Case Presentation
An 18-month-old male was brought to the emergency department after being found unresponsive and apneic at home. According to the patient's mother, she had left the toddler alone in a high chair for 1 to 2 minutes and upon returning she found the patient slumped over and without respirations. She reported scooping food out of the toddler's mouth followed by blowing in his face. The mother's boyfriend meanwhile placed a call to 911. Upon arrival of EMS, the patient was found to be pulseless and apneic with an agonal cardiac rhythm. The patient had no significant medical or surgical history, immunizations were up-to-date, and he had experienced no recent illnesses or illness exposure.

Case Progression
Upon arrival to the emergency department, advanced life support measures were in progress. The toddler had been intubated prior to arrival and endotracheal tube placement was verified on arrival. He also had I/O access obtained and had received atropine and epinephrine prior to presenting at the emergency department. The toddler was noted to be well developed, without evidence of trauma, abdomen soft and symmetrical chest movement was present with bagging. His cardiac rhythm after arrival vacillated between PEA and asystole, and without regaining any sustainable rhythm the resuscitation efforts were terminated after extensive attempts at restoring circulation. After remaining in the room a few minutes, the mother and her boyfriend left the hospital. As a courtesy to the Medical Examiner, the body was taken to radiology for a skeletal survey which revealed multiple fractures. Following the x-rays, the body was returned to the emergency department at which time it was noted that the toddler had a positive battle sign and retinal hemorrhages. The mother and boyfriend were arrested and the case is unresolved at this time.

What Went Wrong
This patient was appropriately triaged as the highest triage acuity designation possible - Level 1 - and all possible life-saving measures were taken without success. Although in this case there were many possible worst-case scenarios to consider including aspiration, asphyxia, sepsis, a toxicological event, and meningitis -- intentionally inflicted injury was not considered until after the skeletal survey revealed multiple fractures. This devastating case is an example of the importance of maintaining a high index of suspicion for non-accidental trauma in children, especially those under the age of four years. Sadly, children less than one year of age accounted for 42.2% of abuse/neglect fatalities for the year 2007 and children under the age of four accounted for 75.7% of all child fatalities due to abuse or neglect for the same time period¹.

¹U.S. Department of Health & Human Services: Child Welfare Information Gateway. (2009). Child Abuse and Neglect Fatalities: Statistics and Interventions. Retrieved October 6, 2009 from http://www.childwelfare.gov/pubs/factsheets/fatality.cfm

Joyce (RN, BSN, CEN, CCRN, CTRN, CPN, CPEN, SANE-A, EMT-P), a registered nurse with 25 years experience, exemplifies the absolute necessity of considering intentionally inflicted injury as a possible worst-case scenario when caring for the pediatric patient at triage when indicated. Joyce has had extensive experience in the emergency arena and, in fact, participated in the development of the Certified Pediatric Emergency Nurse examination, launched last year, by contributing to the writing of the exam questions. Joyce is an emergency department nurse educator as well as a member of a bereavement team that responds to pediatric deaths as well as other circumstances in which this type of support would be beneficial to families. Joyce shared the following experience:

"I am a seasoned nurse but I had a scenario that nearly did me in emotionally just a few years ago and I needed a little mental health break after it. A 3-year-old with a big crater on his head and eye...mom gave a good story about how it happened. My spider sense was tingling and something wasn't right. The charge nurse thought I was crazy for being concerned - 'just a little infection.' The physician saw no reason to intervene...even if we were approaching it from a neglect rather than abuse standpoint. I can honestly say I have never seen anything like it. Soon all the staff thought I was making a mountain out of a molehill, I called child protection anyway and insisted they come in. They did and called the police. The mother was arrested for child abuse and taken out in handcuffs. The child was transferred to a pediatric hospital who requested multiple x-rays before transfer...which showed so many old rib, arm, and leg fractures I am still ill writing this. I guess when my co-workers read the news headline the next morning - Mom Charged with Attempted Murder they didn't think I was over reacting after all.

When I think back now that if I had given in to what everyone was saying and said, 'Yes, maybe I am over reacting,' that sweet precious boy would likely be dead. He is now adopted by an amazing family who just happens to go to my daughter's school, so I have watched him thrive! Huge lesson learned - to believe in your gut."

Child abuse is one of the most devastating presentations encountered by registered nurses at triage. Children who present to the emergency department triage arena with suspected non-accidental trauma can result in a sense of dread for even the most seasoned nurse. Unfortunately, it is not an uncommon presentaiton. According to the U.S. Department of Health & Human Services, in the year 2007 there were approximately 794,000 children who were confirmed victims of abuse or neglect.¹ It is because of this that we must exercise due diligence and consider, when appropriate to the circumstance, that the underlying issue with any pediatric presentation might indeed be child abuse; the intentional harming of children in America. Remember, there is a 33% recidivism rate for those who have abused a child in the past.²

¹U.S. Department of Health & Human Services: Child Welfare Information Gateway. (2009). Child Abuse and Neglect Fatalities: Statistics and Interventions. Retrieved October 6, 2009 from http://www.childwelfare.gov/pubs/factsheets/fatality.cfm

²Hoffman, J.M. (2005). A case of shaken baby syndrome after discharge from the newborn Intensive Care Unit. Advances in Neonatal Care, 5(3), 135-146. Retrieved September 30, 2009 from OVID database.