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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 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 4 Injuries Blunt force: Abrasions/scratches Bruises ___________________________________ ___________________________________ Lacerations/tears Fractures Sharp force: Cuts Stab wounds/puncture wounds ___________________________________ Burns Bite marks ___________________________________ Self-inflicted injuries ___________________________________ ___________________________________ ___________________________________ 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 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 Abrasions How might we describe this injury? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 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 ___________________________________ ___________________________________ ___________________________________ 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 Bruises Bruise to left eye and nose Note the round red area just below the eye caused by a “gem stone” in the ring. ___________________________________ ___________________________________ ___________________________________ ___________________________________ 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 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 Patterned Injury Injury to 28 year-old Vietnamese woman from belt loop ___________________________________ ___________________________________ ___________________________________ Injuries inflicted from rope loop ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 19 Patterned Injury What caused this injury? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 20 Patterned Injury Take a closer look ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 21 Patterned Injury What caused this injury? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 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 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 ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 28 Laceration/Tear ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 29 Laceration/Tear ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 30 Laceration/Tear ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 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 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 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 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 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 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 ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 43 ___________________________________ Bite mark ___________________________________ ___________________________________ Prototypical bitemark; note drag marks as victim pulled away. ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 44 ___________________________________ Bite mark ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 45 Bite mark ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 46 ___________________________________ Bite mark ___________________________________ ___________________________________ Bite marks were used to convict Ted Bundy ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 47 Human Bites ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 48 Petechiae Multiple hemorrhagic spots, pinpoint to pinhead in size ___________________________________ ___________________________________ Not raised, do not blanche ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 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. (/www.coolnurse.com/self-injury.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. 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) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 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 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; 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 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 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? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 64 What do you see? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 65 What do you see? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 66 What do you see? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 67 What do you see? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 68 What do you see? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 69 What do you see? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 70 What do you see? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 71 What do you see? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 72 What do you see? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 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? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________
