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Images in emergency medicine. Child abuse caused by cigarette burns



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Itai Shavit, MD
Hadas Knaani-Levinz, MD
From the Emergency Department, Meyer Children’s Hospital, Rambam Health Care Campus,
Haifa, Israel.
0196-0644/$-see front matter
Copyright ©2008 by the American College of Emergency Physicians.
[Ann Emerg Med. 2008;51:579.]
A previously healthy 4-year-old child was presented because of refusal to eat or drink. No vomiting, fever, or diarrhea was reported by the
parents. Examination revealed a normally behaving afebrile child with no signs of dehydration or sepsis. Multiple “impetigenized” lesions
were noted on his face (Figure 1). The initial diagnosis of impetigo was cast into doubt after more lesions were revealed on patient’s back
and limbs. All lesions were regular in size and round, some had vesicular appearance, and others were more erythematous and raised (Figure 2).
Child protective services were called.
Figure 1. Multiple facial lesions.
Figure 2. Different types of burns on patient’s back.
Figure 3. Burn. The cigarette in the picture was used to compare diameters. Used with permission of Itai Shavit, MD,
Emergency Department, Meyer Children’s Hospital, Rambam Health Care Campus, Haifa, Israel.
For the diagnosis and teaching points, see page 582.
To view the entire collection of Images in Emergency Medicine, visit
Volume , .  : May  Annals of Emergency Medicine 579
drawbacks of nesiritide and intravenous nitroglycerin in
the treatment of patients presenting to the ED with
acutely decompensated congestive heart failure.
4. A. What is the trial registration? Why is it important? This
trial was registered. Find the registration page online. Is
the trial registration information adequate? When was the
trial registered? Are there any potential problems? What
else would you like to see?
B. What is the Consolidated Standards of Reporting Trials
(CONSORT) statement (see http://consort- Discuss the importance of items 6 through
11 in the CONSORT checklist (study outcomes, sample
size, randomization generation, allocation concealment,
randomization implementation, blinding, or masking).
What are the pros and cons of reporting guidelines such as
CONSORT, Quality of Reporting of Meta-Analysis
(QUOROM) and Standards for Reporting of Diagnostic
Accuracy (STAR-D)?
C. Discuss to what extent this study successfully addressed
items 6 to 11 in CONSORT and how any shortcomings
might bias this study.
5. A. In your opinion, what are the most important conclusions
from this article? How might the limitations mentioned by
the authors affect your decision whether to change your
clinical practice with regard to the treatment of patients with
acutely decompensated congestive heart failure in your ED?
B. Nesiritide is a recombinant form of the natural human
peptide, hBNP. Studies have demonstrated that patients
with acutely decompensated congestive heart failure often
already have increased BNP levels in the blood.
If these
patients already have increased levels of BNP circulating in
their blood, how does nesiritide improve the treatment of
acutely decompensated congestive heart failure?
C. What additional information or data analyses would you like
the authors to provide for you to change your clinical practice?
1. Publication Committee for VMAC Investigators. Intravenous
nesiritide vs nitroglycerin for treatment of decompensated
congestive heart failure: a randomized controlled trial. JAMA.
2. Sackner-Bernstein JD, Kowalski M, Fox M, et al. Short-term risk of
death after treatment with nesiritide for decompensated heart
failure: a pooled analysis of randomized controlled trials. JAMA.
3. Hauptman PJ, Schnitzler MA, Swindle J, et al. Use of nesiritide
before and after publications suggesting drug-related risks in
patients with acute decompensated heart failure. JAMA. 2006;
4. Greenland S, Pearl J, Robins JM. Causal diagrams for
epidemiologic research. Epidemiology. 1999;10:37-48.
5. Glymour MM, Greenland S. Causal diagrams. In: Rothman KJ,
Greenland S, Lash TL, eds. Modern Epidemiology. 3rd ed.
Philadelphia, PA: Lippincott; 2008.
6. Heart Failure Society of America. HFSA 2006 Comprehensive
Heart Failure Practice Guideline. J Card Fail. 2006;12:e1-2.
