From the Wake Forest School of Medicine.
Emergency Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC.
Pediatr Emerg Care. 2023 Sep 1;39(9):641-645. doi: 10.1097/PEC.0000000000003012. Epub 2023 Jul 19.
The objective of this study is to determine which of the child abuse clues quoted in the literature predict nonaccidental trauma (NAT): history incongruent with injuries found on examination or imaging, old injuries present, history of trauma denied by caregivers, multiple fractures present, changing history, fractures of varied duration, metaphyseal fracture, ear bruise, neck bruise, different history (second historian), and metaphyseal fracture.
This is a 4-year retrospective study of all suspected NAT cases referred to our medical center. In addition to the index visit, medical records were searched for visits before the index visit with patient historical or physical findings that might have suggested NAT but were not investigated. The association of diagnostic clues and the outcome were assessed by chi-square and logistic regression analysis.
For 48 months, there were 109 cases of suspected NAT referred for evaluation (age range, 1 week to 15 years). After formal investigation by an abuse specialist, 79.3% of the cases were considered "likely abuse". Those historical or physical findings with a univariate association with a final conclusion of likely abuse included history incongruent with injuries, old injuries present, trauma history denied, changed history, and retinal hemorrhage. In multivariate logistic regression, only a history incongruent with injures remained an independent predictor of likely abuse (odds ratio, 8.65; 95% confidence interval, 1.74-43.07; P = 0.0151). After review of prior records, in only 2 of 109 cases (1.8%) was there a prior visit where NAT could have been suspected; however, history was thought to be congruent with the injury at the original visits.
In this 4-year study of NAT, the clinical clue that best predicted likely abuse after expert investigation was a history that was incongruent with the injuries found on emergency department evaluation. The incidence of possible early recognition from a prior emergency department visit in this group was very low, <2% of cases.
本研究旨在确定文献中引用的哪些虐待儿童线索可预测非意外伤害（NAT）：检查或影像学检查发现的损伤与病史不符、存在陈旧性损伤、照料者否认外伤史、存在多处骨折、病史变化、骨折时间不同、干骺端骨折、耳部瘀伤、颈部瘀伤、不同病史（第二位病史提供者）和干骺端骨折。
这是一项对所有转至我们医疗中心的疑似 NAT 病例进行的 4 年回顾性研究。除了就诊时，还对就诊前的病历进行了检索，以寻找可能提示 NAT 但未进行调查的病史或体格检查结果。采用卡方检验和逻辑回归分析评估诊断线索与结果的相关性。
在 48 个月期间，有 109 例疑似 NAT 病例被转来进行评估（年龄范围为 1 周至 15 岁）。在虐待专家进行正式调查后，79.3%的病例被认为“可能存在虐待”。与最终可能存在虐待的结论具有单变量相关性的病史或体格检查结果包括：病史与损伤不符、存在陈旧性损伤、否认外伤史、病史变化和视网膜出血。在多变量逻辑回归中，只有病史与损伤不符仍然是可能存在虐待的独立预测因素（比值比，8.65；95%置信区间，1.74-43.07；P = 0.0151）。在对既往记录进行审查后，在 109 例病例中仅发现 2 例（1.8%）可能在之前就诊时就怀疑存在 NAT；然而，在原始就诊时，认为病史与损伤相符。
在这项对 NAT 的 4 年研究中，经过专家调查后，预测可能存在虐待的最佳临床线索是病史与急诊科评估发现的损伤不符。在该组中，从之前的急诊科就诊中早期识别的可能性非常低，<2%的病例。
