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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2892_Библиотеки_им_академика_М_И_Перельмана
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more formal testing may be necessary in some cases. Since 2013, the United States
Preventive Services Task Force (USPSTF) has recommended (Grade B) that clinicians regularly screen women of childbearing age for IPV. It also found insufficient
evidence to assess the balance of benefits and harms of screening all elderly or vulnerable adults for abuse and neglect and found insufficient evidence to recommend
routine IPV screening. The USPSTF does recommend that all clinicians should be
alert to physical and behavioral signs and symptoms associated with abuse and neglect
and that direct questions about abuse are justifiable due to high levels of undetected
abuse in women and the potential value of helping these patients. Multiple studies
have shown that screening does not result in harm to participants. Recommendations regarding interactions with victims of abuse include exhibiting compassionate, nonjudgmental, supportive care in a private, secure environment.
Human Trafficking
Human trafficking is a form of modern day slavery in which victims are forced or
coerced into performing sexual acts or work against their will. About 90% of victims will seek health care at some point when they are trafficked; therefore, clinicians have an important role to identify and free these individuals. Some red flags
may include
Stated age older than appearance
Accompanying individuals refuse to leave examination room
Tattoos or marks indicating ownership
Delay in seeking medical care
Scripted or mechanically recited history
Evidence of physical violence
Intimate Partner Violence
Although it is common to think of IPV as a man abusing a woman, abuse can occur
in both homosexual and heterosexual relationships with a male or a female victim.
It is estimated that greater than one in five women and nearly one in seven men have
experienced severe violence by an intimate partner. Abuse can occur in any relation-
ship or in any socioeconomic class. Certain situations increase the likelihood, or
escalate the occurrences, of abuse. These situations include changes in family life
(eg, pregnancy, illnesses, deaths); economic stresses; and substance abuse. Personal
and family histories of abuse also increase the likelihood of family violence. Most
women do not disclose abuse to their health care providers.
Clinical Presentation. Victims of abuse can present with varied symptoms and
signs suggestive of the problem. Direct physical findings can include obvious traumatic injuries, such as contusions, fractures, “black eyes,” concussions, and internal
bleeding. Genital, anal, or pharyngeal trauma; sexually transmitted infections; and
unintended pregnancy may be signs of sexual assault. Depression, anxiety, panic,
somatoform and posttraumatic stress disorders, and suicide attempts can also
result from abusive relationships.
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Some signs and symptoms may be less obvious and may require numerous
encounters until the finding of family violence is made. Victims of abuse may present to doctors frequently for health complaints or have physical symptoms that
cannot otherwise be explained. Delays in treatment for physical injuries may be
a sign of IPV. Chronic pain, frequently abdominal or pelvic pain, is commonly a
sign of a history of abuse. The development of substance abuse or eating disorders
may prompt inquiry into family violence as well. Children of women abused often
directly witness the abuse of their mother. Children and adolescents of abused
women can exhibit aggression, anxiety, bed-wetting, and depression.
Assessing Home Safety. When abuse is identified, an initial priority is to assess
the safety of the home situation. Direct questioning regarding increasing levels of
violence, the presence of weapons in the home, and a plan for safety for the victim
and others at home (children, elders) are critical. Resources and support, such as
shelters, community-based treatment, and advocacy programs, should be provided.
It may be helpful to allow the patient to contact a shelter, law enforcement, family
members, or friends while still in the health care provider’s office. Multidisciplinary
interventions, including family, medical, legal, mental health, and law enforcement,
are often necessary.
The laws regarding clinician reporting of partner violence vary from state to state.
It is important to know the statutes in your locality. Many states do not require
contacting legal authorities if the victim of the abuse is a competent adult.
Child Abuse
Epidemiology. Approximately 1 million cases of child abuse, with more than
1000deaths, are reported each year in the United States; the number of unreported cases makes the overall prevalence much higher. Child abuse is the third
leading cause of death in children between 1 and 4 years of age, and almost 20% of
child homicide victims have contact with health care professionals within a month
of their death.
