sexual assault response team - provides consistency, expedites care - familiarity w/ local crime patterns

sexual assault nurse examiners - non-physician forensic examiners, esp. trained in this field- adults & CH - examine, collect & ctrl evidence & testify to findings

special populations Flashcards by Beth Miller

forensic

pertaining to or belonging to the legal process

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ED role in forensic cases

evidence detection, preservation
evidence collection if appropriate
documentation
preserve "chain of custody"
cooperate/work w/ law enforcement

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principles of forensics

observe state of injury- acute/old?
don’t miss, lose, destroy evidence
photos: police or by ED staff
avoid interpreting findings

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how can you avoid missing, losing or destroying evidence

thorough hx & exam
measure, describe injuries
don't throw evidence away or wash it off (clothing, debris, stains, FB's, etc)
do not alter the wound(s) if possible
describe exactly & only what you observe

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wound ballistics

tissue damage is related to:
range
velocity
caliber
type
fragmentation
deformity
*avoid calling entry/exit wounds

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PA’s deal with what type of GSW’s?

extremities

*close range- gook for gunpowder, burns around site; look for clothing in wound, save clothes

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GSW mgnt

stabilize if unstable
determine where, how many, other injury
vascular integrity is the priority in extremities: pulses, pallor, cold distal?, sensory exam
x-ray all- if fx, can tx as closed fx
local wound care, debridemnet
surgery, other consult
consider Abx
splint, close f/u

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knife/stab wounds

often defensive (we deal w/ extremities only)
good hx, police report
count, measure, explore
imbedded objects are removed in OR- don’t pull out
do not extend wounds if possible
repair/leave open for delayed primary closure in 3-5 days
x-ray all- fx, FB
consult surgery, ortho
consider Abx, close f/u

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arterial bleeding of extremity

universal precautions
check for FB, elevate part
direct pressure 1st: 1 finger, gauze, pressure just proximal for 10 min; BP cuff as tourniquet (mark time)
pressure dressing- sub tightly rolled gauze for finger; layer larger on top, wrap

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arterial injury testing: ABI

Ankle-Brachial Index (ABI)

comparison of ipsilateral UE & LE systolic pressure
pt supine, BP cuff, doppler
Doppler brachial SBP, then highest of dorsalis pedis & posterior tibial
ABI= ankle SBP/brachial SBP

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arterial pressure index (API)

compare upper or lower extremities to each other
API=injured SBP/uninjured SBP
> 0.9 nml; if less = concern for vascular injury
duplex ULS, ateriogram if <0.9
pseudoaneurysm concern

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what is normal for arterial pressure index?

> 0.9

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forcible rape (Uniform Crime Reporting Program) old definition

carnal knowledge of a female w/o consent

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forcible rape (Dec. 2011 definition)

penetration, no matter how slight, of the vagina or anus of any body part or object, or oral penetration by a sex organ by another person, w/o the consent of the victim

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SART

sexual assault response team

provides consistency, expedites care
familiarity w/ local crime patterns

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SANE

sexual assault nurse examiners

non-physician forensic examiners, esp. trained in this field- adults & CH
examine, collect & ctrl evidence & testify to findings

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team approach w/ SART

examiner, social services/advocacy, police, DA’s office all collaberate

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sexual assault exam

police, EMS or self- present
stabilize pt (stability trumps evidence-ALWAYS)
police jurisdiction (where it happened) must authorize evidence collection
advocate is w/ pt at all times
detailed hx of assault- CA 923 form
head to toe exam for injuries, forensic evidence
external genitalia, speculum & anal/rectal

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evidence collection for sexual assault exam

swabs
hair
vaginal secretions, etc
coloscopy
toluidine blue
photos

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screening & prophylaxis in sexual assault

STD & UPT

HIV prophylaxis not routine

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colposcopy & Toluidine blue

colposcopy for magnification

toluidine blue highlights disrupted mucosa

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MC sites for injury in sexual assault

posterior fourchette & fossa navicularis

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absence of genital injury is common

T/F

true

about 50% of sexual assault victims will not have genital injuries

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sperm is found in about what % of survivors

10%

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females often know assailant | T/F

85% of females DO know their assailant

the absence of genital injury does not imply what?

consent

absence of sperm does not imply that penetration?

did not occur

presence of sperm implies penetration took place- does not speak of ?

consent

after the assault: the "system" is improving

collaboration, training national DNA data base- "cold hits" qualified expert witness pool sexually exploited minors project

sexual assault and effects on the survivor

PTSD common missed work, disrupted lives cost to society

our role in domestic violence

``` high index of suspicion ID acknowledge inform report (mandatory in CA) refer ```

domestic violence documentation

document injuries & hx using quotes & exact phrasing | *this is key

red flags in domestic violence

``` injury pattern-often ctrl injuries of various ages delayed presentation inconsistent hx partner's behavior (clingy) pt's behavior chronic complaints- HA, GI, pelvic pain pregnancy mental health issues drug/alcohol abuse ```

S.A.F.E questions

Safety/Stress Afraid/Abused Friends/Family Emergency Plan

Safety/stress?

