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91 Cards in this Set
- Front
- Back
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What is the term for carbonaceous material left on the skin after a close range GSW?
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Soot
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What are 4 types of hand guns?
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single shot
derringer (2 barrel) revolver (5-6 cartridge) semi-automatic pistol (17 cartridges) (fires with each pull of the trigger) |
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What is an automatic weapon?
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Fires ammunition as long as the trigger is held
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What makes up a cartridge?
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Primer
Cartridge Case Powder Bullet |
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What may the primer contain?
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Lead
Antimony Barium |
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What is a magnum bullet?
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Additional powder has been added
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What is the calibre of a gun?
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The diameter of the bullet expressed in hundredths of inches
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What is the principle mechanism of tissue damage in bullet wounds?
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Crush
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What cavaties do bullets produce?
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Permanent
Temporary |
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What is the range of fiver?
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The distance from the muzzle to the victim
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Does the size of the entrance wound correlate with caliber?
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No because of the elasticity of tissue
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What are 4 ranges of fire?
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Contact
Near contact/close range Medium/intermediate range Indeterminant or distant range |
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What is the distance and physical properties of contact range?
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0 inches
Soot, seared skin, stellate/triangular lesion |
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What is the distance and physical properties of a close range GSW?
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0-6 inches
soot abrasion collar (close range is the maximum range at which soot exists) |
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What is the abrasion collar?
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Abraded area of skin that surrounds an entrance wound, the result of friction between the bullet and epithelium
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What is pathognomic for intermediate range?
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Tatoo-ing
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What is tattooing?
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Punctate abrasions caused by partially burned or wholly unburned gun powder
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What is the distance and physical properties of intermediate range GSWs?
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<48 inches
tatoo-ing, stipling, abrasion collar |
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What is the hallmark of distant range?
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Only the bullet makes contact with the skin
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When an abrasion collar is the only skin finding, what can be said about the range?
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Indeterminate, cannot say whether 10 or 100 feet
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What are characteristics of exit wounds?
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Skin edges often everted, sharp, irregular margins. Abrasion collar, soot or tattooing are never seen
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Can an exit wound have an abrasion collar?
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No, but it can have a shored exit which may look like an abrasion collar, this happens if the skin of the exit wound is pressed against a firm object or surface
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When are exit wounds larger than entrance wounds?
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High velocity (especially with rifles)
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What is the pattern of direct blow injury?
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Central clearing with parallel linear contusion because the blood underlying the striking object is forcibly displaced to the sides
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Can you determine the age of contusion based on appearance?
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Not accurately
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What is a laceration?
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A defined tear produced by blunt trauma
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What is a stab wound?
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Puncture wound deeper than it is wide
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What characterizes immersion burns?
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Sharp or clear line of demarcation between burned and unburned skin
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What does the term magnum mean?
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Additional gun powder added to the cartridge case -> therefore increased velocity of the projectile
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What are the most common bullet types?
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Round nose
Full metal jacket Wadcutter Semi-wadcutter Hollow point (hole in the tip that causes expansion on contact with tissues, increasing tissue damage) |
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Compare the velocity of bullets fired from a handgun vs a rifle?
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Handgun 700-1600 feet/sec
Rifle 1500-4000 feet/sec |
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What determines wound severity (7)?
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Bullet size
Bullet shape Bullet weight Bullet velocity Deformation Fragmentation The physical characteristics of the impacted tissue |
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What types of weapons cause lead snowstorm on xray
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High velocity rifles
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Define child sexual abuse?
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Involvement of children and adolescents in sexual activity to which they cannot give consent based on development level, involving age disparity, and for sexual gratification of older individuals
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What are patterned injuries?
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Objects that mirror the form of the inflicting object
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Should colour be used to estimate the age of a bruise?
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No
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Where do accidentally incurred bruises occur?
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Over bony prominences
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How can you determine if a bite was caused by a child vs an adult?
