Detecting Child Abuse in the Emergency Department

  1. When there is concern for physical abuse, the physical examination should be completed with the child undressed (in a gown), with specific attention to the skin, scalp and fontanel, mouth and oral cavity (including frena), ears, genitalia, and growth chart.
  2. Any injury in a preambulatory child, including bruises, mouth injuries, fractures, and intracranial or abdominal injury, should raise concern for abuse.
  3. The “TEN 4” rule: bruising of the Torso, Ears, or Neck in children <4 years old and any bruising in children <4 months old should raise concern.
  4. Radiographic skeletal survey should be performed using proper technique for children <2 years old with concern for abuse. Repeating the skeletal survey 2–3 weeks later can identify additional fractures that were not seen initially.
  5. Young (<2 years old) siblings and household contacts of abused children should be examined for abusive injuries and undergo skeletal survey.
  6. Infants evaluated for physical abuse may benefit from neuroimaging even if they don’t have neurological symptoms.
  7. Retinal examination is indicated for children with concern for abusive head trauma but may not be indicated for children without intracranial injury.
  8. Health care providers with a reasonable suspicion of physical abuse have a legal mandate to report their concern to child protective services.

Translating Emergency Knowledge for Kids

Most acutely ill and injured children are managed within emergency departments that are not part of a children’s hospital. Difficulties in getting the right resources and training have been cited as barriers to providing the best possible care in these settings. This has resulted in variable levels of emergency care for children. TREKK is a knowledge mobilization network established to address these critical knowledge gaps and improve emergency care for children. 

2018 AHA PALS Update – Nothing New


The optimal sequence of PALS interventions, including administration of antiarrhythmic drugs during resuscitation, and the preferred manner and timing of drug administration in relation to shock delivery are still not known. One study reported a statistically significant improvement in return of spontaneous circulation when lidocaine administration was compared with amiodarone for pediatric ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest. However, no difference in survival to hospital discharge was observed among patients who received amiodarone, lidocaine, or no antiarrhythmic medication.

Parental Guidance in the Pediatric ED

  • My Emergency Medicine training taught me the importance of “return precautions.”
    • Educate the patients/families about the warning signs of impending doom.
    • Essentially, “come back if things get worse.”
  • In the Pediatric ED (or during acute care related complaints), I find that the combination fo the two is helpful.
    • In the ED, we are seeing only a brief period of time of the illness process. 
      • At the time you are seeing the kid, there may be no obvious emergent danger or urgent condition warranting therapy… but… 
      • Anticipate the potential trajectories that may exist and educate about them.