Guideline for the Evaluation of Suspected Non-Accidental Trauma (NAT)
Original Date: 06/2021 | Supersedes: 06/2021 | Last Review Date: 11/2023
Purpose Statement: Guideline for the Evaluation of Suspected Non-Accidental Trauma (NAT)
| Initial Screening for Occult Injury | ||||||
|---|---|---|---|---|---|---|
| Category | Skeletal Survey | Neuro-Imaging | Ophthalmology Exam | Lab Assessment | Additional Testing | Social Work |
| Age <6 months old with unexplained injury, suspicious injury* and/or witnessed physical abuse | ||||||
| NO indication for head CT based on MHH Closed Head Injury Algorithm or HCT<30 and plt>400 |
Yes⌃ | Head CT and/or Brain MRI (consider c spine MRI)¶ |
Yes, if abnormal head imaging | CBC, CMP, lipase, UA with micro (bag), PT/PTT/vW panel if non-pattern bleeding/bruising or ICH w/out trauma hx¥; UDS for altered mental status° |
Per consultation with CARE team and/or Trauma consultant; abdominal CT with AST or ALT >80; lipase >100 |
Consult for all patients where there is concern for abuse |
| WITH indication for head CT based on MHH ED Closed Head Injury Algorithm or HCT<30 and plt>400 |
Yes⌃ | Head CT and Brain MRI (consider c spine MRI)¶ |
Yes, if abnormal head imaging If normal head imaging, then select cases per CARE team |
CBC, CMP, lipase, UA with micro (bag), PT/PTT/vW panel if non-pattern bleeding/bruising or ICH w/out trauma hx¥; UDS for altered mental status° |
Per consultation with CARE team and/or Trauma consultant; abdominal CT with AST or ALT >80; lipase >100 |
Consult for all patients where there is concern for abuse |
| Age ≥6 months old to <2 years old with unexplained injury, suspicious injury* and/or witnessed physical abuse | ||||||
| NO indication for head CT based on MHH Closed Head Injury Algorithm or HCT<30 and plt>400 |
Yes⌃ | Brain MRI (consider c spine MRI)¶ on select cases per CARE team |
Select cases per CARE team |
CBC, CMP, lipase, UA with micro (bag), PT/PTT/vW panel if non-pattern bleeding/bruising or ICH w/out trauma hx¥; UDS for altered mental status° |
Per consultation with CARE team and/or Trauma consultant; abdominal CT with AST or ALT >80; lipase >100 |
Consult for all patients where there is concern for abuse |
| WITH indication for head CT based on MHH ED Closed Head Injury Algorithm or HCT<30 and plt>400 |
Yes⌃ | Head CT and Brain MRI (consider c spine MRI)¶ on select cases per CARE team |
Yes, if abnormal head imaging If normal head imaging, then select cases per CARE team |
CBC, CMP, lipase, UA with micro (bag), PT/PTT/vW panel if non-pattern bleeding/bruising or ICH w/out trauma hx¥; UDS for altered mental status° |
Per consultation with CARE team and/or Trauma consultant; abdominal CT with AST or ALT >80; lipase >100 |
Consult for all patients where there is concern for abuse |
| Age ≥2 years old with unexplained injury, suspicious injury* and/or witnessed physical abuse | ||||||
| Selective testing based on MHH ED injury guidelines and if requested by CARE team or trauma consultation. Note: Skeletal Survey⌃ indicated when child is disabled or immobilized, including children with 1) cerebral palsy, 2) neuromuscular disorders. |
Consult for all patients where there is concern for abuse |
|||||
* Rib fxs, metaphyseal fxs, multiple extremity fxs or single fx without explanation in non‐ambulatory infant or child, pattern bruising (any bruising <4 month without hx; bruising on torso, ear, neck in <4yo without hx), burn, social isolation, repeated ED visits for the same reason, abdominal injury, vaginal bleeding in prepubertal female
⌃ Need attending read for discharge; <24 month mandatory, 24‐36 months low threshold, decreasing benefit >36 months
¶ May be obtained as inpatient, if patient is admitted
¥ If extensive hematomas, consider UA, myoglobin, CPK, renal panel
° Hair testing may be recommended for children w/ concern for neglect and NAT burn/soft tissue injuries, children w/ a hx of either parental drug use or domestic violence; concern for ingestion
(obtain separate signed consent)
Admission: State Trauma Regulations mandate that children admitted to the hospital for injuries possibly due to NAT are admitted to surgical service for first 24 hours. If only admitted pending safe dispo, may be admitted to pediatrics
Discharge: Ensure protection of the child at discharge by way of the appropriate state department of family services via the ED SW or for in ‐patients, the CPP team.
Repeat Studies: Indicated in 2‐3 weeks whenever abuse is still suspected after initial evaluation
Special considerations: High suspicion for NAT in siblings, particularly twins of patients with evidence of NAT
Community hospitals: Perform clinically necessary imaging, make CPS referral, and transfer to TMC (may defer skeletal survey to TMC)
List of Suspicious Injuries (not all-inclusive)
- Rib fractures without consistent history
- Metaphyseal fractures
- Multiple extremity fractures
- Single fracture without explanation in non‐ambulatory infant or child
- Pattern Bruising
- Any bruising in <4 month without history
- Bruising on torso, ear, neck in <4yo without consistent history
- Burns
- Social isolation
- Repeated ED visits for same reason
- Abdominal injury
- Vaginal bleeding in prepubertal female
References
Anderst JD, Carpenter SL, Abshire TC, Section on Hematology/Oncology and Committee on Committee on Child Abuse and Neglect of the American Academy of Pediatrics. Evaluation for bleeding disorders in suspected child abuse. Pediatrics 2013; 131:e1314.
http://pediatrics.aappublications.org/content/pediatrics/131/4/e1314.full.pdf
Christian CW, Levin AV, COUNCIL ON CHILD ABUSE AND NEGLECT, et al. The Eye Examination in the Evaluation of Child Abuse. Pediatrics 2018; 142.
http://pediatrics.aappublications.org/content/pediatrics/142/2/e20181411.full.pdf
Christian CW, Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse. Pediatrics 2015; 135:e1337.
Raissaki M, Veyrac C, Blondiaux E, Hadjigeorgi C. Abdominal imaging in child abuse. Pediatr Radiol 2011; 41:4.
https://link.springer.com/content/pdf/10.1007%2Fs00247‐010‐1882‐5.pdf
Rubin DM, Christian CW, Bilaniuk LT, et al. Occult head injury in high‐risk abused children. Pediatrics 2003; 111:1382.
http://pediatrics.aappublications.org/content/pediatrics/111/6/1382.full.pdf
Sheets LK, Leach ME, Koszewski IJ, et al. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics 2013; 131:701.
http://pediatrics.aappublications.org/content/pediatrics/131/4/701.full.pdf
Section on Radiology, American Academy of Pediatrics. Diagnostic imaging of child abuse. Pediatrics 2009; 123:1430.
http://pediatrics.aappublications.org/content/pediatrics/123/5/1430.full.pdf
American College of Radiology. ACR appropriateness criteria. Suspected physical abuse ‐ child.
https://www.jacr.org/article/S1546‐1440(17)30143‐6/pdf