Escobar Mauricio A, Pflugeisen Bethann M, Duralde Yolanda, Morris Carolynn J, Haferbecker Dustin, Amoroso Paul J, Lemley Hilare, Pohlson Elizabeth C
Mary Bridge Children's Hospital and Health Center, Tacoma, WA, USA.
University of Washington School of Medicine, Seattle, WA, USA.
Pediatr Surg Int. 2016 Apr;32(4):377-86. doi: 10.1007/s00383-016-3863-8. Epub 2016 Jan 25.
Each year, nearly 1 million children in the USA are victims of non-accidental trauma (NAT). Missed diagnosis or poor case management often leads to repeat/escalation injury. Victims of recurrent NAT are at higher risk for severe morbidity and mortality resulting from abuse. The objective of this review is to describe the evolution and implementation of this tool and evaluate our institutional response to NAT prior to implementation.
A systematic guideline for the evaluation of pediatric patients in which NAT is suspected or confirmed was developed and implemented at a level II pediatric trauma hospital. To understand the state of our institution prior to implementation of the guideline, a review of 117 confirmed NAT cases at our hospital over the prior 4 years was conducted.
In the absence of a systematic management guideline, important and relevant social and family history red flags were often missing in the initial evaluation. Patients with perineal bruising experienced significantly higher mortality than patients without perineal bruising (27.3 vs. 5.7%; p = 0.03) and were significantly more likely to require surgery (45.5 vs. 14.2%; p = 0.02).
Development and implementation of a standardized tool for the differentiation and diagnosis of NAT and creation of a structured electronic medical record note should improve the description and documentation of child abuse cases in a community hospital setting. A retrospective analysis demonstrated that in the absence of such a tool, management of NAT may be inconsistent or incomplete. Perineal injury is an especially ominous red flag finding.
在美国，每年有近100万儿童成为非意外创伤（NAT）的受害者。漏诊或病例管理不善往往导致再次受伤或伤情加重。反复遭受NAT的受害者因虐待而出现严重发病和死亡的风险更高。本综述的目的是描述该工具的演变和实施情况，并评估我们机构在实施之前对NAT的应对措施。
在一家二级儿科创伤医院制定并实施了一项针对疑似或确诊NAT的儿科患者评估的系统指南。为了解在实施该指南之前我们机构的情况，对我院过去4年中117例确诊的NAT病例进行了回顾。
在缺乏系统管理指南的情况下，初始评估中常常遗漏重要且相关的社会和家族史警示信号。会阴部瘀伤的患者死亡率显著高于无会阴部瘀伤的患者（27.3%对5.7%；p = 0.03），且更有可能需要手术（45.5%对14.2%；p = 0.02）。
开发并实施用于区分和诊断NAT的标准化工具以及创建结构化的电子病历记录，应能改善社区医院环境中虐待儿童病例的描述和记录。一项回顾性分析表明，如果没有这样的工具，NAT的管理可能会不一致或不完整。会阴部损伤是一个特别不祥的警示信号。