The situations that increase the risk of child abuse are similar to those that
increase the likelihood of other family violence. These include parental depression and previous history of abuse, substance abuse, social isolation, and increased
stress. Societal factors include dangerous neighborhoods and poor access to recreational resources. Children who are chronically ill or who have physical or developmental disorders may be at even higher risk. Protective factors include family
support from the community or relatives, parental ability to ask for help, and
access to mental health resources. Identification of at-risk families and home visitation interventions have been shown to significantly reduce child abuse. Shortand long-term physical, psychological, and social consequences are often seen in
the victims of child abuse.
Clinical Presentation. Certain history and physical examination findings raise the
suspicion for child abuse. Several presenting history and behavioral features may
be associated with increased risk of maltreatment or abuse (Table 36–1). Injuries
that are inconsistent with the stated history or a history that repeatedly changes with
questioning should raise the suspicion of abuse. Children who are taken to multiple
health care providers or emergency departments, or who are brought in repeatedly
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Table 36–1 • CONCERNING FEATURES THAT MAY BE ASSOCIATED WITH
CHILD ABUSE
Evolving or absent history about injury
Delay in seeking care for concerning condition
Unusual interactions between child and parent
Overly compliant child with painful medical procedures
Overly affectionate behavior from child to medical staff
Overly protective parent
Parental substance abuse or intoxication
Poor self-esteem in parent
History of abuse in parent’s childhood
History of domestic abuse
Loss of control of parent triggered by child’s behavior
Data from Tintinalli JE, Ma O, Yealy DM, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide,
9th ed. 2020. Copyright © McGraw Hill LLC. All rights reserved.
with traumatic injuries, may be victims. Delay in seeking medical care for an injury
may also be a clue to abuse. Any serious injury in a child < 5 years old, especially in
the absence of a witnessed event, should be viewed with suspicion.
Children frequently have bruises, fractures, and other injuries that occur accidentally, and it can be difficult to distinguish with certainty whether an injury is
accidental or intentional. However, certain types of injuries are uncommon as acci-
dents (Table 36–2). The presence of these injuries is highly suggestive of child
abuse. Neglect is also a form of child abuse. An injury or illness that occurred because
of lack of appropriate supervision may be a sign of neglect. Failure to provide for
basic nutritional, health care, or safety needs are other forms of neglect.
Evaluation. When an injury suspicious for child abuse is identified, attention
should initially focus on treatment and protection from further injury. A complete
examination should be performed and all injuries documented with drawings or
photographs. An x-ray skeletal survey can be performed to look for evidence of
current or previous bony injuries. Skeletal survey is typically recommended for all
cases of suspected abuse in children younger than 2 years. Ophthalmologic examination should be performed to look for retinal hemorrhages. Other imaging, such
as computed tomography (CT) of the head, nuclear medicine imaging, or positron emission tomography, may be indicated depending on patient circumstance.
Laboratory studies can be useful both in identifying disorders that might explain
observed findings and in discovering occult or more severe injury not evident on
examination. Testing for sexually transmitted infections may be necessary as well.
The clinical findings, pertinent history, and results of evaluation should be documented carefully and legibly.
