Unexplained bruises in non-cruising child
Bones (Fractures):
-Any fracture in child <6 mo
-Skull fractures other than single parietal skull fracture
-Any other fracture in a non-ambulant child
-Any rib fracture
-Unexplained fracture
-Multiple fractures of varying age
-Any long bone fracture EXCEPT
supracondylar humerus
distal radius
mid-clavicular
distal tibial
Head (Intracranial) injury:
-Alleged shaking mechanism
-Any intracranial bleed
-Any unexplained intracranial collection
Burns:
-Unexplained burn of any type
-Burns to lower limbs or genitals
-Immersion scalds
-Shape of heated object
Internal organ injury:
-Any Unexplained
-Pancreatic trauma / pseudocyst
Unexplained encephalopathy
-Any altered conscious state, collapse or arrest. Consider abusive head trauma, ingestion/poisoning, toxins and suffocation
Other injury
- Immersion (near drowning in bath or similar)
- Strangulation or suffocation
- Injury or serious health consequences as a result of fabricated and induced illness (FII)
- Injury or serious health consequences as a result of ingestion of poisons/substances/medications
- Female genital mutilation
Treatment of drowning in a child :
CP arrest? ->CPR
No arrest ?-> inadequate respiration ? eg hypoxia despite increasing FiO2 ,markedly increased resp effort , inadequate spontaneous ventilation >abnormal conscious state ?-> provide resp support
If no adequate respiration -.> dyspnoea ? eg increased resp effort , abnoral lung ausc , sats <95 % thena dit for observation aiming sats >94% and IX guided by clinical condition
If all no then admit for 8 hours observation from time of immersion
-Key principles of management in child drowning :
Maintaining adequate oxygenation
Preventing aspiration
Stabilizing body temperature
In drowning consider consultation with local pediatric team ?
Sats<95 %
Abnormal resp examination
Increased resp effort
Underlying medical condition for cause of drowning
In drowning consider transfer when ?
Hypoxia
Altered mental state
Requiring resp assistance
In drowning safe discharge when ?
-Observed for 8 hours post immersion time
-Asymptomatic
-Normal resp exam
-Normal obs sats >94%
-No further safety concerns
-Education about water safety provided
-Referral to social work has been made if appropriate
-Parent safety /handout
In drowning child ,adverse prognostic indicators :
-Submersion time >5 minutes
-Time to effective basic life support >10 minutes
-Arrival in hospital with CPR in progress
-GCS <5
-Rectal temperature <30oC
-Arterial blood pH <7.1 on arrival
Drowning child Hx:
?Immersion time
?Time to and type of effective BLS
?Cardiac arrest
?Time to first resp effort
?Details of treatment used
Causes of paediatric drowning?
CNS (seizure)
CVS (Arrythmia like long QT )
Endocrine ( Hypoglycaemia )
Toxicology (drug ingestion/intoxication)
Safety/low supervision
Trauma
Foul play /misadventure
