Approach
History
• Delays in seeking care, hx inconsistent w/ injury, multiple past injuries, injuries in various stages of healing
Team Approach
• Social work, child protective services, trained sexual assault nurses, pt advocate
Documentation
• Record factual events/injuries, avoid judgments, informed consent for forensic collection/release of information, mandatory reporting for child/elder abuse
Child Abuse
History
• Story inconsistent w/ injuries/child’s developmental age, inconsistent stories by caretakers
Physical Findings
• Child neglect: Flattening/alopecia of occiput (supine for long periods of time), decreased SC tissue/prominent ribs/loose skin over buttocks (FTT)
• Child abuse: Bruises/fracture varying stages, bruises in areas not prone to trauma (lower back, buttock, thighs, cheeks, ear pinna), geometric-shaped bruising (belts, cords), scald burns w/o splash marks or in “dip” pattern, multiple deep contact burns, unexplained extremity swelling (long bone spiral fracture, metaphyseal chip fractures, femur fractures in <3 y), posterior rib fractures, MS changes (shaken baby), suspicious oral/facial trauma (torn frenulum, dental trauma present in 50% of abuse)
• Child sexual assault: Penile/vaginal d/c (STDs), UTI, genital/rectal trauma (inner thigh bruising, rectal tears, loss rectal tone), often no physical findings if delay in presentation
Evaluation
• Skeletal series (children <5), head CT (suspected intracranial injury), dilated eye exam (retinal detachment/hemorrhage → shaken baby), CBC, Coags, LFTs, tox screen, growth measurements, vaginal/rectal/oral swabs
Treatment
• Social work/child protective services, treat injuries as appropriate
Disposition
• D/C per child protective services
Pearls
• 2–3% children (physical abuse associated low SES)
• ↑ risk in children w/ mental/physical disabilities/chronic medical problems
• Consider Munchausen syndrome by proxy in cases w/ extensive/neg prior w/u
• Most important to suspect abuse & allow trained specialists to opine if abuse occurred
Sexual Assault
History
• Time, date, number/description of assailants, threats made, weapons used, type of assault, drugs used, LOC, post assault activity (change of clothing, urination, showering, tampon use), last time of voluntary intercourse
Physical Findings
• Document: Appearance of clothes, scratches, bruising, lacerations (can use toluidine dye to identify vaginal lacerations), d/c
Evaluation
• Imaging as needed, have pt advocate present, pregnancy test, ± STD testing, full rape kit if <72 h (modify as appropriate), vaginal/rectal secretions for acid phosphatase/glycoprotein p30, tox screen
• Many areas will have SANE services available & pt may need transfer for SANE exam, must medically clear pt 1st
Treatment
• Pregnancy prophylaxis (levonorgestrel 0.75 q12h × 2 doses), STD prophylaxis (gonorrhea: Ceftriaxone 125 mg IM × 1, Chlamydia: Azithromycin 1 g PO × 1, Hep B: 1st of 2 vaccines, HIV), antiemetics
Disposition
• D/C w/ f/u counseling
Pearl
• 1/5 women is sexually assaulted in lifetime, only 7% reported
Intimate-partner Violence
History
• Story inconsistent w/ injuries, frequent ED visits, vague medical complaints, chronic pain (>abdominal pain), overbearing/controlling partner, injury during pregnancy
Physical Findings
• Injuries face/head/neck/areas covered by clothes (most common)
Evaluation
• Imaging as needed
Treatment
• Photographs as appropriate, determine safety of home/immediate risk (escalating violence, treats, firearms), devise safety plan (avoid sedative/arguments in small rooms/access to firearms, teach children to call 911), social work consult
Disposition
• D/C to shelter if unsafe home
Pearls
• ↑ risk during pregnancy/attempts to leave partner
• Universal screening for all pts should be done in the ED
Elder Abuse
History
• Delayed presentation, h/o med noncompliance/missed appointments, often lives w/ abuser, have dementia, are dependent on abuser for ADLs, RFs for abusive caretaker: Mental illness, substance abuse, h/o family violence/financial stress/stress of being caretaker
Physical Findings
• Poor hygiene, malnutrition, decubitus ulcers, “urine rash,” unexplained injuries to face/head/torso/back/buttocks/limb contractures (restraints)/bilateral upper extremities (grabbing)
Evaluation
• Imaging as needed, CBC, BMP, CK (rhabdomyolysis)
Treatment
• Photographs as appropriate, arrange for support services to relieve stress on caretaker (VNA, meals-on-wheels), arrange for home safety eval
Disposition
• Admit if unsafe to go home
Pearls
• May be as high as 5–10% in elderly
• Decreased reporting for fear of institutionalization