Module 6: Forensic: Sexual Assault, Sexual Child, Lead, Carbon Monoxide, Ethanol

Question 1

First starting off sexual assault we are going to discuss sexual assault. what is it?

Answer 1

Unwanted sexual contact that causes discomfort, fright or intimidation

Question 2

How do you approach the patient in a sexual assault case?

Answer 2

Private Room ASAP: remain in clothing
–no urinating, defecating, drinking, eating or smoking
–social support and offer to contact law enforcement
–informed consent for examination
72 hour rule: STD and pregnancy prophylaxis, collecting evidence and documenting injuries

Question 3

How do you get a history and physical in a sexual abuse patient?

Answer 3

Patients own words and document affect

• -document physical signs of trauma (genital and non genital)
• -tears (tenderness), redness, abrasions, contusions, swelling

Question 4

Does absence of injury rule out assault?

Answer 4

nope!

Question 5

What evidence should be collected in a sexual assault case?

Answer 5

Sexual assault evidence collection kit
—proper collection and presentation; chain of custody
Drug Facilitated sexual assault (GHB, hallucinogens, sedative-hypnotics, opioids)
–Toluding Blue Dye (normal skin surface has anucleated cells but trauma exposes deeper nucleated cells)

Question 6

Moving on to sexual abuse of a child, what is the definition of this?

Answer 6

Engaging of a child in sexual activities when child is developmentally unprepared or violates social and legal taboos
–oral-genital, genital, anal, non touching

Question 7

What is high index of suspicion in sexual abuse of a child?

Answer 7

Coerced into secrecy and general behavioral problems (sleep, enuresis)

Question 8

What are specific signs and symptoms as well as patient history for sexual abuse of children?

Answer 8

Signs: rectal/genital pain, bleeding, infections, STDs, precocious sexual behavior
History: quite environment and caring attitude
–interview all sources and get a comprehensive medical history

Question 9

How is a physical exam of a sexually abused child performed?

Answer 9

Have a trusted supportive adult present
–slow and complete
–consider general anesthesia
A normal genital/anal exam does not rule out abuse

Question 10

Explain diagnosis and follow up procedures for a sexual abuse child case

Answer 10

Dx: careful documentation and discuss with caregivers and child while remaining neutral
Follow up: asses adequacy of healing, document changes, repeated tests for STDs, assess coping skills
Most common findings in sexually abused children is a norma exam (b.c perpetrator does not want to hurt the child)

Question 11

What are normal findings in a non abused child?

Answer 11

Common: Erythema, pigmentation, congestion, anal fissures (Associated with constipation)
Anal dilation: constipation, prone position, neurological disease, post mortem
Normal variants: midline wedge-shaped smooth areas (diastasis ani), midline anal skin tags, folds and failure of midline fusion

Question 12

Moving on to lead, what are sources?

Answer 12

Air, Soil, water, dust, ceramics, food/soft drinks, moonshine, toys, batteries and ammunition

Question 13

What is the absorption and distribution of lead?

Answer 13

Adults ingest 100-500mg daily (10% absorbed)
–kids ingest less but 50% absorbed
–enhanced with mineral (calcium/iron/zinc) deficiencies
Distribution: bone and teeth (85% — lead lines), blood (5-10%) and soft tissues

Question 14

What are the biochemical effects of lead?

Answer 14

Inhibits iron corporation into heme
competes with calcium
inhibits membrane associated enzymes
impairs production of active vit D — calcium deficiency
Fatal lead poisoning due to cardioresp arrest and cerebral edema
Tx with chelation therapy

Question 15

Moving on to Carbon Monoxide, what is this/

Answer 15

Colorless, odorless gas thats a byproduct of combustion (gas, oil, coal, wood, natural gas and cigarette smoke)
–cause of half of all fire deaths

Question 16

What is the pathogenesis for carbon monoxide poisoning?

Answer 16

CO has 230-300 times the affinity for Hb as oxygen – cherry red discoloration of skin

• -impairs release of oxygen from Hb
• -direct toxic cellular effect
• -greater degree of hypoxemia than an equivalent degree of anemia

Question 17

Moving onto ethanol it is the most widely used/abused. What are acute effects and mechanism?

Answer 17

Acute effects: CNS depressant, fatty liver

• -asymptomatic, acute and reversible
• -mechanism: increased catabolism of peripheral fat, increased NADH stimulates lipid synthesis, decreased fatty acid oxidation, decreased transport lipoproteins from liver

Question 18

What are the chronic effects (systemic, vitamin deficiencies) of ethanol on the GI system?

Answer 18

GI: liver cirrhosis, steatohepatitis, pancreatitis, gastritis, ulceration, varices, oral/esophageal cancer

Question 19

What are the chronic effects of ethanol on the nervous system?

Answer 19

Nervous system: peripheral neuropathy, wernicke-korsakoff, cerebral atrophy and cerebellar degeneration

Question 20

What are the chronic effects of ethanol on the cardiovascular system/

Answer 20

Toxic effects: HTN and dilated cardiomyopathy

Protective effects: increased HDL and decreased platelet aggregation

Question 21

What are the chronic effects of ethanol on the reproductive system?

