Laboratory : Evaluation for Suspected Physical Injuries

Evaluation for a Bleeding Disorder

For excellent comprehensive reviews and recommendations for the evaluation of bleeding in an abused child, see the following two resources: Evaluation for Bleeding Disorders in Suspected Abuse (Anderst et al 2022) and Bruising in Infants: An Approach to the Recognition of Child Physical Abuse (Asnes & Leventhal 2022).

Recommendations for laboratory tests that may help to determine the most common coagulopathies are listed below. Other tests for coagulopathies may be indicated based on history, family history, and physical findings.

• Complete Blood Count (CBC) with Platelets
• Prothrombin Time (PT)
• Activated Partial Thromboplastin Time (aPTT)
• Von Willebrand Factor (VWF) antigen
• VWF activity (Ristocetin cofactor)
• Factor VIII activity level
• Factor IX activity level

Bleeding disorders, as well as child abuse, may present with findings beyond cutaneous bruising, such as oronasal bleeding, intracranial hemorrhages, hematochezia or other presentations.

Evaluation for Visceral Injury 

Abdominal trauma is particularly ominous as the signs and symptoms of significant pathology can initially be very subtle. A complaint of abdominal pain, soft tissue evidence of abdominal trauma, or evidence of hemodynamic compromise increases the index of suspicion for intra-abdominal injury. The following injures are commonly associated with abuse: pancreatic trauma, duodenal and proximal jejunal trauma, liver trauma and pharyngeal laceration without explanation. Evidence-based recommended screening tests for abdominal trauma are listed below:

• Liver transaminases such as alanine aminotransferase (ALT, SGPT) and aspartate aminotransferase (AST, SGOT) may be useful in assessing abdominal trauma. Children with transaminase levels >80 IU/L are recommended to undergo definitive testing, such as abdominal imaging, for abdominal injury (Lindberg et al 2013): https://pubmed.ncbi.nlm.nih.gov/23319537/.
• Amylase and Lipase: Combined serum amylase and lipase levels may indicate pancreatic injury. However, the usefulness of the measurement decreases beyond the immediate time frame post injury (Mahajan et al 2014): https://pubmed.ncbi.nlm.nih.gov/24702828/.
• Urinalysis to look for hematuria may be helpful as an adjunct to other studies in the evaluation for abdominal trauma. (Sabzghabaei et al 2016): https://pubmed.ncbi.nlm.nih.gov/26862543/.
• Stool guaiac to check for occult blood may or may not be indicated following a complete history and physical. For example, after rectal penetration or foreign body insertion in the rectum, it may be clinically important to look for occult blood. A positive test may be helpful in the setting of rectal bleeding due to abdominal or anal trauma.

Evaluation for Skeletal Injuries 

Where history and physical examination findings suggest metabolic bone disease, consider testing for Vitamin D, Calcium, Phosphorus, and Parathyroid Hormone (PTH).

For additional details regarding the evaluation of physical abuse, see the CHAMP Evaluation Guidelines for Suspected Physical Abuse: https://champprogram.com/pdf/guidelines-suspected-child-physical-abuse-june-2022.pdf.