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Evaluation and Management of the
Sexually Assaulted or Sexually Abused Patient
Clinical Manifestations—CAUTION!
•
•
“Strangulation survivors who appear stable can harbor insidious injuries associated with high morbidity and
mortality if not recognized and treated in a timely fashion” (Taliaferro, Hawley, McClane and Strack 2009)”
Common pitfalls in caring for strangulation patients:
— Attempting to predict outcome based on initial condition of the patient
— Premature discharge of patient who has been strangled within the past 24–36 hours
Evolving Clinical Approach
•
•
•
Many experts recommend admission/observation of all strangulation patients for at least 24 hours
Recent guidelines: Observe 12–24 hours if any of the following occurred
— History of loss of consciousness
— Facial and/or conjunctival petechiae
— Neck soft tissue injury
— Incontinence (urinary or fecal)
— Intoxicated and/or poor home observation potential
Safe to discharge patient if:
— No loss of consciousness
— No or minimal neck soft tissue injury
— No neurologic complaints/findings
— Reliable home monitoring
Documentation Chart
for Non-Fatal Strangulation Cases
Symptoms
and/or
Internal
InjuryInjury
Symptoms
and/or
Internal
Breathing
Breathing
Changes
Changes
Voice
Changes
Voice
Changes
Swallowing
Swallowing
Changes
Changes
Behavioral
Behavioral
Changes
Changes
OTHER
OTHER
q
DifficultyBreathing
Breathing
Difficulty
q
Hyperventilation
 Hyperventilation
q
breathe
Unable to
to breathe
Unable
Other:
Other:
q Raspy
voice
 Raspyvoice
qHoarse
Hoarse voice
voice
qCoughing
Coughing
qUnable
Unable to
to speak
speak
q Trouble
swallowing
 Trouble swallowing
q
Painful
to
swallow
 Painful to swallow
q
Neck Pain
Pain
Neck
q
Nausea /Vomiting
Nausea/Vomiting
q
Drooling
Drooling
q
Agitation
Agitation
q
Amnesia
Amnesia
q
PTSD
PTSD
q
Hallucinations
Hallucinations
q
Combativeness
Combativeness
qDizzy
Dizzy
qHeadaches
Headaches
qFainted
Fainted
qUrination
Urination
qDefecation
Defecation
Use face and neck diagrams to mark visible injuries
Use face and neck diagrams to mark visible injuries
Clinical Evaluation in the ED
•
ABC’s (airway, breathing, circulation)
— Pulse Oximetry
• Cervical spine precautions
• Structured history and physical exam
— Check-list
— Dedicated form
• Consultation(s)
• Fiberoptic laryngoscopy
— ENT consultation
— Laryngeal pathology only (some life-threatening)
• Imaging Strategies in the ED
— Plain neck X-rays rarely helpful (hanging with drop)
— Neck CT with IV contrast—soft tissue injury
— CT angiography of carotids
▪ Intimal tears
▪ Thrombosis
▪ Maximum sensitivity = 82%
— 4 vessel carotid angiography: 100% sensitivity
— Doppler ultrasound of carotids: 80–90% sensitivity
— MRI
▪ Best overall modality for strangulation
▪ Best early detection of life-threatening problems
▪ Deep soft tissues
▪ Larynx and hyoid bone
▪ Vascular injuries
— MRI is strongly recommended
▪ History of loss of consciousness
▪ Facial or conjuntival petechiae present
Additional Resource
1.
88
Face
Face
Eyes &
Eyes
&Eyelids
Eyelids
Nose
Nose
Ear
Ear
Mouth
Mouth
q Red
Redor
orflushed
flushed
Petechiae
R and/or
to Rtoand/or
L L

qPetechiae
q
Pinpoint
red
spots
eyeball
(circle
one)
eyeball (circle one)
 Pinpoint red spots
(petechiae)
Petechiae
R and/or
(petechiae)
to Rtoand/or
L L
qPetechiae
eyelid
one)
q Scratch
Scratchmarks
marks
eyelid(circle
(circle
one)

redred
eyeball(s)
qBloody
Bloody
eyeball(s)
 Bloody nose
Broken nose
qBroken
nose
(ancillary finding)
(ancillary finding)
q Petechiae
 Petechiae
 Petechiae
q Petechiae
(externaland/or
and/or
(external
ear
ear
canal)
canal)
Bleeding
from
from
qBleeding
ear
earcanal
canal
Bruising
qBruising
q
Swollen
tongue
tongue
 Swollen
q
Swollen
lips
 Swollen lips
q
Cuts/abrasions
 Cuts/abrasions
Under
Chin
Under
Chin
Chest
Chest
Shoulders
Shoulders
Neck
Neck
Head
Head
q Redness
Redness

q Scratch
Scratchmarks
marks

q Bruise(s)
Bruise(s)

q Abrasions
Abrasions

Redness
qRedness
Scratch
marks
marks
qScratch
Bruise(s)
qBruise(s)
Abrasions
qAbrasions
Redness
qRedness
Scratch
marks
marks
qScratch
Bruise(s)
qBruise(s)
Abrasions
qAbrasions
Redness
Petechiae
(on(on
qPetechiae
qRedness
Scratch
marks scalp)
scalp)
marks
qScratch
Ancillary
Finger
nail
Ancillaryfindings
findings
nail
qFinger
pulled
qHair
impressions
impressions
Hair
pulled
qBump
qBruise(s)
Bruise(s)
Bump
qSkull
qSwelling
Swelling
Skullfracture
fracture
Concussion

mark
qLigature
Ligature mark
q Concussion
q Bloody nose
(ancillary finding
finding) )
(ancillary
National Strangulation Training Institute www.strangulationtraininginstitute.org
Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient | ACEP
Strangulation
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