Flashcards in DOMESTIC VIOLENCE Deck (66):
What is difficult about victims of domestic violence and why they go back to their abuser?
Want the abuse to end, but not the relationship. Still love their abuser. Have no support from family or friends. They often have children with their abuser and fear for their safety if they leave.
A women who experiences domestic violence is more likely to have what?
Stroke, heart disease, asthma, alcoholism
*We must always respect their decision
What is our role as a medical provider in domestic violence?
Screening, assessment, intervention (Safety planning, validation), documenting, referrals
“I see patients who are being hurt or threatened by someone that they love, is this happening to you?” “Domestic violence is a problem in peoples lives so I ask every patient I see about the safety of their relationship. Do you feel safe in yours?” Are all examples of what?
Evaluating the injuries, pattern of abuse, immediate safety (safe houses), danger and potential lethality, potential suicide/homicide are examples of what?
What are some patterns of abuse?
Injury inconsistent with history, bruising (multiple areas, different stages of healing, symmetrical bruise), burns, abrasions/scratches, pattern of injury
What are some common areas of abuse?
Back of head, neck/shoulders, face, posterior arms, thighs, buttocks, and back
When you express concern for health/safety privately; offer support and services; being non-judgmental, RESPECT their choices – are examples of what?
What’s involved in medical treatment & saftery planning?
Medical care of injuries; provide hotline numbers; use community resources
What are some things to remember with documentation?
The detail of abuse (use specifics – names, locations, dates, witnesses); use direct quotes; use body maps or photography; ask permission to notify their PCP
What should we always ask the patient when we learn that there is domestic violence occurring?
Ask if they want to report
What’s one of the most lethal forms of DV?
What must you always ask when they report DV?
Ask about strangulation (did he choke you?)
What structures are often affected with strangulation?
Carotid arteries (11lbs of pressure x 10 seconds = unconsciousness
Jugular veins (4.4lbs of pressure x 10 second = unconsciousness/3 minutes permanent damage)
Tracheal occlusion (33lbs can fracture the cartilage)
Voice changes, difficult or painful swallowing, shortness of breath, mental status change, long term memory loss, PTSD, and loss of bladder/bowel control are sxs of what?
If you notice hoarse voice, bruising/abrasion to the neck, HA, painful swallowing, petechiae (face, eyes, eyelids) – are PE findings of what?
So where should you always look when you suspect DV?
EYES! For petechiae
If there was significant strangulation, what imaging might you need to do?
MRI or CTA of neck – dissection can occur later!!
Domestic violence, parent/caregiver psych problems/substance abuse, low birth weight/colicky baby/frequent tantrums are risk factors for what?
Injuries without history of trauma, changing history, different history from one historian to the next, explanation inconsistent with injury, delay in seeking care are all what?
Red flags for child abuse
What is critical to do on PE with suspected child abuse?
Head to toe assessment, undress the child & fully expose the skin to document all injuries.
Fundoscopioc (retinal hemorrhage)
Intraoral exam (petechiae)
Bruising on the front of the body, over bony prominences, extremities, and forehead – accidental or not?
Bruising on the trunk, ear, neck, cheeks, buttocks – accidental or not?
What do you do when you see non-accidental bruising?
What must we remember about kids under the age of 6 months?
They don’t walk…
What laboratory studies should we do in infants with bruising?
CBC, coag studies, and funduscopic (to r/o big things, like leukemia)
If you see burns that are asymmetric, irregular borders on face/neck/upper torso, palms, fingers – accidental or no?
If you see burns in immersion patterns (often on the butt), sharp demarcation with spared areas on the dorsal hands, back, buttock, and feet – accidental or no?
If you see a fracture in a non-ambulatory child, especially humerus, femur, or ribs, what must you do?
Skeletal survey xrays → check for additional fractures
If you suspect any sort of head trauma (hematoma, injury, child not acting right) what should you do?
If you see a skull fracture, what should you do>?
External bruising only present in 20% of cases with what type of injury? What labs should you get?
Liver & small bowel
LFT’s will be elevated & CT scan is best
What non-abuse things must we always consider?
