Page 36 - 63 craniocerebral-and-spinal-trauma30-35_opt

Injuries from Child Abuse 225

• Rickets: renal disease, bowed long bones, blood abnormalities. • painful micturition and recurrent urinary tract infections;
• Scurvy: poor wound healing, bleeding gums, petechiae. • faecal soiling or retention;
• Bleeding disorders: haemophilia, meningococcaemia. • discharge from penis or vagina;
• Skin diseases: impetigo, chicken pox, scaled skin syndrome (may • abnormal dilatation of vagina/anus;
mimic burns).
• genital laceration/bruising;
Of course, genuine accidental trauma may also present—the history,
pattern of injury, and interaction with the parents should help to • vaginal bleeding; and
indicate that this is the case. • signs of sexually transmitted infections.
Initial Management of Injuries Guidelines for Examination after Abuse
The initial stabilisation of the physically assaulted child uses an ABC Examination of a sexually abused child should never be taken lightly;
approach, as with any injured child: 7
if not performed under ideal circumstances, it may seriously contribute
• primary survey with resuscitation; to secondary trauma of the child. Examination should always be per-
• secondary survey with emergency treatment; and formed by a qualified doctor, following a specified protocol:
• A designated private area is needed.
• transfer to definitive care.
• A third person (mother or nurse) should be present.
Treatment of the child is the priority at this stage; care should be
taken to minimise the interference with any forensic evidence on the • The procedure should be explained to the caregiver as well as to the
child’s clothes or skin. child.
Primary Survey • A full general examination is necessary; noting weight, height, and
The primary survey consists of ABCDE: nutritional state.
• Airway with cervical spine control
• The genital examination should be performed only once.
• Breathing with ventilatory support
• Small children can be examined on the mother’s lap with the child’s
• Circulation with haemorrhage control back to the mother and the mother holding the legs.
• Disability with prevention of secondary insult • Older children can be examined in the supine lithotomy position.
• Exposure • The lateral decubitus position should be used to examine the anus.
Useful adjuncts at this stage include chest and pelvic radiographs, • The stage of sexual development should be noted (using the Tanner
initial blood tests (including a cross-match sample), an oro- or scale).
nasogastric tube, and a urinary catheter.
All children with evidence of perineal trauma should be examined
Secondary Survey under anaesthesia to determine the exact nature of the injury and the
The initial priority is resuscitation and treatment of immediate life- need for surgical repair.
threatening problems, followed by the secondary survey, in which the Due to the large discrepancy between sexual organs, penetration
child undergoes a thorough head-to-toe examination. Physically abused rarely occurs in sexually abused children. However, forced penetration
children often have evidence of older injuries at the time of their pre- in small children can cause a mutilating injury. Absence of penetration
sentation to the health services, and the evaluating physician should does not rule out abuse. In a local study, one-third of the paediatric
document these accurately. Treatment of specific injuries is discussed sexual assault victims had no physical injuries. 10
in detail in corresponding chapters in this book. Bruises and first- and second-degree tears can usually be repaired
Transfer primarily. However, when there is violation and laceration of the
anal sphincter or the rectovaginal septum, a diverting colostomy and
The final stage of emergency management is transfer to definitive
washout are needed. When all signs of infection have subsided (usually
care. This involves appropriate packaging for transfer—either within
between 6 weeks and 3 months), the definitive repair can be performed.
the hospital or to another unit—and handover to the receiving staff.
The recommended routine investigations for all cases of sexual
Accurate handover is essential in cases of suspected or proven physi-
abuse are the following:
cal abuse, and the presence of accurate contemporaneous notes greatly
facilitates continuity of care. • Full blood count (FBC) and platelets, international normalisation
ratio (INR) and partial thromboplastin time (PTT) to exclude a
Sexual Assault bleeding disorder.
Sexual abuse is common in all societies. The overall rate of sexual
abuse in children under the age of 18 years is 14% for females, and • Vaginal or penile swab where a discharge is present—send for
7% for males. Any child presenting with perineal injuries or infection microscopy, culture, and sensitivities (MC&S).
8
should be suspected of being a victim of child abuse. In girls, sexual • Blood for Venereal Disease Research Laboratory (VDRL).
abuse can be chronic (without signs of fresh injuries, but absent hymen)
or acute (often with fresh physical injuries). Small children often pres- • Human immunodeficiency virus (HIV) serology. Post exposure pro-
ent with a bruised perineum. In the majority of cases, the perpetrator is phylaxis (PEP) is continued only for those who test negative.
known to the child and is probably a family member. 9 • Photographic documentation for legal purposes. Digital photo-
A child very rarely presents with the history of sexual abuse and graphs have to be printed, dated, and signed immediately to be use-
therefore the clinician should be alert to the following symptoms and ful as evidence in court.
signs of abuse: The child should be checked for syphilis (the VDRL test) and
• recurrent abdominal pain; HIV/acquired immune deficiency syndrome (AIDS). If available,
antiretroviral therapy should be instituted. Do not routinely start
• difficulty walking or sitting;