A two-center retrospective review of the hematologic evaluation and laboratory abnormalities in suspected victims of non-accidental injury

Abstract

Investigation for bleeding disorders in the context of suspected non-accidental injury (NAI) is inconsistent. We reviewed the hematologic evaluation of children who presented with symptoms of bleeding and/or bruising suspicious for NAI to determine the frequency of hematologic tests, abnormal hematologic laboratory results, and hematologic diagnoses. A retrospective cohort study design was employed at two freestanding academic children’s hospitals. ICD-9 codes for NAI were used to identify 427 evaluable patients. Medical records were queried for the details of clinical and laboratory evaluations at the initial presentation concerning for NAI. The median age for the population was 326 days (range 1 day–14 years), 58% were male. Primary bleeding symptoms included intracranial hemorrhage (31.8%) and bruising (68.2%). Hematologic laboratory tests performed included complete blood cell count in 62.3%, prothrombin time (PT) in 55.0%, and activated partial thromboplastin time (aPTT) in 53.6%; fibrinogen in 27.6%; factor activity in 17.1%; von Willebrand disease evaluation in 14.5%; and platelet function analyzer in 11.7%. Prolonged laboratory values were seen in 22.5% of PT and 17.4% of aPTT assays; 66.0% of abnormal PTs and 87.5% of abnormal aPTTs were repeated. In our cohort, 0.7% (3 of 427) of the population was diagnosed with a condition predisposing to bleeding. In children with bleeding symptoms concerning for NAI, hemostatic evaluation is inconsistent. Abnormal tests are not routinely repeated, and investigation for the most common bleeding disorder, von Willebrand disease, is rare. Further research into the extent and appropriate timing of the evaluation is warranted.

Haematological evaluation of bruising and bleeding in children undergoing child protection investigation for possible physical maltreatment: A British Society for Haematology Good Practice Paper

“…Prolongation of the PT has been documented as a consequence of traumatic brain injury, attributable to parenchymal brain damage 32,33 . A retrospective study in victims of suspected non‐accidental injury showed high incidence of prolonged PT and APTT of 22.5% and 17.4% respectively, at presentation 26 …”

“…32,33 A retrospective study in victims of suspected non-accidental injury showed high incidence of prolonged PT and APTT of 22.5% and 17.4% respectively, at presentation. 26 In VKDB, the PT is prolonged and levels of the vitamin K-dependent factors (II, VII, IX and X) are reduced, sometimes accompanied by a prolonged APTT. Correction by administration of oral or parenteral vitamin K, with or without plasma, results in normalisation of the coagulopathy.…”

Changes in admission laboratory tests in patients with maxillofacial fractures and the influence of dento‐alveolar trauma

“…Coagulopathy can reflect the severity of injury rather than its location . Prolonged laboratory values of prothrombin time and aPTT have been reported in trauma series . The main factors to initial acute trauma coagulopathy are tissue trauma, hypoperfusion, inflammation, and sympatho‐adrenal activation leading to hemostatic abnormalities such as hypocoagulability, fibrinolysis, and endothelial hyperpermeability .…”

“…Laboratory testing on trauma patients generally includes evaluation of hematological profiles and blood chemistries including sodium, potassium, chloride, blood urea nitrogen, creatinine, glucose, and amylase levels . In addition, clotting profiles are usually obtained for these patients . In the literature, there are few studies that have evaluated possible alterations in laboratory tests in patients with maxillofacial fractures …”

The Anesthesiologist’s Role in Treating Abusive Head Trauma

“…Rare metabolic disorders that are associated with subdural hemorrhages, such as glutaric aciduria type 1, are diagnosed by characteristic neurologic lesions, urine abnormalities, and other screening tests. 102 Some clinicians may worry that clinical findings suspicious for child abuse may actually be manifestations of a medical disease, such as Ehlers Danlos syndrome, 103 Kasabach-Merritt syndrome, 104 coagulopathy, 105 infection, 106 non-intentional brain trauma, 107 or cardiopulmonary resuscitation. 12 …”