I struggled to find PEM resources for my CT3 year, despite the variety of excellent resources out there. I hope this website will help point you in the right direction. I'm not a PEM expert, but am following the guidance CEM have issued (in the form of a syllabus) to put together this page. This page is not endorsed by CEM, and any mistakes are mine.

Please comment with corrections, additions and further suggestions.

All the information here is collected from the internet, and it might be out of date or inaccurate, so please use your judgement and adhere to your hospital's protocols. If you do notice any errors or omissions please comment so we can put them right!

To navigate, decide whether you want to start with a PMP or a PAP. You can then select which PMP or PAP you want to look at. You will then be taken to the summary page for that PMP, with links expanded topic collections. If you know what topic you want to look at already, click on the link on the right hand side.

Monday, 7 October 2013

Non-accidental Injury in Children

We're all always told to suspect NAI in any child that comes in. In major trauma NAI is very possible and it would be easy to get swept away with making sure the child was physically OK. Even in minor injuries we don't always remember it.

It is difficult to age bruises just from the colour. The following are worrying signs:
 - bruises in a non mobile child
 - shins and knees are normal places to bruise
 - abusive bruises are often seen on soft bits of the body like buttocks, abdomen and back
 - the ear, neck and head are often affected
 - petechiae are commonly seen in abused children, and less common in accidental bruises
 - bilateral bruising, symmetric or geographic bruising is worrying
The NSPCC have a leaflet, and LearnPediatrics has lots of information.

 - In non ambulatory child is worrying
 - Metaphysis fractures are normally because the child has been pulled.
 - Metaphyseal fractures are also called bucket handle fractures.
 - Spiral fractures are suggestive of twisting
 - Posterior ribs, scapular and sternum are pathognomic of child abuse.
 - Humeral fractures


Head Injuries 
 - Clinical prediction rule
 - Skull fractures are uncommon without NAI

- Duodenal perforation 
- Torn frenulum is not a sensitive predictor
- Epistaxis

There is a case here.

All these worrying signs are nicely summarised on LITFL - the Bakers Dozen of Bashed Baby Badness.



  1. My notes from the RSM PEM Conference:
    Child Protection and Child Trafficking
    Ms Mandy John-Baptiste, Children’s Services Manager, NSPCC
    * Most common in the 15- 17 year group
    * Children can be exploited for criminal activity (eg cannabis cultivating or nail bars), sexual exploitation or domestic servitude.
    May present suicidal + very controlling adult, pregnant and paying for healthcare.
    Vital to use language line if needed.

    Child Trafficking Advice Centre (for HCPs): 0808 800 5000

  2. CASPAR will send out weekly email alerts with CP concerns - sign up at www.nspcc.org.uk/inform

    http://www.nspcc.org.uk/inform/trainingandconsultancy/learningresources/coreinfo/thermalinjuries_wda54674.html = information about burns - kids scalded more quickly than

    http://www.nspcc.org.uk/Inform/research/findings/oralinjuries_wda49442.html = torn labial frenulum in isolation does not indicate child abuse. Assess fully.
    Bites are common. 1% of ED attendances due to bites, 1 in 600 children attending have been bitten. Children do bite each other. Difficult to know whether bite is from an adult or not -- British Association for Forensic Odontology can help assess - www.bafo.org.uk

    http://www.nspcc.org.uk/Inform/research/findings/bruisesonchildren_wda48277.html - you can't age bruises reliably.

    http://www.nspcc.org.uk/Inform/research/findings/fracturesinchildren_wda48236.html - 66% of boys, and 40% of girls have a fracture by their 15th birthday (I'm in the majority then!). 85% of accidental fractures are seen in children < 5yrs old. 80% NAI fractures are in children <18months. May not be accompanied by bruising, or be clinically obvious. May have non-specific symptoms. Worrying fractures are - rib #s, femoral fracture, metaphyseal fracture, spiral or oblique humeral fracture, ???skull fracture, tib/fib under 18 months, multiple fractures.

  3. https://twitter.com/_NMay/status/446558585653194752


  4. http://dontforgetthebubbles.com/sudden-thigh-swelling/#more-6117

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