Rosen & Barkin's 5-Minute Emergency Medicine Consult (646 page)

• Syphilis serology
  
• Hepatitis B and C panel
  
• HIV testing and counseling
  
• Drug testing (if suspect victim was drugged, can be used against victim if other agents detected)
  
• Blood type
  
• Pregnancy test
  
• Gonococcus
  culture
  
• Chlamydia
  culture
  
• Other labs as needed based on injuries
  

As indicated by injuries

As indicated by injuries

TREATMENT

• Treat patient in a kind, nonjudgmental manner.
  
• C-spine immobilization for patients with head/neck trauma
  

Treat life-threatening injuries.

• Place patient in quiet, private room.
  
• Assure patient of confidentiality regarding name and reason for visit.
  
• Regularly assure patient of safety.
  
• Enforce nonjudgmental behavior by staff.
  
• Designate nursing and medical provider for entire stay who is familiar with evidence collection kit.
  
• Have SANE perform exam if available.
  
• Contact community or in-hospital advocate to stay with patient while in ED.
  
• Alert hospital security to possibility of assailant presenting to ED.
  
• Contact police if patient consents or local law requires.
  
• Collect evidence as outlined above and according to local law.
  
• Offer pregnancy prophylaxis if not currently pregnant
  
• Administer prophylactic therapy for
  Gonococcus, Chlamydia, Trichomonas
  
• Consider prophylactic HIV treatment
  
• Consider prophylactic therapy or vaccine for hepatitis B
  

Hormonal therapy if within 72 hr:

• Levonorgestrel 0.75 mg PO 1st dose stat and repeat in 12 hr (preferred) or Levonorgestrel 1.5 mg PO, single dose
  
• Ethinyl estradiol 100 μg PO and levonorgestrel 0.5 mg PO 1st dose stat, repeat in 12 hr (less side effects but less effective)
  

• Ceftriaxone 250 mg IM once or Cefixime 400 mg PO single dose (
  Gonococcus
  )
  
• Doxycycline 100 mg PO BID for 7 days
  or
  azithromycin 1 g PO, single dose (
  Chlamydia
  )
  
• Metronidazole (Flagyl) 2 g PO, 1 dose (
  Trichomonas
  )
  

If not already immunized, start hepatitis B vaccination in the ED, HBIG is not required unless assailant is known hepatitis B positive

• High-risk exposures
  (source known to be HIV+ or is an intravenous drug user [IVDU], or history of men having sex with men) – Lopinavir/ritonavir (Kaletra) 200 mg/50 mg 2 tablets twice daily plus emtricitabine/tenofovir (Truvada) 200 mg/300 mg once daily for 28 days
  
• Emtricitabine/tenofovir (Truvada) 200 mg/300 mg once daily for exposures from persons other than those noted above, or lamivudine plus zidovudine (Combivir) 1 tab po twice a day for 28 days
  
• If HIV prophylaxis medications are started, baseline CBC, BMP, and LFTs should be obtained.
  

FOLLOW-UP

Serious traumatic injury

• Medical follow-up for culture and HIV test results and monitoring of HIV prophylactic medication side effects (if applicable)
  
• Psychological follow-up
  
• Safe place for patient to go to
  

• Mental health services and counseling
  
• For all pediatric cases, the Department of Children and Family Services should be contacted.
  

Follow-up should be provided for repeat HIV testing at 6 wk, 3 mo, and 6 mo

• ∼70% of rape victims do not tell their doctors or seeking mental health services
  
• Most victims will not disclose assault, unless in response to direct questions.
  
• Most of the pediatric exams in alleged sexual assault cases will be normal (80–96%)
  
• Extragenital trauma may be more common than genital
  
• Over 600 SANE/SART(specially trained forensic examiners) programs exist in US; use of a SANE, if available, may improve medical, legal, and psychological care of sexual assault victims
  

• Campbell R, Patterson D, Lichty LF, et al. The effectiveness of sexual assault nurse examiner (SANE) programs: A review of psychological, medical, legal, and community outcomes.
  Trauma Violence Abuse.
  2005;6:313–329.
  
• Linden JA. Clinical practice. Care of the adult patient after sexual assault. 2011;365(9):834–841.
  
• Sommers MS. Defining patterns of genital injury from sexual assault: A review.
  Trauma Violence Abuse
  . 2007;8:270–280.
  
• Tjaden P, Thoennes N. Extent, nature, and consequences of rape victimization: Findings from the National Violence Against Women. Washington DC: U. S. Department National Institute of Justice and the Centers for Disease Control and Prevention; 2006.
  

CODES

• 995.53 Child sexual abuse
  
• 995.83 Adult sexual abuse
  
• V71.5 Observation following alleged rape or seduction
  

BASICS

• Inadequate supply of blood flow to tissues to meet the demandsof the tissues
  
• Tissue oxygen requirements are not fulfilled.
  
