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Child Abuse Pocket Atlas, Volume 1. Randell Alexander, MD, PhD
Читать онлайн.Название Child Abuse Pocket Atlas, Volume 1
Год выпуска 0
isbn 9781936590636
Автор произведения Randell Alexander, MD, PhD
Жанр Юриспруденция, право
Серия Pocket Atlas Series
Издательство Ingram
Medical providers may choose to interview the child victim. It is important that the child’s safety is assured and that they will not be longer be harmed. General open-ended questions are preferred, eg, “How did you get hurt?” More detailed, specific questions may be asked after the child victim has had the opportunity to tell their story. It is also important to ascertain whether the child has been coached or threatened, if they tell.
Figure 1-1. Length of time required for second- and third-degree burns to occur when exposed to liquids of varying temperatures, reinforcing the relative importance of time and surface temperature in the causation of cutaneous burns.
Other important factors to consider when examining a burn victim, is the length of time it takes for a second- or third-degree burn to occur relative to the temperature of a given liquid (Figure 1-1), the surface temperature, and the location of the burn on the child’s body (Figure 1-2). The head and thoracoabdominal region are more likely to be involved in unintentional burns, whereas buttocks, genitalia, bilateral hand, and bilateral feet burns are much more likely to be related to abuse. Unintentional scald burns of the trunk usually involve the anterior surface of the body. In most cases, a child pulls a tablecloth edge, causing a hot liquid to spill over and burn them from the table. Gravity causes an inverted triangle burn pattern. Clothing may affect the burn pattern and severity as it insulates the skin. Hot liquid may pool in the diaper area resulting in an unusual burn pattern. The most common indicators of abuse are burns to the genitalia and buttocks, and mirror image burns to the extremities. Bruises, welts, or fractures may also be present. The most important factor in distinguishing abusive from unintentional burns is determining whether the burn pattern is consistent with the history given by caregivers.
A medical provider should consider abuse when the following are present:
1. Multiple hematomas or scars in various stages of healing
2. Concurrent injuries or evidence of neglect, such as malnutrition and failure to thrive (Especially suspicious are old rib fractures and distal femoral or tibial metaphyseal, or transverse fractures.)
Figure 1-2. Diagram of anterior and posterior body surfaces with the results of the Grossman Burn Center Study that was presented at the American Burn Association Annual Meeting in 1999. It represents the frequency of involvement of different body parts with a comparison between unintentional and abusive burns.
3. History of multiple prior hospitalizations for “unintentional” traumas
4. An inexplicable delay between time of injury and first attempt to obtain medical attention (In some cases, a caregiver with medical training may delay as they initially tried to treat the injury themselves.)
5. Burns which appear older than the alleged day of the incident, similarly indicating ambivalence about seeking care due to the possibility of the true etiology of the burn being revealed
6. An account of the incident which is not consistent with the age or developmental ability of the child
7. Allegations by the responsible caregivers that there were no witnesses to the incident and the child was merely discovered to be burned
8. History of relatives other than the parents bringing the injured child to the hospital or a nonrelated caregiver bringing the child (excepting a proper explanation, such as a babysitter caring for a child while the parents are out of town)
9. Burns attributed to the action of a sibling or other child (Although this is often an explanation from parents or other caregivers for abusive burns, it should also be noted that siblings can be abusive.)
10. An injured child who is excessively withdrawn, submissive, overly polite, or does not cry during painful procedures
11. Scalds of the hands or feet, often symmetrical, that appear to be full thickness in depth, suggesting that the extremities were forcibly immersed and held in hot liquid
12. Isolated burns of the buttocks or perineum and genitalia, or the characteristic doughnut-shaped burn of the buttocks
13. Conflicting or changing explanations offered by the responsible caregivers
The burns presented in this chapter illustrate patterns found in abusive burns as well as unintentional burns. The inability to match the caregivers’ description to the patterns observed usually reveals the abusive nature of these intentional burns. The young ages of these victims are typically seen with abusive burns.
IMMERSION BURNS
STOCKING-GLOVE PATTERN
Case Study 1-3
This 11-month-old male presented with bilateral submersion burns of the hands. The initial history given by the mother was that the child had been burned when he spilled hot coffee on himself. The injury was not consistent with a spill and indicated an inflicted submersion burn. The child’s hands were immersed in a pot of scalding water.
Figure 1-3-a. Note the distinct line of demarcation between the burned and unburned areas.
Figure 1-3-b. Note that all digits of both hands are burned.
Case Study 1-4
This 20-month-old girl was in the care of her mother’s boyfriend. He stated that she was sitting in about 4 inches of bathwater when he left the room momentarily. He returned to the bathroom when he heard the child cry and noted that the hot water had been turned on. His explanation was inconsistent with her injuries, which were clearly caused by submersion. The abusive nature of the injuries was evidenced by the stocking-glove pattern and the spared portion of skin in the popliteal area of the left leg, which was protected by either the girl flexing her leg or the boyfriend’s hand as he dipped her into the water.
Figures 1-4-a, b, and c. Stocking-glove pattern burns on both legs of the infant.
Case Study 1-5
The caregivers of this 18-month-old boy stated that the child sustained these burns when he turned on the hot water in the bathroom sink. The bilateral stocking-glove pattern, however, was indicative of immersion burns. The caregivers later admitted to intentionally immersing the boy’s hands in hot water as a form of punishment.
Figure 1-5-a. Bilateral stocking-glove pattern burns on the boy’s hands and forearms.
Figures 1-5-b and c. The palms of each of the