Slide 1. Slide 2. Slide 3 NON-GENITAL INJURIES. Documentation. Documentation

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Slide 1 NON-GENITAL INJURIES YWCA Oklahoma City Created by

SANE-A Slide 2 Documentation Document the location of injury

appearance Note size of injury Note any pattern if

1 Slide 1 NON-GENITAL INJURIES YWCA Oklahoma City Created by LaRae Huycke, RN, MS, APRN-BC, DNP & Shannon Liew, RN, BSN, SANE-A Slide 2 Documentation Document the location of injury in relation to anatomical position Note type of injury Note appearance Note size of injury Note any pattern if applicable Not how the patient states injury occurred Slide 3 Documentation

2 Slide 4 Injuries Blunt force: Sharp force: Burns Bite marks Self-inflicted injuries Abrasions/scratches Bruises Lacerations/tears Fractures Cuts Stab wounds/puncture wounds Slide 5 Injuries BLUNT FORCE INJURIES Slide 6 Abrasions

Slide 7 Abrasions The removal of the outermost skin layer due to compressive and/or sliding

An excoriation, or circumscribed removal of the superficial layers of skin or mucous membrane.

pushed appearance look for debris Implication: Indicate contact with rough surface/object

3 Slide 7 Abrasions The removal of the outermost skin layer due to compressive and/or sliding forces. An excoriation, or circumscribed removal of the superficial layers of skin or mucous membrane. Scraping away of a portion of the surface leaving tender exposed tissue which may/may not ooze serosanguinous fluid / blood. If abrasion is long and narrow = scratch abrasion, wide = graze abrasion Observe: patterns pushed appearance look for debris Implication: Indicate contact with rough surface/object Demonstrate exact site of contact/impact Direction of force wide end toward narrow end Slide 8 Abrasions Abrasion of the lateral leg shearing force from carpet Same patient, dragged down carpeted stairway Slide 9 How might we describe this injury? Abrasions

Slide 10 Bruises/Contusions Slide 11 Bruise/Contusion A bruise or "contusion" is an traumatic injury of the soft tissues which results in breakage of the local capillaries and leakage of red blood

When a sufficient amount of blood is involved there may be swelling of the tissue. This type of injury is typically painful to touch.

4 Slide 10 Bruises/Contusions Slide 11 Bruise/Contusion A bruise or "contusion" is an traumatic injury of the soft tissues which results in breakage of the local capillaries and leakage of red blood cells. In the skin it can be seen as a reddish-purple discoloration that does not blanch when pressed upon. In the early stages it may be warm to touch. When a sufficient amount of blood is involved there may be swelling of the tissue. This type of injury is typically painful to touch. When a bruise fades it becomes green and brown as the body metabolizes the blood cells in the skin. It is best treated with local application of a cold pack immediately after injury. Slide 12 Bruises/Contusions Ecchymosis A purple patch ( black and blue spot) in the skin caused by extravasation of blood Petechiae hemorrhagic spot, red in color, pinpoint to pinhead in size Hematoma a localized mass of blood that is relatively or completely confined to a space, usually clotted Erythema redness of the skin caused by dilation and congestion of blood vessels, often a sign of inflammation/infection, blanches with touch

Note the o bruise in a different stage of healing just laterally.

Bruises Large mid-thigh bruise from being stomped by attacker s foot while on

5 Slide 13 Bruises Punch to face. Bruise caused by stomp, from a hiking boot, to upper thigh. Note the o bruise in a different stage of healing just laterally. Slide 14 Bruise to left eye and nose Note the round red area just below the eye caused by a gem stone in the ring. Bruises Note marks from bracelets as well as absence of bruising Slide 15 Bruises Large mid-thigh bruise from being stomped by attacker s foot while on ground, note shape of bruise Note long bruise from posterior mid-thigh to lateral thigh ending at knee level; caused from car antenna used to hit victim *patient on no medications that would cause increased bleeding

Slide 16 Bruises and Medications Anticoagulants ~ Coumadin, heparin, Lovenox, ASA, Plavix Anticonvulsants ~ valproic acid (Depakote) NSAIDs ~ Aleve, Ibuprofen Estrogen ~ note dose; typically requires

these medications so note, if they are not so note. Slide 17 Bruises new, old, recurrent?

