01Approach to the Critical Patient/attcp51

Immediate priorities

›Stabilization priorities

›Airway risk

›Apnea

›GCS < 13

›Ongoing emesis

›Breathing risk

›Hypoxemia

›Suspected pneumothorax

›Circulation risk

›Shock physiology

›Ongoing hemorrhage concern

›Neuroprotection triggers

›Seizure

›Persistent altered mental status

›Escalation and activation

›Trauma team activation for unstable vitals or significant mechanism mismatch

›Persistent tachycardia unexplained by fever or pain

›Hypotension for age

›Immediate pediatric ICU consult for suspected abusive head trauma with symptoms

›Apnea

›Seizure

›Child protection team consult when available

›Any sentinel injury in precruising infant

›Any concerning bruising pattern

›Safety and safeguarding

›Separation strategy

›Separate caregiver interviews when feasible

02History/hx38

History essentials

›Narrative coherence

›Timeline

›Exact time of last known well

›Symptom onset time

›Mechanism details

›Height of fall in cm

›Surface type

›Witnessing

›Direct witness

›Unwitnessed event

›Developmental context

›Mobility milestones

›Precruising

›Cruising

›Baseline neurologic status

›Feeding baseline

›Sleep baseline

›Prior healthcare contacts

›Prior ED visits

›Similar complaints

›Prior injuries

›Prior imaging results

›Previous skeletal survey

›Previous neuroimaging

›Medical explanations to consider

›Bleeding risk

›Personal bleeding history

03Physical Exam/exam35

Exam domains and red flags

›General and vitals

›Growth parameters

›Weight percentile trend

›Head circumference percentile trend

›Vital sign red flags

›Hypothermia in infant

›Unexplained tachycardia

›Skin and soft tissue

›Bruising assessment

›Location mapping

›Size in mm

›Pattern concerns

›Petechiae with no clear medical cause

›Bite mark concern

›Head and neck

›Scalp and face

›Scalp swelling

›Frenulum injury

›Neuro exam

›Fontanelle tension

›Pupillary asymmetry

›Musculoskeletal

›Limb exam

›Focal tenderness

›Pseudoparalysis

›Spine and torso

›Rib tenderness

04Differential Diagnosis/ddx27

Injury etiologies and mimics

›Trauma related

›Physical assault injury pattern (ICD-10 T74.12XA, T76.12XA)

›Multiple injuries with inconsistent story

›Sentinel injury in infant

›Accidental trauma

›Single injury with consistent mechanism

›Developmentally plausible mechanism

›Medical mimics

›Bleeding disorders

›von Willebrand disease

›Hemophilia

›Platelet disorders

›Immune thrombocytopenia

›Congenital thrombocytopenia

›Connective tissue

›Ehlers-Danlos syndrome

›Fragile skin disorders

›Bone fragility

›Osteogenesis imperfecta

›Rickets

›Dermatologic mimics

›Mongolian spots

›Blue-gray patches since birth

›Stable pattern

›Phytophotodermatitis

›Linear streaks after plant exposure

›Hyperpigmented healing

05Laboratory Tests/lt28

Screening labs by injury domain

›Hematology and bleeding

›Initial screen

›Complete blood count for thrombocytopenia and anemia

›INR and PT for coagulopathy screen

›aPTT for intrinsic pathway disorder

›Targeted expansion if abnormal or high suspicion

›von Willebrand panel for mucosal bleeding pattern

›Factor VIII and IX activity for severe bruising or intracranial bleeding

›Occult abdominal injury

›Hepatopancreatic enzymes

›AST for occult liver injury screen

›ALT for occult liver injury screen

›Pancreatic injury adjunct

›Lipase for pancreatic injury concern

›Bone and mineral

›Fragility evaluation triggers

›Calcium for metabolic bone disease screen

›Phosphate for metabolic bone disease screen

›Nutrition and endocrine adjunct

›25-hydroxyvitamin D for rickets concern

›Alkaline phosphatase for rickets concern

Interpretation pearls

›Limitations

›Normal coagulation screening does not exclude mild bleeding disorders

›von Willebrand disease may require specialized assays

›Factor deficiencies may present intermittently

›Transaminase screening limitations

06Diagnostic Tests/dt58

Scoring Systems

›Bruising decision support

›TEN-4-FACESp

›Torso bruising

›Ear bruising

›Neck bruising

›Any bruising in infant < 4 months

›Frenulum injury

›Angle of jaw bruising

›Cheek bruising

›Eyelid bruising

›Subconjunctival hemorrhage

›Patterned bruising

›Neuroimaging decision support

›Pittsburgh Infant Brain Injury Score

›Use case

›Well appearing infant with concern for brain injury

›Trigger for head imaging when score threshold met

›Limitations

›Does not replace clinical judgement

›Not validated for older children

MRI

›Brain and spine MRI roles

›Indications

›Abusive head trauma evaluation after CT

›Concern for cervical spine injury

›Protocol considerations

›Sedation planning

07Disposition/dispo25

Level of care decisions

›Admission default

›Any intracranial injury

›ICU for apnea, seizures, or depressed mental status

›Stepdown for stable imaging findings with close monitoring

›Any visceral injury

›Surgical consultation

›Hemoglobin trend monitoring

›High concern for ongoing unsafe environment

›Hold for CAS safety plan

›Inpatient social work involvement

›Transfer criteria

›Pediatric tertiary center need

›Neurosurgery availability required

›Pediatric trauma capability required

›Child protection team availability

›Forensic pediatrics consultation access

›Coordinated imaging review

›Discharge criteria

›Low suspicion after full evaluation

›Consistent history

›Developmentally plausible mechanism

›No occult injuries on indicated testing

›Safety confirmation

›CAS notified and plan documented when required

›Reliable follow up arranged

08Treatment/t49

Stabilization and symptom control

›Airway and breathing

›Oxygenation targets

›SpO2 goal >= 94%

›Avoid hypoventilation in suspected intracranial injury

›Seizure management

›Benzodiazepine first line (Class I, consensus)

