ED 2 Abuse Flashcards
what percent of women in the US report experiencing violence at some point in their lives?
25 percent
women who experience domestic violence are at an increased risk for what four diseases?
stroke, heart disease, alcoholism, asthma
as medical providers, when should we screen for abuse?
at EVERY visit PRIVATELY
your patient doesn’t want to report his/her abusive partner, what do we do?
respect their choices, document well (WRITTEN is better)
what is felt to be the best predictor of future homicide victims?
strangulation
50 percent of homicide victims have experienced at least 1 strangulation attempt
do people perform strangulation MC by ligature, manual, or hanging?
manual 80 percent of the time
how long until victim loses unconsciousness when 11 pounds of pressure are applied to the carotids?
10 seconds
when does permanent brain damage occur when 4.4 lbs of pressure are put on the jugular? how long until death?
permanent brain damage in 3 minutes
death in 4-5 minutes
how many pounds of pressure are required to occlude and fracture the cartilage of the trachea?
33 lbs
what are some symptoms of strangulation in your patient?
voice changes (50 percent)
painful swallowing
mental status change
loss of bowel/bladder control
what will you see on PE that will clue you into strangulation? what must you keep in mind?
petechiae (face, eyes, eyelids)
bruising of neck
only half of victims will have PE findings
what complications of strangulation will we worry about down the road?
delayed death due to carotid dissection or stroke
if your strangulation victim presents with petechiae and mental status change, what imaging should you order?
CTA of the neck
what percentage of sexual assaults are not reported to the police?
66 percent
a sexual assault victim presents to the ED and wants to go through with examination. which two specialists should you call to be a part of your workup? what do they do?
SAFE = aid in forensic care and collection of evidence, testify in court
sexual assault advocate = can be present in ED and there for outpatient support and referrals
what two things should you NOT do during your initial evaluation of a sexual assault victim?
1) DON’T give food or fluids – can disrupt evidence
2) DON’T remove clothing or anything unless acutely medically necessary
what are YOUR roles as a PA while a SAFE is doing their job?
1) do limited medical history
2) treat any acute injury
3) assess SAFE in swab collectionand other medical portions
4) obtain UA sample for PG status
5) make safety plan
6) give meds for PPX
if a SAFE is not available, who works as a team to care for the patient, what will your job be?
nurse and ED provider
nurse gets history and does forensic medical exam and collection
we complete anogenital exam collections/swabs and provide medical treatment (PG and STI prophylaxis, symptom management)
NEVER LEAVE THE KIT
just thought i’d say that
what is the time frame allotted for collection of the forensic kit post assault in adults?
5 days
how long will the kit be held, should the patient have the collection done and choose to be anonymous?
90 days
what population should you NEVER do speculum exams or vaginal swabs in?
prepubescent females
what is the risk of pregnancy in younger women (19-26) with unprotected intercourse 1-2 days before ovulation?
50 percent
immediate use of emergency postcoital contraception reduces PG risk to what percentage?
1-2 percent
what are the pros and cons to using plan B post assault?
pros: more effective, less NV SE
cons: ineffective over 176 lbs
what is the biggest pro to using ella as emergency contraception?
better effectiveness at 3-5 days post assault
in terms of STD prophylaxis, should we test before we treat?
no, won’t change TX anyways. just treat
what do we give as PPX to everyone post assault/
1) trichomonas: flagyl 2 gm PO
2) bacterial vaginosis: flagyl 2 gm PO
3) gonorrhea: ceftriaxone IM
4) chlamydia: azithyromycin PO
your patient has known penetration with blood/bodily fluid contact. what do you do?
immunized patient: nothing further
unimmunized patient: heptavax first dose in ED, then at 1-2 months, then 4-6 months
very high risk hep B exposures should consider what in addition to vaccine?
hep B immune globulin IM
what is the risk of HIV transmission in receptive anal intercourse? how about penile-vaginal?
anal = .5 percent
penile-vaginal = .1 percent
KNOW: these rates may be higher in sexual assault due to violent nature
HIV PPX treatment must be started how soon? what two drugs are given?
must start within 72 hours, give truvada and kaletra
when should you consider HIV PPX?
KNOWN unprotected intercourse
KNOWN reception of seminal, vaginal, blood occurred
victim is WILLING to complete TX
during evaluation and management of acute, life-threatening injuries, should you continue to try to preserve evidence?
yes, always!
when should you follow up with HIV PPX patient?
3-5 days, draw labs again at 3 and 6 months
what should you do in the acute (less than 72 hour) setting of pediatric sexual assault? what about in the non-acute (over 72 hour) setting?
less than 72 hours: call SAFE for forensic exam (3 days for kids!)
non-acute: consult spurwink, do medical history/screening exam/documentation – mandatory reporting to DHHS
if the child victim of sexual abuse is too scared or developmentally unstable to answer your questions, what should you do?
do not question the child, do not do repeated interviews
what maneuver provides all the visualization needed for inspect of female victim of sexual assault?
labial tractions
which 3 genital exams are NOT indicated in child victims of sexual assault?
1) speculum (not on prepubescent)
2) digital rectal exam
3) vaginal exam
forensic evidence collection is rarely helpful after ____ hours in child sexual abuse cases
24 hours
contact spurwink
is it okay to photograph/film injuries on children?
YES
is STD prophylaxis used in pre-pubescent children?
NO
yes once they hit puberty
when should PG testing and PPX be offered to female child victims of sexual assault?
tanner stage 2 or higher (from the first pubic hair)
don’t wait till first period!
what are some risk factors in the CHILD to consider that could lead to child abuse?
low birthweight mental/physical health disability excessive crying/colicky frequent tantrums twins/multiple gestations
can a parent decline your request to perform a full head to toe assessment in a child should you suspect abuse?
nope!
what 3 components should ALWAYS be included in your PE in a child who you suspect abuse in?
1) fundoscopic exam (retinal hemorrhages)
2) intraoral exam (petechiae)
3) anogenital exam
what will accidental vs. non-accidental bruising look like in a child?
accidental = brusing on front of body, over bony prominences, extremities, forehead
non-accidental: trunk, ear, neck, cheeks, buttocks (likely symmetric)
you see a big bruise on the 4 month old you are examining for a well-child check. is this normal?
NO
infants don’t bruise; less than 0.6 percent of infants less than 6 months bruise
what should be a part of your workup for a child that presents with frequent bruising?
coagulation studies, CBC – rule out clotting/platelet disorders
accidental bruises vs. non-accidental bruises on children?
accidental = asymmetric, irregular borders on face, neck, upper torso, palms, fingers
non-accidental: immersion patterns, sharp demarcation
what percentage of abusive fractures are seen in children under 18 months?
85 percent
you should ALWAYS suspect abuse in a non-ambulatory child under what circumstances?
fracture to humerus, femur, or rib
do full skeletal survey x-ray
a child with many fractures should be considered for abuse, but what should you also do?
consider osteogenesis imperfecta
what 7 incidences MUST you report to DHHS in any child under 6 months?
1) fracture
2) bruising
3) subdural hematoma
4) burns
5) poisoning
6) substantial bleed, impaired organ
7) any confirmed child abuse case
what mnemonic do we use for attempting to put a stop to elder abuse?
RADAR! R = routinely ask about abuse A = ask questions in private D = document findings A = assess for safety R = resources and review options
who do you report suspected elder abuse to?
adult protective services, DHHS
who do you report confirmed elder abuse to?
adult protective services, DHHS, local law enforcement, safety planning