6 Slide 16 Bruises and Medications Anticoagulants ~ Coumadin, heparin, Lovenox, ASA, Plavix Anticonvulsants ~ valproic acid (Depakote) NSAIDs ~ Aleve, Ibuprofen Estrogen ~ note dose; typically requires a dose above 1 mg / day Steroids ~ burst therapy or long term Supplements: bilberry, garlic, ginger (potentates other anticoagulants), ginkgo Chemotherapeutic agents If the individual IS receiving these medications so note, if they are not so note. Slide 17 Bruises new, old, recurrent? Bruises change color because of the degradation of hemoglobin The timescale of this degradation is not fixed Estimation of the age of a bruise not evidence based Characteristic color changes occur: dark blue/ purple (fresh) blue brown green yellow As a SANE, you CANNOT date a bruise (For a review of estimating the date of bruises, see the American Journal of Forensic Medicine and Pathology 16:203 (1995). Slide 18 Injury to 28 year-old Vietnamese woman from belt loop Patterned Injury Injuries inflicted from rope loop

7 Slide 19 What caused this injury? Patterned Injury Slide 20 Take a closer look Patterned Injury Slide 21 What caused this injury? Patterned Injury

are applied to the skin and left in place for several

8 Slide 22 Patterned Injury Slide 23 Patterned Injury caution Cupping: used as a healing practice Warmed cups are applied to the skin and left in place for several moments, drawing tissue up and into the cup. Slide 24 Patterned Injuries

Slide 25 Laceration/Tear Slide 26 Laceration/Tear Defect in soft tissues from tearing, ripping, crushing, over stretching, pulling apart, over bending, and / or

margin is a tear incomplete separation of tissue bridge present of blood vessels, connective tissue, nerves, etc Slide 27 Laceration/Tear Tear to elderly patient s

9 Slide 25 Laceration/Tear Slide 26 Laceration/Tear Defect in soft tissues from tearing, ripping, crushing, over stretching, pulling apart, over bending, and / or shearing Note: may / may not be seen with bruising due to impact injury may be larger at site of impact most often debris is present Observe: ragged, irregular margin is a tear incomplete separation of tissue bridge present of blood vessels, connective tissue, nerves, etc Slide 27 Laceration/Tear Tear to elderly patient s thigh just lateral to the right labia majora, caused by finger of attacker Lower leg skin tear to patient; note bruising lower and to the right which pre-dated the assault

10 Slide 28 Laceration/Tear Slide 29 Laceration/Tear Slide 30 Laceration/Tear

Slide 31 Bruise, Abrasion, Tear Young woman punched in lip.

Slide 32 Bruise, Abrasion, Tear This photo represents an

11 Slide 31 Bruise, Abrasion, Tear Young woman punched in lip. Assailant wearing a large ring. Note pattern to the left, as she pulled away as punch was landed. Slide 32 Bruise, Abrasion, Tear This photo represents an excellent way to depict injuries. Slide 33 Fractures Bone will fracture in different ways, depending upon the amount of force and fashion in which it is applied

$Blow out fractures can$ occur.

12 Slide 34 Fractures Blow out fractures can occur. Early identification is key Slide 35 Fractures Boxer s Fracture ~ note swelling at the base of the fifth digit; typically caused by impact with hard object Slide 36 INJURIES

Slide 38 Cuts Cut above the left eye; note it is longer than it is wide and longer than it is deep. What caused this cut? How strong was the person who did this?

13 Slide 37 Cut A cut is the dividing of the skin as a result of a sharp object coming against the skin with sufficient force to divide the tissue. Cuts typically have clearly identified borders are longer than wide are longer than deep Characteristics of object used not usually well reflected by cut Cannot determine amount of force used Slide 38 Cuts Cut above the left eye; note it is longer than it is wide and longer than it is deep. What caused this cut? How strong was the person who did this? Slide 39 Stab Wounds Whenever a sharp, narrow object is forced inward. Degree of injury to underlying organs is determined by the length of the object used. Stab wound to outer left upper quadrant; note the hilt of the knife leaving an impression to the left of the wound

14 Slide 40 Stab Wounds This is an autopsy photo taken from the Sharon Tate murders. Slide 41 Defensive Injuries Slide 42 Burn Injury Burns from Bic lighter

15 Slide 43 Bite mark Prototypical bitemark; note drag marks as victim pulled away. Slide 44 Bite mark Slide 45 Bite mark

16 Slide 46 Bite mark Bite marks were used to convict Ted Bundy Slide 47 Human Bites Slide 48 Multiple hemorrhagic spots, pinpoint to pinhead in size Not raised, do not blanche Petechiae

Slide 49 Self-Inflicted Injuries Slide 50 Secret Shame Self Inflicted Injuries Cutting is most common form Razors, utility knives, scissors, needles, broken glass, or whatever they find to make

htm, 2000-2007) Slide 51 Self-Inflicted Injuries "I hurt myself for different reasons, depending on my state of mind. I do it sometimes as a way to get relief from the pain I am feeling inside.