All 50 states require reporting of suspected child abuse to child protective services or other appropriate authorities (refer to local laws to determine the appropri-
ate authority). Communication to parents should be in a neutral, nonaccusatory
manner. They should be informed that a report is going to be made and educated
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Table 36–2 • INJURIES SUGGESTIVE OF CHILD ABUSE
Stocking-and-glove burns of the extremities (immersion in scalding water)
Burns of the buttock and groin that spare the intertriginous areas (immersion in scalding water)
Centimeter-size circular burns (cigarettes)
Multiple bruises of differing ages (most common manifestation of child abuse)
Epiphyseal separations
Multiple fractures and/or fractures in different stages of healing
Unexplained injury to buttocks, thighs, ears, or neck
Bite marks
Bruises in the shape of a hand, belt buckle, or loops of a cord
Retinal hemorrhages (“shaken baby syndrome”)
Corner or “bucket-handle” fractures of metaphysis of long bones
Spiral fracture of femur or humerus
Rib fractures, especially posteriomedial fractures
Vertebral body fractures and subluxations
Digital fractures
Scapular fractures
Spinous process fractures
Sternal fractures
Complex, bilateral, or wide skull fractures
Injury to external genitalia
Sexually transmitted infections, genital warts
Circumferential hematoma of anus (forced penetration)
Data from Tintinalli JE, Ma O, Yealy DM, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study
Guide, 9th ed. 2020. Copyright © McGraw Hill LLC. All rights reserved.
regarding the process that is likely to occur after the report is made. Your role as
an advocate for the child’s health and safety should be explained. Consideration
must also be given to the possibility that there are other victims of abuse in the
home (spouse, other children, elders). Any health care provider who makes a good-
faith report of suspected abuse or neglect is immune from any legal action, even if the
investigation reveals that no abuse occurred. Providers may be held liable for failure
to report child abuse.
Elder Abuse
Epidemiology. Many types of elder abuse may occur, including physical, sexual, and
psychological abuse; neglect; and financial exploitation. The estimated prevalence
of elder abuse ranges from 2% to 10%, and out of the 1 in 10 elders that may experience abuse, only 1 in 5 incidents are reported. Along with the other risks for
domestic violence, several factors unique to the care of elders may play a role. The
majority of abusers are family members. Caregiver frustrations and burnout are
commonly heard excuses for abuse. Abusers often have histories of mental health
problems or substance abuse and have little insight into the fact that they are abusing the patient. Women older than 75 years are statistically the most abused group.
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Persons who are older, are more cognitively and physically debilitated, and have less
access to resources are more likely to be abused or exploited.
Evaluation. A history of abuse may be difficult to obtain, as the patient may fear
worsening of the abuse or may not have the cognitive ability to make an accurate
report. If feasible, it is helpful to interview the patient without the presence of the
caregiver. Screening the caregiver for stress, in private, with referral for community
resources may prevent abuse in the elderly. The physical examination, like in child
abuse, should carefully document any injuries that are found. Suspicions of dehydration or malnutrition should be confirmed with appropriate laboratory testing,
and radiographs should be performed as necessary.
By law, elder abuse should be reported to the appropriate adult protective services, but the reporting requirements vary by state. A multidisciplinary approach
involving medical providers, social workers, legal authorities, and families is usually
necessary to address the issues involved.
CASE CORRELATION
See also Case 5 (Well-Child Care), Case 18 (Geriatric Health Mainte-
nance and End-of-Life Issues), and Case 37 (Limping in Children).
COMPREHENSION QUESTIONS
36.1 A 42-year-old woman presents to your office for evaluation of chronic
abdominal pain. She has seen you multiple times for this complaint, but the
workup has always been negative. On examination, her abdomen is soft, and
there are no peritoneal signs. She has no rash, but she does have a purpuric
lesion lateral to her left eye orbit. Which of the following is the best next step
in the management of this patient?
A. Ask the patient about physical abuse and report suspicions to the local
police.
B. Ask the patient about physical abuse and provide information about local
support services.
C. Exclude a bleeding diathesis before inquiring about abuse.
D. Order an abdominal x-ray.
E. Refer to psychiatry.
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36.2 A 7-month-old boy is brought to the emergency department by his father
after a 1-day history of intractable vomiting. On examination, the child is
lethargic. The anterior fontanel is closed. An abdominal x-ray shows a nonspecific bowel gas pattern and incidentally reveals a midshaft fracture of the
right femur. When confronted about the fracture, the father states that the
child climbed onto a chair and jumped off yesterday. Which of the following
is the most appropriate next step in management?
