NON-ACCIDENTAL TRAUMA (NAT) SCREENING

and MANAGEMENT GUIDELINE (Inpatient and Outpatient)

“Red Flag” History of Present “Red Flag” Physical Exam Findings Infant “Red Flag” Radiographic Findings
Injury  Torn frenulum  Metaphyseal fractures (corner)
 No history or inconsistent hx  FTT (weight, length, head circumference)  Rib fractures (especially posterior)
 Changing history  Large heads in infants (consider measuring of OFC in in infants
 Unwitnessed injury children < 1 yr)  Any fracture in a non-ambulating
 Delay in seeking care  Any bruise in any non-ambulating child - “if you don’t cruise infant
 Prior ED visit you don’t bruise”  An undiagnosed healing fracture
 Domestic Violence in home  Any bruise in a non-exploratory location {especially the TEN  SDH and/or SAH on neuro-imaging
 Premature infant (< 37 weeks) region-Torso (area covered by a standard girl’s bathing suit), in young children, particularly in
 Low birth weight/IUGR Ears and Neck} < 4yrs old (TEN-4) the absence of skull fracture
 Chronic medical conditions  Bruises, marks, or scars in patterns that suggest hitting with < 1 year
an object

Recommended evaluation in cases of suspected physical abuse

Note: If patient presents at any MHS Hospital other than Mary Bridge Children’s Hospital, with “Red Flag” findings,
please call the MBCH Emergency Department at (253) 403-1418 to arrange transfer for complete NAT workup.
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Laboratory
General for most patients: If fractures are present:
 CBC & platelets; PT/PTT/INR  Phos
(if concern of low/falling Hgb, repeat in am with retic)  PTH
 CMP  Vit D 25-OH
 Lipase
 Urinalysis – Dip, send for microscopic

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Radiology
 Skeletal survey for < 2 years old (with 2 week follow up)
 In ED if needed for disposition; or
 Within 24 hours of admission
 Head CT (non-contrast with 3D reconstruction) if
 < 6 months of age and other findings of abuse
 Bruising to face or head injuries AND < 12 months of age
 Neurologic symptoms < 12 months of age (including soft symptoms such as vomiting, fussiness)
 Abdominal CT if
 S/Sx of abdominal trauma
 ALT or AST if twice normal

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Consults
 Crisis Intervention Social Work
 Call CAID if diagnosis of abuse or likely abuse at:
 403-1478, Monday-Friday 8 am to 5 pm; if after hours, leave a message and call will be returned when they return
 403-1418, MB ED, after hours and weekends (they can reach the CAID Medical Director if necessary)
 Report to Child Protective Services if:
 Injuries are severe and above diagnosis is clear cut and/or
 There are other young children in the same home
 Pediatric General Surgery for trauma evaluation
 If Head CT abnormal and abuse is being considered, call
 Neurosurgery
 Ophthalmology for retinal exam*
 Neuropsychology
 Child Advocacy
*An Ophthalmology consult for a dilated eye exam is not necessary as part of the evaluation for physical abuse
IF ALL OF THE FOLLOWING CRITERIA ARE MET:
 NORMAL head CT or CT with only a single, simple non-occipital skull fracture
 NORMAL mental status/neurologic exam

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Disposition
 If any suspicion of NAT has been raised during the ED encounter, a face-to-face care team “huddle” must take place prior to ED discharge. All mem-
bers involved in the patient’s care should participate including (at a minimum) the ED physician, ED RN and Social Worker.
 For suspected abusive head trauma NAT cases that require admission as clinically indicated with either Intracranial abnormality identified on head CT
or suspected seizures from abusive head trauma:
 Medical/Surgical trauma service admission with Q4 hour neuro checks for further child abuse work up
 Consider PICU admission for:
 Any child with intracranial injury/bleed or skull fracture(s) identified on head CT
 Any child with normal head CT/no seizures but GCS < 15
 For suspected NAT cases not involving head trauma, admission to Medical/Surgical or PICU after injuries are reviewed by ED MD and Pediatric General
Surgeon as medically indicated.
 Prior to hospital discharge: care team “huddle” including all members involved in the patient’s care. Phone communication between may be utilized as
necessary.
 Outpatient CAID follow-up as needed.

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Communication
 Inform parents if a CPS Referral has been filed and/or if Child Advocacy is consulted.
 Be direct and objective. Inform parents inflicted trauma is part of diagnostic consideration.
 Keep the focus on the child. Avoid appearing judgmental. Assure parents of thoroughness of evaluation.
 If you are unable to have this conversation with the parents, ask SWS or a senior colleague to do so.