Environmental / IPV Flashcards
IPV Risk Features
Delay in seeking care
Incongruent Hx
Unwilling to disclose
Hx that changes over time
Posterior rib fracture
Restraint injuries
Repeat visit
Chronic pain syndromes
Mental health concerns
Substance Use Disorder
Commonly used drugs in DFSA
Alcohol (#1)
Rohypnol
Benzos
GHB
Sexual Assault History
Helps to guide the medical and forensic exam:
- Agenda setting; tell as much as comfortable. Can take a break at any time. Only asking to help.
- Use quotation marks
- Don’t include superfluous information
- What acts were completed
- Restraints etc
- Assessing HIV transmission
IPV Escape Plan
Safe place / Shelter, friends, family etc.
Have to be willing to cut all ties (“Witness protection”)
- Bank accounts, phone, social media (d/c or change), password changes
Police statement (may make it, does not mean charges - makes a history available)
Tell Others (family, friends etc)
Safety planning for those who plan to stay
advise:
- come back any time
- as in escape plan
- vital docs (passport, birth cert, etc.)
Human Trafficking
ED is usually only place for care.
Needs to be kept safe. Must be inside walls of ED, not waiting room etc.
Police have HT departments.
Sexual assault physical exam ./ documentation
Describe all of the PE acts prior to the exam
- Treat as a normal trauma exam.
- Head to toe unnecessary
- Base physical exam on history
Document: Patient states, etc. “ “ if it matters
- If you don’t document it, it didn’t happen
- EPIC .sampselsex
HIV PEP in Sex Assault
Source + Type of exposure
- Known HIV
- High risk HIV
- Multiple assailants
+
- Non-consdenual
- Unknown if barrier
- Vaginal Penetration
- Unknown exposure
Unkown HIV + anal or unknown if barrier used - the 3 day HIV PEP.
Truvada and Tivacay po od x 28 days
Must start by 72 hours post exposure
Hypothermia Stages (temps and symptoms and treatment)
HT1: 32-35. Conscious and shivering
Tx: Warm environment, warm sweet drinks, active movement if possible
HT2: 28-32. Impaired consciousness, no shivering - Increased risk AFib
Tx: Cardiac monitoring, minimal and cautious movements to avoid arrhythmias, horizontal and immobilized, full body insulation, active external warming, warm parenteral fluids
HT3: 24-28: Unconscious vital signs present - Increased risk of VFib with moving patient
Tx: HT2 + airway management, ECMO or CPB with cardiac instability
HT4: < 24: Vital signs absent
Tx: HT 2/3 + CPR and UP TO 3 doses Epi and defibrillation, ECMO or CPB or CPR with external warming.
OR
AVPU
Stage I - A
Stage II - V
Stage III - P/U
Stage IV - U and VSA
Heat Related Illness Characteristics
Heat Rash -> Heat Cramps -> Heat Edema -> Heat Tetany -> Heat Syncope
Heat Exhaustion:
- NORMAL MENTAL STATUS
- Dizzy, H/A, perspiration, N/V, temp 38-40 C
- Possibly abnormal electrolytes
- LFTs Norm
Heat Stroke:
- Classic vs Exertional
- Classic - Elderly, during heat waves
- Exertional - Young with exercise/partying in hot environment
- Symptoms: ALTERED MENTAL STATUS (Neurologic dysfunction with cerebral edema), possible seizure, anhidrosis, temp > 40.5, jaundice (late), lab abnormalities
Often liver injury as well.
Abnormal hemostasis / bleeding prone
Heat stroke treatment
Rapid cooling:
- Immersion in cold water preferred
- Can use cold water blankets, cool IV fluids, evaporative cooling with mister and fan, ice packs in groin/pits
- MOVI
- ECG
- Can use benzos or paralysis to prevent shivering
Poor Prognostic Features:
- Coma, ALT > 1000, delay in cooling, DIC, hypotension, renal failure in < 48 hours, lactate
Complications:
- ARDS, electrolytes abnormal, renal failure, DIC, hepatic injury, rhabdomyolysis
Cold Related Injury Spectrum and Characteristics
Chilblains: Painful/inflamed skin lesions, may evolve to plaques or ulceration ,lesions at 12-24 hours post
Trench Foot (Immersion foot): Cold wet feet (0-10degrees) over hours to days.
- Feet appear cold, mottled and pale. After warming - red, painful and swollen
Frostnip: Superficial freezing without tissue loss or destruction. Transient numbness that resolves. Superficial blistering may occur.
Frostbite: Ice crystal formation in skin leads to tissue destruction, microvasular compromise, thrombosis, ischemia
- Degrees:
1st - central white plaque with surrounding hyperemia
2nd - clear blisters
3rd - Hemorrhagic blisters, eschar and tissue loss
4th - Full thickness affecting skin, muscle and bone
OR: Superficial (no tissue loss) vs Deep (tissue loss and underlying tissues are hard)
Frostbite treatment
Rapid rewarming in immersion at 37-39 C. (20 mins +/- 5 min breaks). REMOVE RINGS
- Will require opioids for pain, ASA or NSAIDS
Tetanus prophylaxis
Aspirate clear blisters, LEAVE hemorrhagic
For Grade 3-4 / deep:
< 24 hrs, MR angiography, thrombolysis per protocol or iloprost infusion.
Technetium bone scan @ 48 hrs.
Iloprost SE: Headache, hypotension, flushing, palpitations
Other grading systems by level of penetration:
1 - peripheral DIP
2 - PIP
3 - MCP
4- Carpals
Severe: Perfusion assess, TPA within 48 hrs, Enox, rescan at 48 hours, consider Iloprost if chance for improvement.
Hypothermic Arrest Management
CPR
Consider ECMO, CBS, or dialysis
Defib defer until warmed
Only 1 shock in Vfib until T > 32
Core afterdrop can occur when circulation retrns - cold peripheries return to core.
Electrical Injuries Current Thresholds
AC
1-4 mA: tingling sensation
6-9 mA: “let go” threshold” - results in tetanic contraction
>70 mA: cardiac depolarization, VF
DC:
- High voltage results in extensive tissue damage (non-visible)