7. Topol EJ. Nesiritide—not verified. N Engl J Med. 2005;353:113-116.
8. Collins SP, Hinckley WR, Storrow AB. Critical review and
recommendations for nesiritide use in the emergency department.
J Emerg Med. 2005;29:317-329.
9. Dao Q, Krishnaswamy P, Kazanegra R, et al. Utility of B-type
natriuretic peptide in the diagnosis of congestive heart failure in
an urgent-care setting. J Am Coll Cardiol. 2001;37:379-385.
10. Maisel AS, Krishnaswamy P, Nowak RM, et al. Rapid
measurement of B-type natriuretic peptide in the emergency
diagnosis of heart failure. N Engl J Med. 2002;347:161-167.
(continued from p. 579)
Child abuse caused by cigarette burns. The patient’s mother admitted that she had purposely inflicted cigarette
burns to her child. Cigarette burns are a major diagnostic problem.
Burns located on a child’s back or buttocks
are unlikely to have been caused nondeliberately and therefore are more suspect than burns about the face and
eyes, which can occur accidentally if the child runs into a lighted cigarette held by an adult.
Multiple lesions
caused by cigarette burns are distinctively suggestive of child abuse, especially if they are of uniform size, circular,
and showing groupings on the face, back, or limbs.
A typical lesion has a diameter of 0.5 to 0.8 cm and a well-
defined smooth edge (Figure 3). Lesions in various stages of healing may be misdiagnosed as staphylococcal bullous
impetigo or varicella virus infection.
These cases are probably underreported because of low index of suspicion. A
missed diagnosis can result in inappropriate medical care, ongoing abuse, and future fatality.
1. Barber MA, Sibert JR. Diagnosing physical child abuse: the way forward. Postgrad Med J. 2000;76:743-749.
2. Ojo P, Palmer J, Garvey R, et al. Pattern of burns in child abuse. Am Surg. 2007;73:253-255.
3. Porzionato A, Aprile A. Staphylococcal scalded skin syndrome mimicking child abuse by burning. Forensic Sci Int. 2007;
4. Greenbaum AR, Donne J, Wilson D, et al. Intentional burn injury: an evidence-based, clinical and forensic review. Burns.
Journal Club Barrett & Schriger
582 Annals of Emergency Medicine Volume , .  : May 
... [34] Cigarette burns appear as 7 to 10 mm round, well-demarcated burns that have a deep central crater. [43] They often appear grouped on the face, hands, and feet. [29,44] When accidental, they tend to be oval or eccentric and more superficial, as the child usually brushes against the cigarette. ...
Full-text available
This article reviews cutaneous manifestations of physical and sexual abuse and a stepwise approach that dermatologists can apply to differentiate abusive from accidental injuries.
... Such a bias is likely to develop in the setting of a study that only analyzes admitted patients because the majority of NEG or abusive contact burns result from cigarettes, irons, and other small surfaces that create minor TBSA burns not requiring admission. 53,56,68,[84][85][86][87][88] ...
Full-text available
Inflicted burns are one of the leading causes of abuse-related fatalities in children. Between 30 and 60% of children accidentally returned to abusive homes suffer reabuse. Given the high chance for abuse recurrence and the associated morbidity/mortality, it is critical that inflicted burns are promptly identified to guide appropriate medical and child welfare management. Although previous studies proposed historical and mechanistic features using noncomparative or poorly powered data, this study utilized comparative data from a 6-year period (2009-2014) at a certified burn center along with expert analysis from Child Advocacy and Protective Services (CAPS) to provide higher level evidence supporting classical findings while elucidating new features with respect to burn severity and required interventions. A retrospective chart review of 408 pediatric burns was cross-referenced with the respective CAPS consultations to construct a multidisciplinary, deidentified database. The average age was 2.9 years (0.04-17 years) with 232 (57%) males and 330 (81%) African-Americans. CAPS investigations confirmed burn etiologies: noninflicted (346 [85%]), negligent (30 [7%]), and inflicted (32 [8%]). In comparing the three etiologies, statistical significance (P Language: en
A majority of burns are accidental with 70% of these occurring in infants and children under three years of age. Inflicted burns constitute 6–20% of all child abuse cases [1].
