臨床意思決定ケース：非意図的外傷

This clinical decision-making (CDM) case is intended for emergency medicine (EM) residents of all levels.

Non-accidental trauma (NAT) is a leading cause of morbidity and mortality in pediatrics. Every year in the United States, more than 656,000 children are found to be victims of NAT, causing over 1,800 deaths annually.1 Subtle abusive injuries are frequently missed in medical settings,1-3 and children may subsequently experience escalating or life-threatening abuse if interventions do not occur.2 Timely identification of abusive injuries in acute care settings is crucial to provide appropriate and potentially lifesaving care.

By the end of this clinical decision-making case, learners will be able to: 1) demonstrate familiarity with the CDM case format and case play, 2) describe important historical information to obtain when suspecting non-accidental trauma, 3) recognize potential physical exam findings in non-accidental trauma, 4) justify appropriate diagnostic studies based on clinical findings and current evidence on occult injury in suspected pediatric abuse, and 5) propose an appropriate disposition plan for patients with non-accidental trauma.

This is a clinical decision-making boards case as outlined by the American Board of Emergency Medicine (ABEM). Each learner was paired with one instructor for the case, a scoring checklist by the instructor was used, and learners were given the opportunity to provide feedback after the case.

Each CDM case session lasted approximately 20 minutes, with 15 minutes for the case and 5 minutes for debriefing and feedback. A 25-point critical action checklist was developed to evaluate each learner's performance. Learners then provided verbal feedback on the cases to the examiners at the conclusion of their assessments.

Thirty-nine emergency medicine residents participated as learners for this clinical decision-making session, including 10 third-year residents, 12 second-year residents, and 17 first-year residents. Scoring checklists had a possible score of 25 points, with each point reflecting an equally weighted item. The average overall score was 16.85 of 25 possible points. Performance with respect to post-graduate year (PGY) is as follows: 18.0 for PGY-3s, 18.9 for PGY-2s, and 14.7 for PGY-1s. One resident had a perfect score of 25/25. There was no threshold passing score; therefore, no one resident "failed" this mock structured interview.

Performance of our learners varied and unexpectedly, our second-year residents outperformed our third-year residents. We believe this is due to our PGY-2 learners being responsible for the primary care of stroke patients in our department, which makes their identification of head bleed likely more recently retrievable. We reviewed outlier items (where residents all scored very high or if the score was lower compared to other items) to determine if this is an appropriately written item, and if so, we will use lower-scoring items as learning opportunities to emphasize within future didactics sessions. One of these items involved asking who the patients' caregivers were, which may be attributed to being unaware of the relevance of this question to NAT, or, more likely, that NAT was not a top differential diagnosis in the early aspects of the case.Verbal feedback from our learners primarily focused on widening our accepted differential diagnoses for future iterations. We believe that this case is appropriate for all levels of learning, particularly when a formative approach (assessment for learning) is used. Given the feedback learners and instructors provided, we believe this case has high value impact in reviewing high-risk or high-acuity pediatric pathology.

Emergency medicine, pediatrics, non-accidental trauma, pediatric head trauma, head bleed.