1. In patients who may be at higher risk for undeclared domestic abuse (e.g., the elderly, individuals in same-sex relations, pregnant women, substance abusers, frequent presenters to the ED) look for and recognize discrete indicators of possible abuse when establishing the differential diagnosis for their complaints.
Clues on history
- Vague or changing story
- History not consistent with injury
- History not consistent with developmental capabilities
- Unexplained delay in care
- Recurrent injuries in patient or sibling, death of sibling
2. In a patient who presents with an injury or injuries, look for and recognize presentations that may be suggestive of undeclared abuse (e.g., typical and atypical patterns of injury, late presentations, recurrent presenters).
Bruises – most common
- usual area – Pinna of ears, cheek, neck, truncal brusing
- normal in pretibia area
- Child not cruising
- Object shaped – belt, bites
Other Soft tissue injuries
- Immersion pattern burn
- Frenulum tear
- blood in mouth/nose
Fractures suspicious for abuse / non-accidental trauma:
- unexplained fracture
- Multiple fractures in different stages of healing
- Fractures with an unlikely mechanism
- High specificity site: sternal, scapula, spinous process, rib (posteromedial) fractures
- High specificity type:
- metaphyseal fracture “corner” or “bucket handle”) – tibia/femur from grabbing/shaking – pathognomonic for abuse
- spiral fracture except tibia (toddler’s fracture) – thought to be pathognomonic for abuse, but not true
- retinal hemorrhage, papilledema
3. When abuse is suspected, use appropriate means to find and confirm all injuries or manifestations of abuse, both recent and old (e.g., old files, skeletal survey, fundoscopy).
Skeletal survery – x-rays of major bones
- should be done in all cases of suspected child abuse
- AP – arms, forearms, hands, thighs, legs, feet, abdomen, pelvis
- AP + lateral – cervical, thoracic, lumbar spine
- 2 views of skull
4. When abuse is suspected, or declared, provide a confidential, non-judgmental, supportive, and safe environment for the patient to facilitate disclosure and the establishment of an effective therapeutic relationship.
5. When abuse is suspected or confirmed, use a multidisciplinary approach to intervene and provide support (e.g., sexual assault team, domestic abuse counselors, and crisis/social workers).
6. When abuse is suspected or confirmed, ensure that management includes the patient’s informed consent and agreement to the plan, reports to authorities as appropriate, and a disposition that ensures the safety of the patient and other vulnerable parties (e.g., children, elders).