EM E2: Abuse/Assault

What are signs of child neglect in infants?

diaper rash, alopecia on back of head, emaciated, ribs showing, not meeting milestones, dirty/unkept, inappropriate clothing for environment, suspicious injuries

What are signs of child neglect in children?

stealing food, often absent from school, poor dental health, emotionally w/drawn, poor eye contact, aggressive, falls asleep during school, dirty/unkept, tells you they are home alone

What should you do if you suspect child abuse?

required to report, can admit child, call police if parent wants to leave w/ child

What behavioral problems may indicate a child has been victim of sexual abuse?

excessive masturbation, regression from achieved milestones, not wanting to be alone, anxiety, nightmares, provocative behavior

In sexual abuse cases, speculum exams are NOT needed unless what?

victim is older adolescent or perforating vaginal trauma is suspected

In sexual abuse cases, invasive exams or touching the area should be deferred until when?

after discussed w/ investigator, unless emergent intervention needed

What is extremely important and should be highly detailed, in case you are called to testify?

chart -use quotes, pictures, as much info as possible

*if testifying ONLY say what is in the chart, do not add opinion

What are signs of child abuse?

story is inconsistent w/ extent of injury, multiple bruises (buttocks, thigh, cheek, ankles, wrist, corners of mouth, lips), bites > 3 cm, scald burns, cigarette burns ~5 mm, skeletal injury (spiral fx), abd injury, head injury

What is a common cause of death in child abuse?

abdominal injuries

You should be suspicious of any serious injury in pts how old?

< 5 yo

What are behavioral sx of child abuse?

very compliant and submissive, readily submit to painful procedures, overly affectionate to medical staff, protective of abusive parent (lying)

What parental behaviors raise suspicion of child abuse?

may not comfort or support child, become angry at physician, refuse diagnostic studies, appear intoxicated, readily confess they can no longer cope w/ the child

What happens if you do not report abuse?

3rd degree felony to not report child abuse to DCF

misdemeanor to not report adult abuse

*have high index of suspicion and listen to your gut; if you suspect, report

What is Muchausen syndrome by proxy?

parent induces or fabricates an illness in a child to secure prolonged contact w/ health care providers; usually the mother

What are sx of Muchausen syndrome by proxy?

bleeding, seizures, AMS, apnea, diarrhea, vomiting, fever, rash, multiple organ system involvement

What is mandatory for evaluation and management of children that are victims of Muchausen syndrome by proxy?

social service and psych evaluation

T/F: Clinician’s responsibility is to provide for the pt’s physical and psychological well-being first and then provide police w/ corroborative forensic evidence

True

If SA evidence is collected, does in have to be reported?

no, but gives them the power to in the future

What is important to maintain once SA evidence is collected?

chain of custody - once evidence is collected and sealed must be held until the police comes, DO NOT set it down or leave it alone

What is ALWAYS needed when collecting sexual assault history, exam, or collecting evidence?

chaperone

SA evidence should be kept in what container?

paper bags, NO plastic bc it degrades evidence

What should be done for SA?

tx any injuries, offer STD tx, offer Plan B, give information on support groups and victim’s advocacy

What are the 4 types of intimate partner violence?

physical, sexual, stalking, psychological (isolation, financial, emotional)

What findings are suggestive of intimate partner violence?

scratches, bite marks, cigarette burns, forearm bruises or fx, central pattern of injury, injury doesn’t match explanation, multiple injuries in various stages of healing, delayed medical care, suicide attempts

What is the most dangerous time for victims of IPV?

after they leave or seek help

After identifying a victim of IPV, what are high risk indicators that indicate their safety is at risk?

escalation in frequency or severity, threat or use of weapon, homicide or suicide threats, obsession w/ the victim, hostage taking, stalking, substance abuse

What are the three categories of elder abuse?

domestic, institutional, self-neglect or self-abuse (can be intentional or unintentional)

What are risks of elder abuse?

social isolation from family and friends, functional disability, worsening cognitive impairment, personality problems of caregiver

What are signs of elder abuse?

pt appears fearful of their companion, conflicting accounts of injury, absence of assistance from caretaker, caretaker displays an attitude of indifference or anger, caretaker overly concerned w/ cost, caretaker denies chance for pt to interact privately w/ physician

Why are EDs high risk areas for violence?

unlimited and unrestricted access, have readily available drugs, frequented by homeless, substance abusers; high emotions, long wait times, etc

What is the MC functional disorder related to violent pt behavior?

schizophrenia

Who are the common perpetrators of violence in the ED?

males w/ hx of substance abuse

Which phase of violence:

inc anxiety indicated by body language, unwillingness to stay in the tx area

Goal: attempt to develop rapport

Phase 1- Anxiety

Which phase of violence:

pts behavior is volatile and becomes verbally abusive and profane

Goal: prevent loss of control by the pt, offering pt a choice, remain calm and professional

Phase 2 - Defensiveness

Which phase of violence:

pt is totally out of control, verbal intervention is ineffective, dangerous area

Goal: restraints, security, police

Phase 3 - Physical Aggression

What is the purpose of restraints and seclusion?

ensure the safety of pts and others

What is warranted for pts that are too violent even when restrained to perform an evaluation?

medication/sedatives IM

What meds are used to restrain pts?

B52 -Benadryl/Haldol/Ativan

Geodon, Benzos, Lorazepam, Ketamine

What is the most important factor in curbing ED violence?

education of ED personnel