Anyone who manages burn patients must be aware that some patients may have been burned intentionally. One must consider whether the “story” matches the burn pattern. Intentional burns have recognizable patterns and the perpetrators have typical traits. When suspicion arises all caregivers are obligated to report their concerns to the authorities. This chapter provides information on how to recognize burn-related child and adult abuse.
Abuse takes many forms, including physical abuse, sexual abuse, emotional abuse, and neglect. The definition of child abuse, by the Center for Prevention and Treatment of Child Abuse (USA), is stated as the mental and physical injury, sexual abuse, neglect, or mistreatment of individuals under 18 years of age, perpetrated by a caregiver, which indicates that the health of the child is threatened [1]. Physicians must always be alert for signs indicating any manifestation of abuse, looking for symptoms beyond skin lesions. The authors consider any form of abuse a medical emergency, recognizing that most children, or elderly, are unable to articulate their condition or alert authorities of any wrongdoing and rely nearly exclusively on the awareness of astute professionals. Many cases of abuse are left unrecognized by professionals, the findings being exceedingly subtle, often written off as innocuous lesions. Early recognition is crucial, not only to prevent subsequent injury which occurs in 30-70 % of children, but reports have indicated that abuse tends to increase in severity with time [2], and early intervention may avert these avoidable events. © Springer Science+Business Media, LLC 2013. All rights are reserved.
This systematic review identifies features of intentional non-scald burns in physical abuse. Fifteen bibliographic databases of international literature (1950-2011) were searched to identify potential studies that were critically appraised using standardised methods. Primary studies with confirmed intentional non-scald burns in children aged<18years were included to provide a descriptive analysis of the causation,xz appearance and distribution of burns. 'This systematic review identifies features of intentional non-scald burns in physical abuse' Twenty studies were included: one cross-sectional, one case control and 18 case studies/small case series representing 73 children with intentional non-scald burns. The majority were contact burns from household items: the agents included cigarettes (18), irons (9), electric fires/heaters/radiators (10), cigarette lighters (2), hairdryers (7), curling tongs (3), chemicals (3), microwaves (2) flame burns (7), miscellaneous (7) and burns of unknown cause (5). The burns occurred throughout childhood. The majority of children were older than three years. The characteristic features were of clearly demarcated contact burns or scars in shapes that mirrored the agent. They were predominantly recorded on the limbs, trunks and the backs of hands; they were frequently multiple and co-existed with additional signs of abuse. These features should raise concerns of suspected physical abuse.
Full-text available
The rate of adoption of new therapies for cardiovascular diseases following the publication of favorable clinical trial results has been studied; however, less is known about the rates of de-adoption of a drug when negative studies are published. To evaluate the use of nesiritide before and after March and April 2005 publications in 2 high-impact journals that suggested an increased risk of renal failure and mortality with intravenous nesiritide for acute decompensated heart failure. Analysis of a large prospective hospital database, developed for quality and utilization benchmarking, of 491 acute care US hospitals at which 385,627 inpatient admissions occurred with a primary International Classification of Diseases, Ninth Revision (ICD-9) code for heart failure between January and August 2001 (prior to nesiritide release) and January 2004 to December 2005 (before and after publication periods). In addition, any patient admitted who received nesiritide in the absence of a primary or secondary heart failure code was evaluated for potential off-label use of the drug. Use of nesiritide and other intravenous vasoactive therapy among patients admitted with heart failure. Nesiritide use decreased from a peak of 16.6% (2351 of 14,167 admissions) in March 2005 to 5.6% (611 of 10,822 admissions) in December 2005 (P<.001). Among those patients treated with nesiritide, the mean duration of treatment changed minimally, from 2.3 to 2.1 days. Although the use of inotropes also decreased during the period under study, the changes were more modest; furthermore, of those patients who were prescribed intravenous vasoactive therapy, a higher percentage were prescribed inotropes after publication (3272 [21.5%] of 15 193 patients from January-April 2005 vs 5750 [29.6%] of 19 445 patients from May-December 2005, P<.001). The use of nesiritide, in the absence of an ICD-9 heart failure code, was small. Rapid de-adoption of nesiritide occurred following 2 publications suggesting risk with the drug. Further analyses are required to evaluate the consequences of these changes on patient outcomes and to anticipate how publications of adverse findings can influence practice.