A. Outpatient radiographic bone survey
B. Consulting a child abuse specialist
C. Social services consult
D. Disclosing to the parent the intention of contacting child protection
services
E. Inpatient noncontrast CT of the head
36.3 Which of the following injuries is most likely to be caused by abuse in a
toddler?
A. Three or four bruises on the shins and knees
B. Spiral fracture of the tibia
C. A displaced posterior rib fracture
D. A forehead laceration
36.4 An 80-year-old man who resides in a local nursing home is seen in your office
for unexplained scratches on his arms and band-like bruises on his wrists
and ankles consistent with restraint use. The patient is mildly demented and
appears scared. There is no family to contact. Examination and laboratory
results show no medical reason for easy bruising. Which of the following
should be your next step?
A. Refer to nursing home social worker.
B. Contact nursing home ombudsmen program.
C. Have the patient observed by nursing home staff.
D. Contact nursing home vice president for nursing care.
E. Send the patient back to the nursing home.
ANSWERS
36.1 B. It is appropriate to discuss your concerns in a nonaccusatory, nonjudgmental fashion with your patient. Waiting for her to bring up the subject may
result in her suffering further abuse. The reporting of the abuse (answer A)
of competent adults (not elders) is not mandated by law in most states. You
should offer assistance, evaluate her safety, and provide her with information
regarding available services in the area. There is no reason to exclude a bleeding diathesis (answer C) before approaching the subject of abuse. Answer D
(abdominal x-ray) is not needed since there are no abdominal complaints.
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Answer E (refer to psychiatry) is not indicated since there is no evidence of
depressive disorder.
36.2 E. This child has injuries consistent with physical abuse. Although the findings and further investigation for abuse are important, the most important
primary concern is (a) assessment for a life-threatening injury, which in this
case is possibly a head injury; and (b) protection of the child from possible
further injury. For this reason, CT of the head is of primary importance. In
children younger than 1 year of age, 75% of fractures are due to abuse. Moreover, the shape of a fracture—spiral, transverse, or other—is less important
in suspected abuse than the age of the child and location of the fracture. The
purported history of fall is inconsistent with the developmental abilities of
a 7-month-old child. The child has intractable vomiting and is lethargic on
examination. These findings are worrisome for neurologic damage. An inpatient evaluation with CT of the head should be ordered to exclude intracranial bleed since this disorder may lead to irreversible brain damage or even
death if not identified quickly; additionally, the child is protected from further abuse while workup is being completed. Of note, the anterior fontanel
closes between 4 and 26 months of age (average 13.8 months). It may bulge in
conditions such as meningitis or intracranial hemorrhage that increase intracranial pressure. Outpatient management with close follow-up and referral to
child protective services is appropriate if caregivers are not suspected of being
the abusers. While a radiographic bone survey (answer A) is indicated in all
children younger than 2 years of age with suspected abuse, it should be done
after excluding more urgent conditions. If you are concerned that the child
may be at further risk of abuse and that notifying the parents of your concerns would put the child at immediate danger, it is not necessary to notify
the parents of your report to law enforcement or child protective services
(answer D). However, in most cases, the parents should have the opportunity
to discuss these concerns with you.
36.3 C. A posterior rib fracture is often the result of grabbing and squeezing the
chest violently. It is very suspicious for abuse. A spiral fracture of the tibia
(answer B) is known as a “toddler’s fracture” and is a common injury that
is often confused with abuse, but not often caused by abuse. Bruises on the
anterior and over bony prominences, such as the shins and knees (answer
A), and forehead injuries (answer D) are common from falls while learning
to walk. Well-padded areas that are bruised such as the thigh, buttock, and
cheeks increase the likelihood of abuse.