Answer 21

Fetal alcohol syndrome (most common preventable cause of mental retardation)

• -microcephaly
• -short palpebral fissures
• -flat midface
• -thin upper lip
• -epicanthal folds
• -low nasal bridge
• -short nose

Question 22

What is the pharmacology of ethanol?

Answer 22

Absorption: stomach and small intestine
Metabolism: 9gm/her and 90% metabolized to acetaldehyde and acetic acid in gastric mucosa and liver
Elimination: 10% excreted unchanged in urine, sweat and breath

Question 23

Moving on to Ethylene Glycol, what is it?

Answer 23

Colorless, odorless, sweet alcohol in antifreeze, deicing and industrial solvents
fatal dose= 100-200mL

Question 24

What are the stages of ethylene glycol poisoning?

Answer 24

Neurologic: 0.5-12 Hrs: nausea/vomiting, inebriation/euphoria and CNS depression and seizures
Cardiopulmonary: 12-24 hrs: compensatory hyperventilation and heart failure
Renal: 24-72 hours: acute tubular necrosis

Question 25

How is a dx of ethylene glycol poisoning made?

Answer 25

Intoxication to come with severe metabolic acidosis, seizures to acute renal failure and death

• -high anion gap: greater than 18mEq/L
• -Urine microscopy: sodium fluorescein and calcium oxalate crystals

Question 26

Moving on to Methanol (Wood Alcohol), what is it?

Answer 26

Colorless, clear alcohol found in antifreeze, pain and varnish solvent, methylated spirits and alternative energy
–fatal dose: 15-500mL

Question 27

What are the stages of methanol (Wood alcohol) poisoning?

Answer 27

Early: transient euphoria, inebriation, drowsy
Latent: 6-30 hrs: blurred vision, abd pain, vomiting, metabolized to formic acid and formaldehyde
Delayed: systemic effects of metabolic acidosis (high anion gap)
CNS: mild/moderate: HA and severe: parkinson like syndrome
Ocular: blurred vision to blindness
GI: abd pain
Cardio: resp arrest and shock

Question 28

Moving on to drug abuse, what are therapeutic drugs?

Answer 28

Adverse drug reaction:
—undesired response at therapeutic doses
–predictable or idiopathic/idiosyncratic
Prescription drug abuse

Question 29

What are risk factors for drug abuse?

Answer 29

Family history 
Male 
Psychiatric disorders 
Ethanol abuse 
Access and peer pressure

Question 30

What are the top drugs of abuse?

Answer 30

Marijuana
Pain relievers
Cocaine

Question 31

Moving on to opioid analgesics, what does this include?

Answer 31

Heroin
Oxycodone
Methadone
Morphine

Question 32

What are acute effects of opioid analgesics?

Answer 32

Anxiolytic, sedation, mood changes, nausea, resp depression

Convulsion: cardioresp arrest, death

Question 33

What are chronic effects of opioid analgesics?

Answer 33

Tolerance and dependence

Infectious complications of IVDA: cellulitis, endocarditis, viral hep and pneumonia

Question 34

In regards to heroin (diacetylmorphine), what are some features?

Answer 34

Source = poppy plant
Cutting agents: talc, quinine
Routes: IV or SQ injection, smoking and snorting
Effects: euphoria, hallucinations, sedation
Adverse effects from: heroin and/or cutting agents, HSR, injection

Question 35

What are the toxic effects of heroin (Diacetylmorphine)?

Answer 35

Sudden death: profound resp depression, arrhythmia, pul edema
Pulmonary: edema, septic emboli, abscess
Skin: abscess, cellulitis, ulceration, vein thrombosis and scarring/hyperpigmentation
Infection: endocarditis, hep and AIDS

Question 36

Finally cocaine, what are some features/

Answer 36

Source: leaves of erythroxylon coca
Forms: cocaine HCL + cutting agent (talc and lactose) or crack cocaine
Routes: snorted, smoked, ingested and injected
Mechanism: blocks reuptake of DA, E and NE

Question 37

What are the effects of cocaine?

Answer 37

Fast acting stimulant of short duration

• -rush: pleasure, strength, power, and excitement
• -high: increased alertness, confidence, disinhibition
• -side effects: weight loss, insomnia and fatigue

Question 38

What are the toxic effects of cocaine?

Answer 38

Toxic effects: 
CNS: hyperpyrexia, seizure 
Cardio: increased BP and HR 
Pulmonary dysfunction 
Pregnancy: abruption 
Other: perforated nasal septum

Question 39

In regards to cocaine what is fatal excited delirium syndrome (acute onset)?

Answer 39

Delirium (transient disturbance in consciousness and cognition and hallucinations)
Violent behavior
Sudden cardiac death
History of chronic stimulant abuse
Fatal Arrhythmia precipitated by ischemia
—accelerated atherosclerosis and thrombosis