Causal diagrams have a long history of informal use and, more recently, have undergone formal development for applications in expert systems and robotics. We provide an introduction to these developments and their use in epidemiologic research. Causal diagrams can provide a starting point for identifying variables that must be measured and controlled to obtain unconfounded effect estimates. They also provide a method for critical evaluation of traditional epidemiologic criteria for confounding. In particular, they reveal certain heretofore unnoticed shortcomings of those criteria when used in considering multiple potential confounders. We show how to modify the traditional criteria to correct those shortcomings.
Each year in England and Wales, as many as 40 000 children are the subject of a case conference for suspected physical abuse. Abuse has major physical and psychological consequences for the health and welfare of the affected children. The evidence indicates that a significant proportion of abused children experience serious long term effects and they carry the legacy of their abuse with them into adult life.1 2 The management and diagnosis of abuse in children is therefore of great importance. The management of child abuse must start with accurate diagnosis. With such an important subject one would expect there to be a considerable number of publications giving quantitative evidence on which to base diagnosis. Unfortunately, this is not the case and there has been little work giving probabilities for diagnosis, risk, and outcome for the abused child. In this article, we will review the evidence we have on the diagnosis of physical abuse in children. We will also review the differential diagnosis, the process of differentiation of physical abuse from accident, and what basis we have for giving evidence to the child protection process. The initial recognition of the possibility of abuse is in some ways the most important step in the child protection process. This is done by social workers, health visitors, neighbours, teachers, and many other people involved with children. It is also the responsibility of all doctors who deal with children. There are, of course, many disincentives for this happening. Some doctors may be unhappy about even recognising the possibility that parents could have harmed a child. Doctors may feel uncertain about the diagnosis and they may accept accidental explanations readily. Every doctor who may suspect a child is abused should have access to expert advice. One should never walk alone in child protection! Help is …
The goal of this study was to evaluate the utility of a rapid "bedside" technique for measurement of B-type natriuretic peptide (BNP) in the diagnosis of congestive heart failure (CHF) in an urgent-care setting. B-type natriuretic peptide is a protein secreted from the cardiac ventricles in response to pressure overload. One potential application of measurements of BNP in blood is distinguishing dyspnea due to CHF from other causes. B-type natriuretic peptide concentrations were measured in a convenience sample of 250 predominantly male (94%) patients presenting to urgent-care and emergency departments of an academic Veteran's Affairs hospital with dyspnea. Results were withheld from clinicians. Two cardiologists retrospectively reviewed clinical data (blinded to BNP measurements) and reached a consensus opinion on the cause of the patient's symptoms. This gold standard was used to evaluate the diagnostic performance of the BNP test. The mean BNP concentration in the blood of patients with CHF (n = 97) was higher than it was in patients without (1,076 +/- 138 pg/ml vs. 38 +/- 4 pg/ml, p < 0.001). At a blood concentration of 80 pg/ml, BNP was an accurate predictor of the presence of CHF (95%); measurements less than this had a high negative predictive value (98%). The overall C-statistic was 0.97. In multivariate analysis, BNP measurements added significant, independent explanatory power to other clinical variables in models predicting which patients had CHF. The availability of BNP measurements could have potentially corrected 29 of the 30 diagnoses missed by urgent-care physicians. B-type natriuretic peptide blood concentration measurement appears to be a sensitive and specific test to diagnose CHF in urgent-care settings.
