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ER28 Emergency Medicine
Approach to Common ED Presentations
Toronto Notes 2019
• pelvicexamandspecimencollection
■ ideally before urination or defecation
■ examine for seminal stains, hymen, signs of trauma ■ collect moistened swabs of dried seminal stains
■ pubic hair combings and cuttings
■ speculumexam
◆ lubricate with water only
◆ vaginal lacerations, foreign bodies
◆ Pap smear, oral/cervical/rectal culture for gonorrhea and chlamydia ◆ posterior fornix secretions if present or aspiration of saline irrigation ◆ immediate wet smear for motile sperm
◆ air-dried slides for immotile sperm, acid phosphatase, ABO group
• fingernailscrapingsandsalivasamplefromvictim
Investigations
• VenerealDiseaseResearchLab(VDRL):repeatin3moifnegative
• serumβ-hCG
• bloodforABOgroup,Rhtype,baselineserology(e.g.hepatitis,HIV)
Management
• involvelocal/regionalsexualassaultteam(sexualassaultforensicexaminerorsexualassaultnurse examiner)
• medical
■ suture lacerations, tetanus prophylaxis
■ gynecology consult for foreign body, complex lacerations ■ assume positive for gonorrhea and chlamydia
◆ management: azithromycin 1 g PO x 1 dose (alt: doxycycline 100 mg PO bid x 10 d) and ceftriaxone 250 mg IM x 1 dose
■ may start prophylaxis for hepatitis B and HIV ■ pre and post counselling for HIV testing
■ pregnancy prophylaxis offered
◆ levonorgestrel 1.5 g PO STAT (Plan B®) • psychological
high incidence of psychological sequelae
have victim change and shower after exam completed
Disposition
• dischargeifinjuries/socialsituationpermit
• follow-upwithphysicianinrapecrisiscentrewithin24hforrepeatpregnancyandSTItesting. • bestifpatientdoesnotleaveEDalone
DOMESTIC VIOLENCE
• womenareusuallythevictims,butmalevictimizationalsooccurs • identifytheproblem(needhighindexofsuspicion)
■ suggestive injuries (bruises, sprains, abrasions, occasionally fractures, burns, or other injuries; often inconsistent with history provided)
■ somatic symptoms (chronic and vague complaints)
■ psychosocial symptoms
■ clinician impression (your ‘gut feeling’, e.g. overbearing partner that won’t leave patient’s side)
• ifdisclosed,besupportiveandassessdanger
• patientmustconsenttofollow-upinvestigation/reporting(unlessforchildren)
Management
• treatinjuriesanddocumentfindings
• askaboutsexualassaultandchildrenathome(encouragenotificationofpolice) • safetyplanwithgoodfollow-upwithfamilyphysician/socialworker