›Levetiracetam second line option (Class IIa, consensus)

›Circulation and hemorrhage

›Shock resuscitation

›Isotonic crystalloid 10 to 20 mL/kg bolus

›Reassess after each bolus for fluid responsiveness

›Blood products

›Packed RBC 10 to 15 mL/kg for hemorrhagic shock or significant anemia with symptoms

›Massive transfusion protocol activation per pediatric trauma pathway

Analgesia and sedation

›Non-opioid analgesics

›Acetaminophen PO or PR 15 mg/kg every 4 to 6 hours

›Maximum 60 mg/kg/day

›Maximum 4000 mg/day

›Ibuprofen PO 10 mg/kg every 6 to 8 hours

›Maximum 40 mg/kg/day

›Avoid in dehydration or renal risk

›Opioid analgesics

›Morphine IV 0.05 to 0.1 mg/kg

›Repeat every 10 to 20 minutes as needed

›Monitor respiratory status

›Fentanyl IV 1 mcg/kg

09Special Populations/sp24

Pregnancy

›Pregnancy considerations

›Adolescent pregnancy possibility in older pediatric patients

›Confidentiality constraints by jurisdiction

›Sexual assault screening triggers

›Imaging considerations

›Radiation minimization strategies

›MRI preferred when equivalent diagnostic value

Geriatric

›Not applicable emphasis

›Pediatric NAT pathway only

›Alternate framework for elder abuse

Pediatrics

›Age specific risk patterns

›Highest risk groups

›Infants under 1 year highest abusive head trauma risk

›Age <= 24 months highest yield for occult fracture screening

›Sentinel injury concept

›Minor injuries in infants predicting later severe harm

›Bruising in precruising infant as high concern trigger

›Imaging by age

›Skeletal survey

›Universal screening exam in suspected physical abuse for age <= 24 months

›Repeat limited skeletal survey at about 2 weeks to detect additional fractures

›Head imaging

›Low threshold in young infants even without neuro symptoms (ACEP Level C, expert consensus)

›MRI for occult injury characterization after CT

10Background/b27

Epidemiology

›Epidemiology anchors

›Vulnerable age group

›Infants most vulnerable to severe physical abuse outcomes

›Abusive head trauma concentrated in children under 5 years

›Miss risk

›Missed abusive head trauma described in literature with high morbidity

›Recurrent presentation pattern common before definitive diagnosis

Pathophysiology

›Injury mechanisms

›Blunt impact mechanisms

›Acceleration deceleration forces

›Rotational forces

›Fracture patterns

›Rib fractures linked to compression forces

›Metaphyseal lesions linked to traction and torsion

›Visceral injury patterns

›Solid organ injury from abdominal blows

›Hollow viscus injury from compression and shear

Therapeutic Considerations

›Clinical priorities

›Child safety as time critical intervention (Class I, consensus)

›Prompt reporting when suspicion exists

›Safe disposition planning

›Imaging strategy balance

›Occult injury detection value in infants and toddlers

›Radiation minimization with targeted protocols

›Documentation as clinical intervention

11Patient Discharge Instructions/pdi13

Copy discharge instructions

›Discharge guidance

›Follow up plan

›Pediatrician appointment within 24 to 72 hours

›Imaging follow up appointment if arranged

›Return to ED now

›Any seizure

›Increasing sleepiness or difficult to awaken

›Repeated vomiting

›New weakness or trouble walking

›Poor feeding in infant

›Safety instructions

›Supervised environment

›Avoid contact sports until cleared if head injury concern

12References/r20

Clinical guidelines and key sources

›Imaging and fracture evaluation

›ACR Appropriateness Criteria Suspected Physical Abuse - Child

›Skeletal survey as screening exam in children <= 24 months

›Repeat limited skeletal survey at about 2 weeks to detect additional fractures

›AAP Clinical Reports 2025 evaluating young children with fractures for child abuse

›Skeletal survey consideration for 24 to 60 months based on suspicion

›Structured evaluation approach

›Abusive head trauma

›AAP 2025 Abusive Head Trauma in Infants and Children

›MRI roles for brain and cervical spine injury characterization

›Serial imaging considerations in selected cases

›Canadian Paediatric Society guidance on suspected traumatic head injury assessment and maltreatment

›Canadian context for assessment and reporting considerations

›Legal and reporting framework in Ontario

›Ontario MCCSS Reporting Child Abuse and Neglect: It’s Your Duty

›Duty to promptly report suspicion to a Children’s Aid Society

›Definition framework for child in need of protection

›CPSO Advice to the Profession: Reporting Requirements

›PHI disclosure permitted to support CAS statutory functions

›Practical guidance for clinician communication

Evidence & Review

Evidence & Review