36.4 B. Clinicians have a legal duty to report possible elder abuse to adult protective services in their community. If the patient is living in a nursing care facility, each state has nursing home ombudsmen who can investigate. The
Ombudsman Program is mandated by the Federal Older Americans Act. If
you feel that this patient is in immediate danger, he can be admitted for evaluation of bruising while the ombudsman and local adult protective services
investigate for substandard care or abuse at the nursing care facility. Social
worker referral (answer A) may be indicated once there is an investigation to
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ensure that the patient is not being abused. Observation by nursing home
staff (answer C) would not determine whether there is abuse. Contacting the
nursing home vice president (answer D) often leads to administrative and
legal correspondences rather than safeguarding the patient. Sending the patient
back to the nursing home (answer E) is the worse option, since the patient
may very well be in a harmful environment.
CLINICAL PEARLS
» Suspected child and elder abuse must be reported to either child or adult
protective services, respectively. Good-faith reports of suspected abuse
are a shield to lawsuits; failure to report can result in legal action against
the clinician.
» When a patient presents with an injury, there should be a nonjudgmental
and nonthreatening method of gathering information to try to reconcile
the reported mechanism of injury and the physical findings.
» Injuries that are inconsistent with reported activity, delayed seeking
medical care, and multiple injuries over time are suspicious for abuse.
» Clinicians are in a unique position to identify victims of human traffickers.
» When seeing a suspected abuse victim, always consider the possibility
that there could be other abuse victims in the household.
REFERENCES
Breiding MJ, Basile KC, Smith SG, Black MC, Mahendra RR. Intimate Partner Violence Surveillance:
Uniform Definitions and Recommended Data Elements. Version 2.0. Atlanta, GA: National Center for
Injury Prevention and Control, Centers for Disease Control and Prevention; 2015.
Colbourne M, Clarke M. Child abuse and neglect. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD,
Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study
Guide, 9e New York, NY: McGraw Hill; http://accessmedicine.mhmedical.com/content.aspx?bookid=
2353§ionid=220291943. Accessed May 21, 2020.
Dicola D, Spaar E. Intimate partner violence. Am Fam Physician. 2016;94(8):646-651.
Glauser J, Hustey FM. Abuse of the elderly and impaired. In: Tintinalli JE, Stapczynski J, Ma O, Yealy
DM, Meckler GD, Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide.
8th ed. New York, NY: McGraw Hill; 2016: Chap. 295.
Hancock M. Intimate partner violence and abuse. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM,
Meckle GD, Cline DM, Meckler GD, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study
Guide. 8th ed. New York, NY: McGraw Hill; 2016: Chap. 294.
Hoover R, Polson M. Detecting elder abuse and neglect: assessment and intervention. Am Fam
Physician. 2014;89(6):453-460.
Kodner C, Wetherton A. Diagnosis and management of physical abuse in children. Am Fam Physician.
2013;88(10):669-675.
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CASE 37
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A 12-year-old boy is brought to the office with right thigh pain and a limp. His
mother has noticed him limping for the past week or so. He denies any injury to
his leg but says that it hurts some when he plays basketball with his friends. He
denies fever, weight loss, back pain, hip pain, or ankle pain. He occasionally gets
some pain in the right knee but does not have any swelling or bruising. He has no
significant medical history, does not take any medications regularly, and other wise
feels fine. On examination, he is a well-appearing, overweight adolescent with
normal vital signs and initial physical examination. When you have him walk, he
has a prominent limp. You note that he seems to keep his weight on his left leg for
a greater proportion of his gait cycle than he does on the right leg. Examination
of his back reveals a full range of motion, no tenderness, and no muscle spasm.
He gets pain in the right hip when it is passively internally rotated. When the hip
is passively flexed, there is a noticeable external rotation. His right knee and the
remainder of his orthopedic examination are normal.
▶ What is the most likely diagnosis?
▶ What is the most appropriate test to order first for this patient?
▶ What complication could occur if this problem is not diagnosed and treated?
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