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Case 126

Veena Ramaiah


A 2 year old presents to the emergency department with these burns.

Is this burn abusive or accidental?


This is actually a trick question! Before making any determination about manner of injury a history of the injury must be obtained. Clinicians should avoid making rapid judgments based on an appearance, photo, or x-ray. Many injuries can have an accidental explanation or an abusive explanation, and jumping to conclusions prematurely can do harm to a patient or their family. This is the purpose of child welfare or police

investigation. In a busy emergency department, there may not be time or ability to elucidate all the details of an event, or the caretaker during the event may not be present so the history is secondhand. It is important, however, to recognize when something is suspicious and warrants an investigation.

Per the father, he went to give the patient a bath, turned on the water, put the stopper in, and placed the patient in the tub. He did not think the water was hot but did not check it, and the patient did not scream or cry immediately. He starting whining and the father took him out of the water. He was in the water for about 2 minutes. The father denies that the water felt hot after he took him out. The father denies leaving the bathroom. He then noticed the skin looking dark and wrinkled. He called the patient’s mom to ask what to do and she advised him to go to the emergency room.

On arrival, he was tachycardic, afebrile, and normotensive. He was quiet if left alone but began crying with any movement of his feet or exam on his feet. After IV access is obtained and he is given pain medicine, a thorough skin examination is done that is negative for bruises, marks, scars, or other burns aside from those pictured. He receives IV fluids and is admitted to the burn unit for burn care.

There are a few things that are concerning: the pattern, the absence of crying or screaming even after being in the water for about 2 minutes, and the father denying that the water felt hot. The pattern of the burn is an immersion pattern. This is indicative of someone being placed or immersed in hot water. The absence of any splash or spill pattern is concerning in that a child this age would be moving or kicking to attempt to get out of the water. There are no splash burns or irregular edges of the burn to indicate movement. In addition there is sparing of the soles. This particular pattern is often seen when the feet are against the bottom of the tub sparing the soles from being burned at all or burned as deeply. Burns cause pain. In a neurologically normal child, he would be crying or screaming in response to being burned.

There is a well-documented freeze response that sometimes children have in response to pain or heat but that lasts a few seconds before they react. Last, the water was hot enough to burn the child which means an adult who is neurologically intact would be able to feel the heat. This part of the history is obviously false as you have evidence of an injury since the patient is burned.

This patient’s feet were debrided as shown in Image 126.2.

It is important to recognize when seeing injuries that as a mandated reporter it is required to have a reasonable suspicion of abuse, not to know that abuse has occurred. A manner of abuse often cannot be determined without a thorough investigation that may include a scene investigation. Determining the manner of injury without enough information can be detrimental to the patient and the family. Immersion pattern burns can be accidental; however, that is much less common and again would warrant a full investigation in order to corroborate an accidental mechanism being provided.

Keywords: child abuse, dermatology, environmental


Pawlik M-C, Kemp A, Maguire S, Nuttall D, Fedlman KW, Lindberg DM, ExSTRA Investigators. Children with burns referred for child abuse evaluation: Burn characteristics and co-existent injuries. Child Abuse Negl 2016;55:52–61.

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