Trauma

A 10-month-old female presents to the emergency department after a reported ground-level fall from the couch. The caregiver states she “just rolled off” onto a carpeted floor but has since been irritable and sleepy. 

History
The child is in the care of her mother’s boyfriend while the mother is at work. According to the boyfriend, she was playing on the couch and rolled off onto the floor, hitting her head. He reports she cried immediately, vomited once, and then became sleepy. The incident was unwitnessed by anyone else. The child has no significant past medical history, was born at term, and has had normal development. She has not been seen by a primary care provider in the past 6 months. 

Physical Exam
Vitals: T 37.2°C, HR 125 bpm, RR 26/min, BP 90/54 mmHg, SpO₂ 97% on room air
General: Somnolent but arousable, irritable when examined
HEENT: Large parietal scalp hematoma, no external bruising of ears or frenulum, anterior fontanelle full but not bulging
Lungs: Clear to auscultation bilaterally
Cardiovascular: Normal S1/S2, brisk cap refill
Abdomen: Soft, non-tender, no organomegaly
Neurologic: Opens eyes to voice, withdraws all extremities, PERRL, symmetric pupils, mild right gaze preference
Skin: Healing bruises noted on the left upper arm and posterior thighs; no petechiae

• Abusive Head Trauma (AHT) – Most likely, given the severity of the neurologic findings relative to the mechanism described, presence of suspicious bruising, and developmental incongruity (rolling off a couch is unlikely to cause significant head injury in an infant). 
• Accidental Head Trauma – Although plausible in toddlers, the mechanism and clinical findings (vomiting, altered mental status, focal neurologic signs) are concerning for more than a minor fall. 
• Bleeding disorder – Could account for bruising and hematoma, though much less common and usually not presenting with neurologic symptoms. 
• Metabolic or genetic disorders – May mimic signs of trauma but would not explain the specific bruising pattern and acute findings. 

When nonaccidental trauma (NAT) is suspected, clinicians must balance emergent medical care with a high index of suspicion and careful documentation. The TEN-4-FACESp rule is a validated clinical decision tool designed to help identify bruising patterns that are highly suspicious for abuse in children. It flags any bruising on the Torso, Ears, or Neck in children under 4 years of age, and any bruising anywhere on infants under 4 months as concerning. The expanded FACESp component adds the Frenulum, Angle of the jaw, Cheeks, Eyelids, and Sclerae—locations where accidental bruising is rare. The final “p” reminds clinicians that these signs are especially significant in premobile children, for whom bruising is uncommon and should raise immediate concern for non-accidental trauma. This tool helps differentiate between accidental injuries and those that warrant further evaluation, imaging, and involvement of child protection services. 

Initial Evaluation 

• Laboratory evaluation: 

• • CBC, PT/PTT/INR to assess for bleeding diatheses. 

• • CMP to assess liver function, helping identify occult abdominal trauma. 

• • Lipase/amylase to screen for pancreatic injury. 

• • Urine toxicology if ingestion is suspected. 

• • Venous blood gas and point-of-care glucose for overall metabolic status. 

• Imaging: 

• • CT Head without contrast to evaluate for intracranial hemorrhage or edema. 

• • Skeletal survey, typically obtained in children under 2 years old with suspected NAT, to assess current or healed prior fractures.  

• • Consider abdominal imaging to screen for solid organ injury, especially in preverbal children. 

• Additional studies: 

• • Ophthalmology consult for dilated eye exam to evaluate for retinal hemorrhages, suggestive of shaking injuries. 

• • Social work and child protection team consult immediately. 

Management: 

• Airway/Breathing/Circulation: Maintain airway, administer oxygen as needed, and monitor vitals. 

• Neuroprotection: Elevate head of bed and monitor for increased ICP. 

• Consult neurology or neurosurgery to review imaging findings. 

• Report to Child Protective Services (CPS) – Mandatory reporting required by law for suspected abuse. 

• Admission to the PICU for close monitoring and multidisciplinary team involvement (child protection, social work, trauma, etc.). 

• Inconsistent or vague histories are red flags for abuse. A fall from low height rarely causes severe head injury or neurologic findings in non-ambulatory infants.
• Always undress the child fully to identify patterned bruising or sentinel injuries. Careful exam includes looking for signs of oral trauma, rib fractures, bruises in various stages of healing, bucket-handle fractures.
• “Those who don’t cruise rarely bruise”. Bruising in non-mobile infants is highly suspicious and contextualizing the apparent injury by the patient’s age is crucial. 

• Mandated reporting laws protect clinicians who report in good faith. It is not your role to confirm abuse — just to suspect it and act accordingly. 

• Retinal hemorrhages, subdural hematomas, and posterior rib fractures are classic findings in abusive head trauma, though not always all present. 

Answers

Q1. False. While highly suggestive, retinal hemorrhages can occur in other conditions (e.g., severe coagulopathy), but are strongly associated with abusive head trauma. 

Q2. False. Skeletal surveys are recommended for all children under 2 years with suspected abuse, even without visible signs of injury. 

Q3. B. Ophthalmology evaluation and mandated reporting are essential next steps. This child’s presentation is highly concerning for abusive head trauma. 

• CHOP Physical Abuse Clinical Pathway
• AAP Clinical Report: The Evaluation of Suspected Child Physical Abuse
• Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics.
• CHOP PEM Podcast: Abusive Head Trauma
• CHOP PEM Podcast: PECARN Head Trauma