13.4 Non-Accidental Trauma, Smoke Inhalation (Carbon Monoxide & Cyanide) & Heat Illness

Non-Accidental Trauma, Smoke Inhalation & Heat Illness

Non-Accidental Trauma (Child Physical Abuse)

Physical abuse is a leading cause of serious head injury and trauma death in infants. Transport teams are often among the first clinicians to examine an injured child and hear the caregivers' first account.

Red flags in the history

• No explanation, a changing explanation, or an explanation that does not fit the injury
• A mechanism inconsistent with development (for example, "he rolled off the couch" in a 3-week-old who cannot roll)
• Delay in seeking care
• A short fall (less than about 4 feet) blamed for severe brain injury
• Injuries blamed on a sibling or the child themselves

Red flags on examination

• Sentinel injuries: Bruises, intraoral injuries (torn frenulum), or other minor injuries in young infants that precede severe abuse
• TEN-4-FACESp bruising rule: Bruising on the Torso, Ears, or Neck in a child 4 years or younger; any bruising in an infant younger than 4 months; bruising of the Frenulum, Angle of the jaw, Cheeks (fleshy), Eyelids, or Subconjunctivae; or patterned bruising (hand, loop, or object marks)
• Burns: Immersion burns with sharp "stocking" or "glove" borders, symmetric burns, sparing of flexor creases, and patterned contact or cigarette burns
• Fractures: Classic metaphyseal lesions, posterior rib fractures (from squeezing), multiple fractures of different ages, and any fracture in a non-ambulatory infant without a clear mechanism

Abusive head trauma

• Subdural hemorrhage (often of different ages or in multiple locations), retinal hemorrhages (especially extensive and multilayered), and encephalopathy, sometimes with cervical ligament or cord injury and hypoxic-ischemic injury
• Infants may present with only vomiting, lethargy, irritability, apnea, seizures, or a bulging fontanelle. Consider abuse in any infant with unexplained seizures or apparent life-threatening events.
• Management follows TBI principles (Section 13.2), with spinal motion restriction when cervical injury is possible.

The transport clinician's role

1. Treat the child first. Resuscitation and stabilization do not change because abuse is suspected.
2. Document objectively. Record injuries by location, size, color, and shape. Write the caregivers' statements in quotes, with who said them and when. Avoid opinion words such as "abused" or "suspicious" in the record.
3. Do not accuse or interrogate. Confrontation can endanger the child, siblings, and staff and can compromise the investigation.
4. Mandated reporting: Health care professionals, including transport clinicians, are mandated reporters of suspected child abuse in every U.S. state. A report requires reasonable suspicion, not proof. Coordinate with the referring team, the receiving child protection team, and the program's policy so the report is made.
5. Preserve evidence (clothing, as directed) and hand off all findings. The receiving team will typically perform a skeletal survey in children younger than 2 years, neuroimaging, and ophthalmology examination.
6. Siblings and other children in the home may also need evaluation. Mention them in the report.

Medical child abuse (fabricated or induced illness, formerly called Munchausen by proxy) should be considered when reported symptoms do not match objective findings or occur only in one caregiver's presence.

Smoke Inhalation: Carbon Monoxide and Cyanide

Fires in enclosed spaces cause three injuries at once: thermal airway injury (Section 13.3), carbon monoxide (CO) poisoning, and hydrogen cyanide poisoning from burning plastics, wool, and synthetics.

Carbon monoxide

• CO binds hemoglobin with more than 200 times the affinity of oxygen, forming carboxyhemoglobin (COHb). This lowers oxygen content, shifts the dissociation curve left, and poisons mitochondrial respiration.
• Standard pulse oximetry reads COHb as oxyhemoglobin, so SpO2 can look normal while oxygen delivery is poor. Measure COHb by co-oximetry.
• Symptoms: Headache, vomiting, confusion, syncope, seizures, and coma. The "cherry red" skin color is a late and unreliable sign. Infants may present only with irritability or vomiting, and whole families may be affected (a clue in winter heater exposures).
• Treatment: 100% oxygen by non-rebreather mask or ventilator. COHb half-life is about 4–6 hours in room air, about 1–1.5 hours on 100% oxygen, and shorter with hyperbaric oxygen.
• Hyperbaric oxygen is considered for loss of consciousness, neurological deficits, cardiac ischemia, markedly elevated COHb, or pregnancy. Fetal hemoglobin binds CO avidly, so pregnant patients need a lower threshold. Transport to a hyperbaric center depends on the patient's stability and the chamber's ability to accept critically ill children.

Cyanide

• Cyanide blocks cytochrome oxidase, halting aerobic metabolism. This is histotoxic hypoxia: tissues cannot use oxygen even when delivery is adequate (Section 3.2).
• Suspect it in enclosed-space smoke inhalation with altered mental status, seizures, hypotension or shock, apnea, and marked lactic acidosis (a lactate above about 8–10 mmol/L in a smoke-inhalation victim is highly suggestive).
• Hydroxocobalamin (Cyanokit) binds cyanide to form cyanocobalamin, which is excreted in urine. Pediatric dose: 70 mg/kg IV (maximum 5 g) over about 15 minutes. Expected effects include red skin and urine, transient hypertension, and interference with colorimetric laboratory tests and blood-leak alarms, so draw labs first when possible.
• Avoid sodium nitrite in smoke-inhalation victims with possible CO poisoning. Nitrites induce methemoglobinemia, which further reduces oxygen-carrying capacity. Sodium thiosulfate may be used as an adjunct.

Heat Illness and Hyperthermia

Hyperthermia is not fever. Fever is a hypothalamic set-point change and responds to antipyretics. Hyperthermia is failure of heat loss or excess heat production, and antipyretics do not work.

Complications of heat stroke: Rhabdomyolysis, acute kidney injury, liver injury, DIC, cerebral edema, and hypoglycemia. Monitor glucose, potassium, and urine output, and anticipate seizures. Transport vehicles and aircraft can themselves be hot. CAMTS requires aircraft cabin temperatures to be monitored and documented.