Osteogenesis imperfecta, Mongolian blue spots (buttocks), coining/cupping, moxibustion (circular red burns on area involved – burning an herb)
IF you suspect child abuse, what must you do?
REPORT IT!!! & always consider siblings in the home
Report – DHHS & Law enforcement
What is mandatory reporting in infants?
Where does elder abuse most commonly occur?
Common in community setting & long-term care settings
Is elder abuse more common in men or women?
What does RADAR stand for?
R = routinely ask about abuse
A = ask questions in private
D = document your findings (body map/photography)
A = Assess for safety
R = Resources & review options (safety plan, local services)
If you suspect elder abuse, who do you report to?
If you have confirmed elder abuse, what do you do?
Report to adult protective services
Alert law enforcement
What are some different forms of elder abuse? What’s most common?
Physical, emotional, sexual, financial, neglect, abandonment, and self-neglect
Neglect is most common
What are the components of the sexual assault forensic medical evaluation?
History (using patients own words/quotes), PE/injury documentation, evidence collection, documentation, assure advocate can be present, medical treatment, and appropriate follow-up/safety planning/discharge support
Most victims of sexual assault are females younger than what age?
What is a SAFE?
Sexual assault forensic examiner
What does a provider do when a SAFE is available?
Limited medical history/screening; ABC’s, explain that the SAFE will be obtaining the full history; if patient must be undressed for medical necessity (collect all clothing & preserve all evidence), obtain UA and keep it on ice
What is the chief complaint when the SAFE is available?
Reported sexual assault (NOT “alleged”)
If a SAFE is not available, what medical treatment should you do?
Use your kit!
Pregnancy, STI prophylaxis, evaluates risk for HIV, symptomatic management, and consider mental health
How many days post assault can you still collect data?
When does the forensic kit have to be picked up?
You MUST stay with the kit until law enforcement comes and you must document all changes of hands → maintain a chain of custody
If you have a prebuescent female what exams must you withhold from doing?
Speculum exam & blind vaginal swabs
If a patient declines a speculum exam, how else can you get data?
Blind vaginal swabs (for semen)
What is the best technique to visualize female child’s anatomy, the hymenal ring, and assess for injury?
Labial Traction (pull out and down)
In sexual assault, uncontrolled bleeding, head injury with history of LOC, strangulation with history of LOC, abdominal pain, cervical spine injury, concern for bony fractures are all apart of what?
Immediate medical intervention!! Sexual assault patient is a TRAUMA patient
What are some of the long term sequelae for sexual assault?
Depression, Drug/ETOH, PTSD, suicide attempt
Thus, F/U is critical
Why should a sexual assault victim be NPO?
Because you need to swab the mouth!!
How do you treat pregnancy prophylaxis?
Emergency postcoital contraception → Plan B (Levonorgesrel) & Ella (Ulipristal if over 165lbs) (can be taken up to 5 days after assault)
But its not 100%!
How do we treat STI’s prophylactically?
Azith 2grams + Ceftriaxone 250mg IM single dose (covers gonorrhea & chlamydia)
Flagyl (Trich & Bacterial vaginosis) – remember* if they drank in the past 24 hours, start Flagyl the next day
How would you treat Hep B prophylaxis?
Immunized – none
Unimmunized – Heptavax ( + Ig if highly suspected!)
How would you treat genital herpes?
None – just educate the patient
If it is known that the attacker has HIV – what can you do?
PEP – must be started within 72 hours
Truvada & Kaletra
More likely if anal intercourse
How does the testing for HIV go?
HIV test at baseline, follow-up at 3 and 6 months
When and who should a sexual assault patient follow-up with?
PCP or GYN in 2-4 weeks
If HIV – f/u in 3-5 days
What is considered an acute setting of child sexual abuse?
less than 72 hours – call the SAFE in
If a child is complaining of anogenital problems – what must you do?
Do a medical history and exam. If concern, consult a SAFE
What do you when trying to obtain a history from a pediatric patient when you suspect sexual abuse?
NEVER take a history from a parent (have the parent sit behind the patient)
Use their language & always record in verbatim/quotes