• Toxic metabolites are not removed.
  
• If untreated, inevitable progression from inadequate perfusion to organ dysfunction and ultimately to death.
  
• Major categories of shock:
  
  • Hypovolemic shock:
    
    • Decreased blood volume
      
    • Suspect hemorrhage if acute onset
      
    • Severe dehydration if progressive onset and elevated hematocrit, BUN, and creatinine
      
  • Obstructive (cardiogenic) shock:
    
    • Decreased cardiac output and tissue hypoxia with adequate intravascular volume and myocardial dysfunction
      
    • Venous congestion with increase in central venous pressure
      
    • Compensatory increase in SVR
      
    • May be caused by cardiac dysfunction, obstruction to inflow of blood to the heart, or obstruction to outflow of blood from the heart
      
  • Septic shock:
    
    • An initial infectious insult overwhelms the immune system.
      
    • Biochemical messengers (cytokines, leukotrienes, histamines, prostaglandins) cause vessel dilatation.
      
    • Capillary endothelium becomes disrupted and the vessels leak.
      
    • Drop in SVR leads to inadequate tissue perfusion.
      
    • Secondarily, decreased cardiac output from “cardiac stun” resulting in cold septic shock
      
  • Neurogenic shock:
    
    • Spinal cord insults disrupt sympathetic stimulation to vessels.
      
    • Loss of sympathetic tone causes arteriodilating and vasodilatation.
      
    • Lesions proximal to T4 disrupt sympathetic, spares vagal innervation causing bradycardia.
      
  • Anaphylactic shock:
    
    • An antigen stimulates the allergic reaction.
      
    • Mast cells degranulate.
      
    • Histamine releases, along with autocoids, stimulate an anaphylaxis cascade.
      
    • Vascular smooth muscle relaxes.
      
    • Capillary endothelium leaks.
      
    • Drop in SVR leads to inadequate tissue perfusion.
      
  • Pharmacologic agents may cause shock through smooth muscle dilation or myocardial depression.
    

• Hypovolemic shock:
  
  • Abdominal trauma, blunt or penetrating
    
  • Abortion—complete, partial, or inevitable
    
  • Anemia—chronic or acute
    
  • Aneurysms—abdominal, thoracic, dissecting
    
  • Aortogastric fistula
    
  • Arteriovenous malformations
    
  • Blunt trauma
    
  • Burns
    
  • Diabetes
    
  • Diarrhea
    
  • Diuretics
    
  • Ruptured ectopic pregnancy
    
  • Epistaxis
    
  • Fractures (especially long bones)
    
  • Hemoptysis
    
  • GI bleed
    
  • Mallory–Weiss tear
    
  • Penetrating trauma
    
  • Placenta previa
    
  • Postpartum hemorrhage
    
  • Retroperitoneal bleed
    
  • Severe ascites
    
  • Splenic rupture
    
• Toxic epidermal necrolysis:
  
  • Vascular injuries
    
  • Vomiting
    
• Cardiogenic shock:
  
  • Cardiomyopathy
    
  • Conduction abnormalities and arrhythmias
    
  • MI
    
  • Myocardial contusion
    
  • Myocarditis
    
  • Pericardial tamponade
    
  • Pulmonary embolus
    
  • Tension pneumothorax
    
  • Valvular insufficiency
    
  • Ventricular septal defect
    
• Vasogenic shock:
  
  • Acute respiratory distress syndrome
    
  • Bacterial infection
    
  • Bowel perforation
    
  • Cellulitis
    
  • Cholangitis
    
  • Cholecystitis
    
  • Endocarditis
    
  • Endometritis
    
  • Fungemia
    
  • Infected indwelling prosthetic device
    
  • Intra-abdominal infection or abscess
    
  • Mediastinitis
    
  • Meningitis
    
  • Myometritis
    
  • Pelvic inflammatory disease
    
  • Peritonitis
    
  • Pyelonephritis
    
  • Pharyngitis
    
  • Pneumonia
    
  • Septic arthritis
    
  • Thrombophlebitis
    
  • Tubo-ovarian abscess
    
  • Urosepsis
    
• Anaphylactic:
  
  • Drug reaction (most commonly to aspirin, β-lactam antibiotics)
    
  • Exercise (rare)
    
  • Food allergy (peanuts, tree nuts, shellfish, fish, milk, eggs, soy, and wheat account for 90% of food-related anaphylaxis)
    
  • Insect sting
    
  • Latex
    
  • Radiographic contrast materials
    
  • Synthetic products
    
• Pharmacologic:
  
  • Antihypertensives
    
  • Antidepressants
    
  • Benzodiazepines
    
  • Cholinergics
    
  • Digoxin
    
  • Narcotics
    
  • Nitrates
    
• Neurogenic:
  
  • Spinal cord injury