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Distance between maxillary canine teeth
child <2.5cm adult >3cm |
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What is the appearance of a palmar or soler GSW?
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Slit - may look like a stab wound
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Differentiate inadvertant cigarette burn and inflicted cigarette burn?
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Indirect - less severe or linear burns
inflicted - circular, measures 8-10mm which becomes blistered and then ulcerates |
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How long must exposure be to cause 1st or 2nd degree burns in 52 degrees celsius vs 64 degrees celsius.
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52-> 70s
64-> 1s |
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What # patterns are suspicious for abuse?
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-long bone in pre ambulatory infant
-metaphyseal fracture -rib fractures (especially posterior) -scapular # -spinous process # Skull fractures (multiple, wide (>3cm), growing, >1 cranial bone, occipital |
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What is the appearance of accidental spill burns?
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Drip appearance, more extensive and severe injury proximal to the point of contact
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What is the shaken baby syndrome?
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Head trauma
Retinal hemorrhages Skeletal injuries Typically in patients <1 but up to <3 |
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Should speculum examinations be done in pre-pubertal children?
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No, if intravaginal trauma then OR
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What can be mistaken for burn injuries?
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Bullous impetigo
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What is a trauma series?
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Skull radiography
Long bones Ribs Vertebrae |
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What condition may be mistaken for inflicted head trauma?
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glutaric aciduria type 1
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What is prophylaxis for children for chlamydia and gonorrhoea?
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<45kg - Ceftriaxone 125mg IM
erythromycin 50mg/kg/d QID >45kg - Ceftriaxone 125mg IM x 1, Azithromycin 1g PO x 1 |
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What is phytophotodermatitis?
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Brown discoloration that develops on sun-exposed skin in contact wiht fruits or juices (lime and/or lemon)
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What is lichen sclerosis et atrophic us?
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Dematologic condition in prepubertal boys and girls
atrophic skin and blood blisters hypopigmentation |
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What may cause vaginal discharge?
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Shigella
GAS candida pinworm FB |
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What epidemiological factors are associated with increased prevalence of abuse?
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Poverty
Social isolation Parental mental illness Parental alcohol and substance abuse Domestic violence |
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What information obtained during history taking is suspicious for child abuse?
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Child expresses complaints related to abuse
History is inconsistent with the medical findings History is inconsistent with the developmental stage of the child Delay in seeking medical care Parent is uncertain how the child sustained injury Unwitnessed events leading to injury The child was well at bedtime and awoke with a lesion or pain |
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What is predictable color change patter as a bruise evolves?
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purple->green->yellow->brown
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What is a skeletal series?
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AP view of the extremities
frontal and lateral views of the thoracolumbar spine (including ribs) AP and lateral skull series |
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When should a skeletal survey be ordered?
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Susptected physical abuse in children <2
Between 2 and 5 ->case by case >5year rarely needed |
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What is the falling zone of facial trauma in toddlers learning to walk?
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perioral region, nose and forehead
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What are potential physical exam findings in a child victim of sexual abuse?
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Disruption of the hymen
petechiae hematomas vaginal tears anal scars change in anal tone anal spasm penis rarely has noticeable injury |
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What conditions mimic fractures?
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birth related injuries
accidental trauma osteopenia of prematurity congenital rubella congenital syphilis osteogenesis imperfecta hypervitaminosis A Rickets Scurvey Menke's kinky hair syndrome |
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What conditions mimic bruises of child abuse?
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noninflicted bruises
mongolian spots physophotodermatitis |
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What conditions mimic cerebral edema?
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meningitis
encephalitis hypoxia |
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What conditions mimic sexual abuse
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accidental trauma (straddle injury)
lichen sclerosis vaginitis priapism paraphimosis anal fissure |
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What conditions mimic sexual abuse
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accidental trauma (straddle injury)
lichen sclerosis vaginitis priapism paraphimosis anal fissure |
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What conditions mimic sexual abuse
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accidental trauma (straddle injury)
lichen sclerosis vaginitis priapism paraphimosis anal fissure |
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What are factors associated with youth violence?
