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Department of Pediatrics : Academic Divisions : Emergency Medicine : Resident Manual : Victims of Physical or Sexual Abuse : Initial Evaluation and Referral Guidelines

When a child with an allegation of abuse and/ or neglect presents to the Emergency Department (ED), the following guidelines are recommended:

Sexual Abuse

During triage:

  1. Assess for timing from the last incident (child has provided a clear statement of the allegation)
  2. Inquire for the presence of acute bleeding, discharge, bruising/ abrasions/ lacerations to anogenital tissues
    1. Emergent examination:
      • Last incident of anogenital contact occurred = 72 hours
        and/or
      • Positive genitourinary review of system (see #2)
        • Forensic evidence collection (if within 72 hours of incident)
          • Activate Pediatric SANE protocol, if available
          • Contact Children’s Advocacy Center (CAC) medical provider as needed
        • Perform a complete physical assessment with attention to skin, oral and anogenital tissues
          • Document injuries and photograph, if available
        • Contact Department of Social Services (DSS) if parent/ guardian is the alleged perpetrator and/ or Law Enforcement (LE).
        • Contact hospital social worker or CAC Child Advocate Program if such service available
        • Referral to CAC for:
          • Medical follow up
          • Forensic interview
          • Mental health assessment
    2. Non-emergent examination:
      • Last incident of anogenital contact occurred > 72 hours
        and
      • Negative genitourinary review of system (see #2)
        • Perform a general physical examination of child (in compliance with EMTALA) and defer to CAC for further assessment of anogenital tissues through colposcopic examination
        • Contact DSS if parent/ guardian is the alleged perpetrator and/ or LE
        • Contact hospital social worker of CAC Child Advocate if such service available
        • Referral to CAC for:
          • Medical follow up
          • Forensic interview
          • Mental health assessment

Physical Abuse

When assessing children presenting with injuries that do not merit in-hospital admission, the following should raise concern for possible abuse and/ or neglect:

  • Cutaneous and skeletal injuries in non-ambulatory children
  • Bruises:
    • Located on head, neck, trunk, buttocks
    • Involving multiple body planes
    • With a recognizable pattern
  • Contact/ pattern burns or scald burns in children < 4 years old when associated with a lack of or developmentally inconsistent history of trauma
  • Skeletal injuries in the = 3 years old group with a lack of history or history is inconsistent with the developmental capabilities of the child


If any of the above scenarios are present, we recommend:

  • Phone consultation with CAC medical provider as needed
  • Contact DSS if parent/ guardian is the alleged perpetrator and/ or LE
  • Contact hospital social worker or CAC Child Advocate if such service available
  • Refer to CAC for:
    • Medical follow-up
    • Forensic interview
    • Mental health assessment

Neglect

For children identified at a methamphetamine lab, we recommend the following:

  • Assess if lab was actively manufacturing methamphetamine
  • Obtain from DSS or LE a list of chemicals found at the lab
  • Assess for symptoms/ signs of acute intoxication from methamphetamine or chemicals used in its manufacture
  • Obtain urine toxicology screen; ask for report as a quantitative value in lieu of a positive or negative result
  • Obtain an oxygen saturation level; consider chest X-ray (AP / lateral) if clinically indicated
  • Perform a complete blood count with differential and complete metabolic panel at immediate assessment if child clinically symptomatic from drug exposure
  • Refer to CAC for:
    • Medical follow-up
    • Forensic interview
    • Mental health assessment

For Referral to CAC

  1. Please have parent/ legal guardian of child sign the Authorization for Release of Medical Information form
  2. Provide parent/ legal guardian with Medical Follow-up Information letter
  3. Fax the following items to the CAC:
    1. CAC Referral/ ED Tracking form
    2. ED Medical Report
    3. Child Maltreatment Protocol or Sexual Assault Examination Protocol (Rape Kit) if completed

Note: Referral for a CAC medical evaluation/ follow-up is not exclusively limited to the above scenarios

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