Burn injury can be inflicted intentionally either by one person to another whenever one has the ability to physically control the other, or it can be self-inflicted. There is scant evidential basis for much that is written about and practiced in the evaluation and care of patients that have sustained intentional burn injuries. Yet this is an area in which medical personnel must necessarily be trained in both the therapeutic and forensic aspects of a complex problem. Failure to appreciate the complexity of medical and forensic interactions may have far reaching effects. A missed diagnosis can result in inappropriate medical care, on-going abuse and future fatality. Inept management can result on the one hand, in blame levelled inappropriately placing incomparable strain on family units and innocent parties, and on the other, allow abusers to continue unchecked. This is the first review on the subject in which lawyers and doctors collaborate to produce a holistic approach to this subject. In it we describe the legal considerations that medical staff must appreciate when approaching patients who may have suffered intentional burns. We analyse the various scenarios in which intentional burning can be found and challenge the clinical dogma with much of the management of paediatric inflicted burns has become imbued. We suggest a rational and balanced approach to all intentional burn injuries-especially when children are involved. In the light of current case law in which dogmatic medical evidence has been implicated in wrongful convictions for child abuse in the UK, it is imperative that medical professionals gather evidence carefully and completely and apply it with logic and impartiality. This paper will aid clinicians who may not be experienced in dealing with burn injuries, but find themselves in the position of seeing a burn acutely, to avoid common mistakes.
Nesiritide improves symptoms in patients with acutely decompensated heart failure compared with placebo and appears to be safer than dobutamine. Its short-term safety relative to standard diuretic and vasodilator therapies is less clear. To investigate the safety of nesiritide relative to noninotrope-based control therapies, primarily consisting of diuretics or vasodilators. Primary reports of completed clinical trials as of December 2004 were obtained from the US Food and Drug Administration (FDA), the study sponsor (Scios Inc), a PubMed literature search using the terms nesiritide, clinical trials, and humans, and a manual search of annual meetings of 3 heart associations. Of 12 randomized controlled trials evaluating nesiritide, 3 met all inclusion criteria: randomized double-blind study of patients with acutely decompensated heart failure, therapy administered as single infusion (> or =6 hours), inotrope not mandated as control, and reported 30-day mortality. Data were extracted from FDA and sponsor documents and corroborated with published articles when available. Thirty-day survival was assessed by meta-analysis using a fixed-effects model and time-dependent risk by Kaplan-Meier analysis with Cox proportional hazards regression modeling. Where deaths were described within a range of days after treatment, an extreme assumption was made favoring nesiritide over control therapy, an approach relevant to the time-dependent analyses. In the 3 trials, 485 patients were randomized to nesiritide and 377 to control therapy. Death within 30 days tended to occur more often among patients randomized to nesiritide therapy (35 [7.2%] of 485 vs 15 [4.0%] of 377 patients; risk ratio from meta-analysis, 1.74; 95% confidence interval [CI], 0.97-3.12; P = .059; and hazard ratio after adjusting for study, 1.80; 95% CI, 0.98-3.31; P = .057). Compared with noninotrope-based control therapy, nesiritide may be associated with an increased risk of death after treatment for acutely decompensated heart failure. The possibility of an increased risk of death should be investigated in a large-scale, adequately powered, controlled trial before routine use of nesiritide for acutely decompensated heart failure.
Dr. Eric Topol asks, How can a drug that is associated with higher rates of both renal dysfunction and death than placebo — and that costs 50 times as much as standard therapies — be given to more than 600,000 patients and be promoted throughout the United States for serial outpatient use, an indication not listed on the label?
Heart failure is a disease of epidemic proportions. Almost five million Americans suffer from heart failure and over 400,000 patients are newly diagnosed with heart failure each year. Indeed, heart failure is now the only cardiovascular disease that is increasing in incidence and prevalence. Costs related to heart failure are $18.8 billion per year and are steadily increasing. Although the outpatient management of these patients has seen substantial improvement in the last two decades, emergency department (ED) treatment of acute decompensated heart failure has remained largely unchanged since the late 1970s. Current ED therapy consists of diuretics, intravenous vasodilatators, and inotropes. Recently, the outcomes of several high-profile clinical trials evaluating intravenous nesiritide (human B-type natriuretic peptide) have suggested a benefit in select hospitalized patients. Such a therapy has potential to provide a therapeutic addition or alternative for emergency heart failure management. We discuss these trials' results, suggest their relationship to the ED population, and provide recommendations for appropriate ED use.