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History of violence victimization
Exposure to violence Access to weapons substance abuse antisocial beliefs low parental involvement low income poor academic performance social rejection low levels of community participation high levels of community transience |
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What factors are associated with protection from violent behaviour?
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High grade point average
strong religious beliefs connectedness to family ability to discuss problems with parents large amounts of social capital in the community |
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What are general guidelines to precent gang violence in the ED?
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-once and injured known or suspected gang member has arrived, hospital security should be immediately involved and stationed in the ED and waiting area
-the patient should be undressed and searched for concealed weapons -evidence of previous major trauma may be indicative of previous gang injury -Ed staff should question the patient in a calm and non-judgemental way -ED visitation should be limited to patients parent If admission is required, the gang member should be admitted under a pseudonym -hospital security should be availalble 24/7 -if large numbers of gang members are present at the hospital local law enforcement should be advised -it may be useful to illicit the help of local community leaders who are experienced with local street gangs -hospitals should have lock-down or evacuation plans for personnel and visitors in the event of violence |
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Define sexual assault?
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Sexual activity where consent is not obtained or freely given
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What affects the likelihood of finding genital injury at time of sexual assault?
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Time to examination
Nongenital injury Penile penetration Sexual inexperience and hymenal tearing Post-menopausal History of anal contact History of stranger assault History of nonconsensual intercourse Victim use of alcohol Victim college graduate |
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Describe the typical genital injury seen in sexual abuse victims?
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Involves >/=1 site
External Located posteriorly between 3, 6 and 9 o'clock Injury is the result of blunt force Posterior fourchette |
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What is the best method for determining genital injury?
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Colposcopy - because it can differentiate trauma from intravaginal changes
Currently many centers use digital photography and videography with excellent results and less cost |
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What are the maximum reported time intervals for sperm recovery in the vagina, cervix, mouth, rectum?
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motile sperm
Vagina 6-28 hours Cervix 3-7 days non-motile sperm vagina 14hours-10days cervix 7.5-19days mouth 2-21 hours rectum 4-113 hours anus 2-44hours |
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What is the recommendation regarding testing for STDs?
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Disadvantages
-expensive -requires a reassessment of the patient -has no forensic value -most protocols no longer require or pay for it -many victims have preexisting STDs Most providers prefer preventative therapy |
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What is the risk of Gonorrhea, Chlamydia, Syphilis and HIV after assault?
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Chlamydia 6-18%
Gonorrhea 4-17% Syphilis 0.5-3% HIV 0.1-0.2% (consensual), 0.5-3% for rectal, much lower for oral |
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What is STD prophylaxis and HBV infection in adult sexual assault victims?
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Ceftriaxone 250mgIM x 1 or Cefixime 400mg PO x 1
Metronidazole 2 g orally x 1 Azithromycin 1g PO x 1 or doxy 100mg PO BID x 7days HBV - serologic testing is not required -give vaccinations if SAV is unimmunized -follow up doses should be given at 1 month and 4-6 months |
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Discuss HIV PEP in sexual assault victims?
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The highest efficacy is if prophylaxis given as soon as possible and must be within 72 hours
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What is the rape trauma syndrome?
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Acute phase
Expressed crying, angry, restless Controlled Calm, quiet, emotionless somatic increased muscle tension, headaches, GU, GI discturbance, fatigue, Anger/self blame Outward adjustment phase Alteration of daily routine change of residence change of phone number seeking family support fears and phobic reactions daytime anxiety nightmares Integration accepts the rape as part of her life begins to integrate the crisis into her life experiences |
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What factors place persons at risk for intimate partner violence?