Do you feel safe now? Stressors?

Afraid/Abused?

Afraid now? Abused before

Friends/Family

Do friends/family know

Emergency Plan

Prepared &/or safe place to go

recognizing child abuse

****injuries inconsistent w/ hx ****injuries inconsistent w/ stage of CH development multiple differing hx's poor eye contact, nutrition, hygiene minimizing jnjury, delay in tx pt clings to suspected batterer CH excessively attached to or afraid of parent CH excessively ingratiating to examinar patterned burns, classic injury patterns

classic metaphyseal-epiphyseal injuries of child abuse

metaphyseal lucency corner fx bucket handle

elder abuse

``` hx does not match bruises or injury wt loss dehydration depression decubitus ulcerations poor hygiene medical "noncompliance"- missed appt, etc ```

developmentally & intellectually disabled (DD & ID) have significantly__________pain thresholds

increased 25% have this atypical & late presentations

anxiolytics are often useful when working w/ ?

deelopmentally & intellectually disabled pts

cardiovascular issues in DD & ID

congenital heart dz great vessels CAD common as get older

infection issues in DD & ID

``` skin (MRSA) OM dental UTI/ pyelo occult infxns ```

injury issues in DD & ID

``` self0inflicted (often d/t anxiety), abuse osteopenia common: fx pica FBs bezoars ```

endocrine issues in DD & ID

DM hypothyroidism vit deficiency

psych issues in DD & ID

agitation- consider it delirium

neurologic issues in DD & ID

``` seizures very common delirium more common hearing loss vision loss (cataracts) atlantoaxial instability (Down's) ```

abuse issues in DD & ID

DV sexual assault (3-5x higher than typically developed) neglect poor support

GI issues in DD & ID

``` esophagitis PUD constipation fissures impaction appy volvulous perf etc. all harder to dx ```

FTT

pt's who cannot adequately care for themselves in their current situation- inadequate care, resources, food, situation

social admit

admitting a person who doesn't have anywhere to go- admit until placed by Social Services

dumping

family disappears, takes a break

homeless women

always ask about abuse, sexual assault- common to exchange sex for food, drugs, protection homeless women w/ kids-very high risk

ED work-up for homeless pt

undress pt- tx as any other pt | VS, d-stick, UPT, alcohol, tox, assess suicide risk,.......

issues in wheelchair, quad/paraplegia often related to?

``` home support/transfer catheter issues infxn pressure sores aspiration ```

biggies not to miss in wheelchair, quad/paraplegia pts

``` fever, abnormal VS UTI infected pressure sores, osteomyelitis pneumonia GI issues: perf, obstruction DVT, PE risk from immobility ```

IVDU often have a___________& require higher_________doses d/t tolerance

lower pain threshold | narcotic

IVDU often require what type of IV access?

central line, ULS guided

use what to reverse overdose?

narcan | observe for 60-90 min

IVDU w/ fever DDx

``` endocarditis epidural abscess pneumonia dyspnea abscess wound botulism cotton fever ```

IVDU & endocarditis

S. aureus 50% | tricuspid valve 40%

IVDU & epidural abscess

back pain w/ weakness & IVDU: MRI

pneumonia & IVDU

often atypical organisms, TB

dyspnea & IVDU

think septic pulmonary emboli-CXR

abscess & IVDU

fever is worrisome | necrotizing fasciitis

wound botulism

descending wakness pstosis weak voice DTR's intact

coton fever

rapid onset flu-like sx's benign resolves in 24 hrs

a complication of "pocket" shooters

pneumothorax

heroin w/d

``` n/v diarrhea chills malaise feeling miserable ```

tx for heroin w/d

Benzo's | IV fluids for dehydration

special issues in pts under arrest, prisoners

``` traumatic injuries substance abuse in prison psych issues manipulative behavior, fictitious illness FB ingestion ```

special populations Flashcards

(73 cards)