Suspected inflicted abdominal injury — long case

Objectives

1. Recognise that a delayed rigid abdomen with an under-explanatory mechanism is inflicted injury until proven otherwise. [1]
2. Construct the laboratory occult-injury screen and imaging strategy for a stable child. [2] [6]
3. Run trauma-team care and safeguarding concurrently, not sequentially. [1] [5]
4. Secure safe disposition before discharge. [1]

Candidate brief

A 16-month-old is referred by a general practitioner for two days of vomiting, abdominal distension and fever attributed to gastroenteritis. The carer mentions a short fall two days ago. Examination reveals a rigid, guarded abdomen and a faint flank bruise. The child is tachycardic but perfusing. [1]

Expected actions

• Run a structured primary survey, quantify shock through perfusion and lactate, and obtain large-bore access. [1]
• Recognise the pattern: a pre-verbal child, a rigid abdomen, delay, and an under-explanatory mechanism with a sentinel bruise. [1] [3]
• Request AST, ALT, lipase, amylase, FBC, lactate, coagulation and group-and-save; bedside FAST, and contrast-enhanced CT abdomen and chest if the child remains stable. [2] [6]
• Arrange a high-detail skeletal survey with oblique rib views and a repeat at two weeks. [4] [6]
• Activate the paediatric trauma team for peritonitis or instability; prepare theatre for a likely hollow-viscus perforation. [5]
• Notify child protection during resuscitation, file the mandatory report, and document and photograph injuries. [1]
• Plan disposition with a safe place for recovery before the MDT case conference agrees the destination. [1]

Marking

Pass: identifies the high-specificity pattern; requests the AST/ALT and lipase screen plus skeletal survey; operates for peritonitis; runs safeguarding in parallel; refuses premature discharge to the index household. [1] [2]

Fail: accepts gastroenteritis as the diagnosis on a soft early abdomen; omits the skeletal survey; defers child-protection notification until after surgery; discharges without a safe-placement plan. [1] [3]