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Flashcards in SCAN Deck (52)
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1

Bruising red flags

Non-ambulatory/babies not yet cruising
Bruises on the ears, neck, feet, buttocks, torso
Bruises not on the from to the body and/or overlying bone
Patterned (loop marks, handprints, bite marks, belt)
Bruises that do not fit with causal mechanism described
Bruises that are unusually large or numerous

2

What is the differential diagnosis of bruising?

ITP (most common acquired coagulopathy)
HSP
Vitamin K deficiency (CF, malabsorption, hemorrhagic disease of the newborn)
Vitamin C deficiency
Malignancy (Leukemia, neuroblastoma)
vWD (most common inherited coagulopathy)
Hemophilia
Infection (e.g. Meningococcemia)
DIC
Connective tissue disorder (Ehler's danlos)
Gardner-Diamond Syndrome

3

What are some mimics of bruising?

Slate grey nevi/Mongolian spots
Post-inflammatory skin changes
Phytophotodermatitis
Resolving hemangiomas
Skin staining from dyes
Cupping/coining

4

General indicators of child maltreatment

Injury not compatible with history provided (mechanism, developmental age, amount of force)
Delay in seeking medical care
Inconsistent history
Multiple injuries
Injuries of different ages

5

Risk factors for child abuse

Parents characteristics:
History of abuse
Mental illness
Substance abuse
Cognitive deficits
Anger control problems
History of criminal behaviour
Young, single, unemployed

Family characteristics:
Marital conflict
Social isolation / lack of Supports
Early mother-child separation
Crowded household

Child characteristics:
Behaviour problems
Difficulties with feeding and Sleeping
Difficult temperament i.e. colic
Pregnancy or birth complications
Physical disabilities

Parent-child relationship:
Unrealistic expectations of child
High arousal to child distress/anger
Child perceived as difficult
Lack of emotional connection

Environmental characteristics:
Poverty
Higher perceived stress
Frequent changes in residence
Low maternal education

6

Bruising work up

CBC
Peripheral smear
INR/PTT
Factor 8, 9
Fibrinogen
vWF antigen/ristocetin cofactor
Blood type
LFTs and RFTs (for secondary platelet dysfunction)

7

What work up is needed for all non-ambulatory children/<2 years of age with suspected abuse?

Skeletal survey
MRI head if <1 year
Eye exam if findings on neuroimaging

8

Screen for abdominal trauma

AST, ALT, amylase

9

How are most NAI fractures detected?

Incidental finding on XR obtained for something else

10

Red flags for fractures

Non-ambulatory
Location (Metaphyseal, ribs, scapula, vertebrae, sternum)
Pattern (complex skull fracture, multiple fractures)
Age (delay in seeking medical attention, fractures at different ages)

11

What locations of fractures are most concerning for NAI?

Metaphyseal, ribs (especially posterior), scapula, vertebrae, sternum

12

How many x-rays are taken for a skeletal survey?

Typically 21 views

13

Differential diagnosis for fractures

Accidental fractures
Birth injury (rib, humerus, clavicle)
Osteomyelitis
Congenital syphilis
Rickets
OI/other bone dysplasias
Neuromuscular disorders
Copper deficiency (preterm, Menke’s)

14

Causes of retinal hemorrhages other than NAI

Accidental trauma
Birth-related (until 6 weeks of age)
Coagulation disorders
Leukemia
Metabolic disorders

15

What is the only situation where you are mandated to report DIRECTLY to police?

Gun shot wounds

16

What does Canada's criminal code say about physical disclipine?

Allows use of "reasonable" force for the purposes of "teaching" child
Age 2-13
No hits to head/abdomen, objects, marks

17

Workup for abusive head trauma

Dilated eye exam
Skeletal survey
Coag work up +fibrinogen+F8 and 9+FXIII
Metabolic-Glutaric aciduria (GA1)
MRI brain+spine
Photography
CAS

18

What characteristics of retinal hemorrhages are most concerning?

Massive hemorrhage
Multiple layers
Extending to edge of retina

19

What is the most common physical exam finding in sexual abuse?

Normal exam

20

Differential diagnosis of vaginal redness

Vulvovaginitis
Infection
-GAS
-Pinworms
Contact dermatitis
Psoriasis

21

Findings consistent with sexual abuse

Bruising, petechiae, abrasions on hymen
Acute laceration of hymen
Vaginal laceration, perianal laceration to below dermis
Healed complete transection of hymen

22

Diseases suspicious for sexual contact

Neisseria gonorrhea
Syphilis (outside of newborn period)
Trichomonas vaginalis
Chlamydia from ano-genital region
HIV (if not perinatal, blood products, needle contamination)

23

Differential diagnosis for prepubertal vaginal discharge

Foreign body

Nonspecific infection (Strep, Bacterial vaginosis)

STD (Gonorrhea, Chlamydia, Trichomonas)

24

When should HIV testing be repeated ?

3 and 6 months

25

Which 3 STD do you definitely report to CAS and Public Health?

Trichomonas
Gonorrhea
Chlamydia

26

How can HPV be transmitted?

Perinatal
Non-abrasive skin contact (warts on hands)
Sexual contact
Fomite transmission

27

After how long could one consider perinatal transmission of HPV?

Up to 5 years (maybe 8)

28

What investigations do you do for an acute sexual assault?

Exam (general, SMR stage, external genital/anal)
Speculum exam in adolescents
Pregnancy test
Tox screen (based on history)
Sexual assault evidence kit
Don't do STD swabs acutely!

29

In what time frame can you collect a sexual assault evidence kit ?

Vaginal/penile swab-12 days
Anal swab-3 days
For prepubscent, after 24 hours, yield is VERY LOW

30

Management of sexual assault

STI prophylaxis (Azithromycin 1g, Cefixime 800 mg)
Emergency contraception
Consider HepB, HIV prophylaxis