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Female gender
Young age (<35) single, separated or divorced immigrant homeless exposure to violence in family of origin direct childhood physical or sexual victimization Alcohol use Physical or mental disabilities Relationships with lower socioeconomic status Unemployed abuser or abuser of lower levels of academic achievement |
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What Ed presentations should provoke consideration of intimate partner violence?
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Women with injuries to the head, face and neck
Female patient who has attempted suicide Trauma in preganncy |
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What are comorbid conditions associated with Intimate partner violence?
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Depression
PTSD HA Stress related illness Alcohol substance abuse Trauma in pregnancy Chronic pain STI/HIV |
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What are the historical clues that an injury may be the result of intimate partner violence?
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Patient refuses to say who assaulted her
Changing history History that in insconsistent with injuries Patient claims to be accident prone Delay in seeking medical care Past history of injuries Noncompliance Alcohol and substance abuse |
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What are physical exam clues that an injury is intentional?
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Central location
bilateral defensive patterned extremity injuries with grab marks anogenital trauma in pregnancy |
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Is routine inquiry about intimate partner violence recommended in the ED?
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Yes, using validated tools
HAve you ever been emotionally or physically abused by your partner or someone important to you Within the last year have you been hit, slapped, kicked, or otherwise physically hurt by someone Within the last year has anyone forced you to have sexual activities Are you afraid of your partner or anyone mentioned above |
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What variables significantly differentiate fatal and nearly fatal intimate partner violence assaults form more benign ones?
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Stalking and harassment
estrangement perpetrator access to a gun prior threats with a gun history of forced sex physical abuse during pregnancy |
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What are the 3 main categories of elder abuse?
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Domestic elder abuse - any form of elder abuse that occurs in the elder's home by a family member or caregiver
institutional abuse - any form of elder abuse that occurs in a residential facility for elderly persons, usually by individuals who are hired to provide care Self neglect or self abuse - refusal or failure of elderly individuals to provide themselves with basic necessities such as food, water, shelter medications if indicated and appropriate personal hygiene (does include mentally competent elderly individuals who understand the consequences of their decision) |
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What are 6 types of elder abuse
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Physical
Sexual Emotional or psychological abuse Financial or material exploitation Neglect (most common) Abandonment |
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What are risk factors for elder abuse?
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Caregiver RF
-alcohol or drug abuse -mental illness -financial stress -stress resulting form caring for the elder -outside factors resulting in stress -financial dependence on the elder -unrealistic expectations regarding caregiver responsibilities -lack of caregiving skills -long duration of time as a caregiver Elder RF -physical functional impairment -financial dependence on caregiver -cognitive impairment/dementia -social isolation -history of family violence -aggressive behavior -advanced age -female -incontinence -frequent falls environmental family RF -share living situation -overcrowded living conditions -lack of family/community support -socially isolated Risk Factors for Institutional abuse -poor working conditions -inadequate training -low wages -low staff to patient ratio |
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What are indicators from the medical history of possible ongoing elder abuse?
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-implausible history of MOI
-inconsistent history of injury mechanism between the patient and caregiver -delay between onset of medical illness or injury and seeking medical attention -unexplained injuries -elderly patient referred to as accident prone -past history of frequent injuries -noncompliance with medications, appointments or physician directions -caregiver not able to give details about patients medical history or routine medications -care giver answers the questions regarding the patient -patient or caregiver reluctant to answer questions -strained patient-caregiver interactions -poor living conditions according to paramedics or others |
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What are physical exam findings that are suggestive of elder abuse?
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contusion
contusions on bilateral upper arms abrasions burns sprains patterned injuries traumatic alopecia bite marks restraint marks fractures multiple injuries in various stages of healing blunt head trauma intra-abdominal injuries gag marks ocular injuries dehydration evidence that the patient has been lying in urine and stool malnutrition poor oral hygiene skin breakdown elongated toe nails untreated injuries or medical problems |
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What should be done when an abused elderly patient refuses intervention?
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Assess decision making capacity
If has DMC -> respect the patient's decision |