17 Slide 49 Self-Inflicted Injuries Slide 50 Secret Shame Self Inflicted Injuries Cutting is most common form Razors, utility knives, scissors, needles, broken glass, or whatever they find to make repetitive slices on their arms, legs or other body parts. Some people burn themselves with cigarettes or lighters, others pull out their own hair. (/ ) Slide 51 Self-Inflicted Injuries "I hurt myself for different reasons, depending on my state of mind. I do it sometimes as a way to get relief from the pain I am feeling inside. Other times I do because at the time I feel I deserve to be punished, or I am angry at myself, but really I think someone else. Other times I do it to "shout out" to the world that I need help and here is the proof. I am a incest survivor, so I think that it's some of the pain that I have had to live with trying to escape my body. (Dianne, Age 30, Canada) "I cut myself because I feel so much pain inside that I need a way to release it all. So by cutting myself, it acts as an outlet for that l pain, I guess, somehow. It feels like it's all running out of me when I see myself bleeding. I know that probably sounds gross to most people who don't do this. Yes, I am in group therapy for people who selfinjure". (Chrissy, Age 17, USA)

18 Slide 52 Secret Shame Slide 53 Self-Inflicted Injuries This young man reported being injured while running through brush to escape his attackers. Later, he was able to tell us the wounds were self-inflicted. Note the regular spacing between cuts and the differences in points of initial impact. He is right handed and the bulk of injuries were to his left leg. Slide 54 Self-Inflicted or Assault?

Slide 55 Body Modification Branding Slide 56 Avulsion Avulsion a forceful separation or detachment, tearing

accompanied by boyfriend Patient in obvious distress: pulse 142; respirations 42 / shallow; BP supine

poorly responsive; multiple trauma noted with severe head and neck trauma; no lung sounds on left; chest

19 Slide 55 Body Modification Branding Slide 56 Avulsion Avulsion a forceful separation or detachment, tearing away of a body part Slide 57 CASE STUDY 1430: 19-year-old Black female arrives at ER via private vehicle, accompanied by boyfriend Patient in obvious distress: pulse 142; respirations 42 / shallow; BP supine 94/68; pulse ox (on room air) 88%. poorly responsive; multiple trauma noted with severe head and neck trauma; no lung sounds on left; chest tube inserted 500cc frank blood returned; right thumb nearly severed from hand; right third finger crushed; IV inserted NS wide open; unable to obtain history from patient due to condition

Slide 58 The History Boyfriend reports following: he had been contacted 10 hours PTA by patient who reported she had been abducted and raped; was able to escape when she jumped from moving vehicle;

20 Slide 58 The History Boyfriend reports following: he had been contacted 10 hours PTA by patient who reported she had been abducted and raped; was able to escape when she jumped from moving vehicle; he arrived at xxx and found her; she refused police involvement and did not want to go to hospital. Boyfriend he took her home, cleaned her up and allowed her to rest; later became concerned about her condition and insisted she come to the ER. He repeats she does not want a rape exam but wants to be treated for her injuries. Slide 59 Continuing Care Not following commands, no eye opening, not able to speak, blood from left ear canal Boyfriend attentive, attempting to contact patient s Mother, without success Police contacted Patient moved to the CCU in critical condition Slide 60

21 Slide 61 SANE SANE called and arrives at ~ 2130; Advocate arrives 5 minutes later Gather equipment and go immediately to the ICU Slide 62 What do you see? Slide 63 What do you see?

22 Slide 64 What do you see? Slide 65 What do you see? Slide 66 What do you see?

23 Slide 67 What do you see? Slide 68 What do you see? Slide 69 What do you see?

24 Slide 70 What do you see? Slide 71 What do you see? Slide 72 What do you see?

So, they just stood at the foot of the bed and cried without making a sound?

25 Slide 73 What do you see? Slide 74 Tell me What did you see? Did you see a Mom, dearly loved? Did you see a Sister idolized by six brothers, who suddenly were afraid to touch her? So, they just stood at the foot of the bed and cried without making a sound? Did you see a Daughter, whose parents thought we had called the wrong family because they did not recognize her when they came into the room? Slide 75 Look again tell me what do you see?

Genital Injury and Human Sexual Response in Sexual Assault. Cheryl Graf, ARNP, MSN

Genital Injury and Human Sexual Response in Sexual Assault Cheryl Graf, ARNP, MSN Reasons to Identify Injury To recognize the need for treatment Refer for further evaluation /treatment Identify a pattern