Abuse and Assault
CCFP EM Core Lecture
March 26, 2015
Dr. Jo-Ann Talbot
Department of Emergency Medicine
Dalhousie University
Saint John Regional Hospital
Abuse and Assault
CCFP EM Core Lecture
March 26, 2015
Dr. Jo-Ann Talbot
Department of Emergency Medicine
Dalhousie University
Saint John Regional Hospital
Learning Objectives
1.
2.
3.
4.
5.
6.
7.
8.
Define abuse and assault
Discuss the extension of abuse to all ages
Sexual assault in adults and in children
Risk factors for abuse, red flags
Principle of the chain of evidence
Consent for blood ethanol testing for legal purposes
The role of the medical expert witness
Preparation for provision of evidence in court
3
Abuse and Assault

Definition of abuse :
Maltreatment of another individual
 A pattern of coercive control


Definition of Assault :

Any act or threatened act of violence
3/12/2016
4
Case 1




4 month old with fever, cough, runny nose, for
past 3 days
Increased irritability, decreased po intake, no
vomiting or diarrhea
Bruise noted on right ear which mom states is
from banging his head on the crib and he
bruises easily
Discussion
6
Bruising in Children



Bruising is often overlooked because it is usually
clinically insignificant, and requires no
immediate treatment.
Are there patterns of bruising that raise a
suspicion of child abuse?
Discuss
7
Bruising in children
Systematic review in 2005 by Maguire et al
Patterns of bruising suggestive of abuse
23 observational studies
7 looked at bruising in normal children
14 looked at abused children (13 case series, 1
cross sectional)
2 looked at both abuse and non abuse
8
Bruising in children

Bruising must be assessed in the context of
medical, social, and developmental history
 explanation given
 patterns of non-abusive bruising

Maguire, Mann, Sibert and Kemp. Are there patterns of bruising in
childhood which are diagnostic or suggestive of abuse? A systematic
review Arch Dis Child. 2005;90:182-86.
9
Bruising in Children





Conclusions
Bruising in infants who are not moving
independently is rare less than 1%.
In infants starting to mobilize 17% have bruises
In walking toddler 54%
Most preschool and school age children have
bruises
Maguire et al Arch Dis Child 2005
10
Bruising suggestive of physical
abuse







Bruises in children not independently mobile
Bruising in babies
Bruises away from bony prominences
Bruises to face, trunk arms, ears and hands
Multiple bruises in clusters
Multiple bruises of uniform shape
Bruises that carry imprint of implement
Maguire et al Arch Dis Child 2005
11
Bruises


Bruising characteristics discriminating physical child
abuse from accidental trauma.
Pierce, Kaczor, Aldridge et al. Pediatrics. 2010;125:6774.
12
Bruises




Objective to develop a bruising CDR.
Case control study of children 0 to 48 months
old admitted to PICU for trauma, retrospective
as all participants identified through the trauma
registry
42 cases physical abuse
53 controls children admitted with accidental
trauma over the same time period
13
Bruises


Conclusions Pierce et al
Number of bruises
Abuse cases median of 6, as many as 25
 Accidental controls median of 1, all had ≤ 4


Regions predictive of abuse
Ear, neck, hand, right arm, chest, buttocks and torso
 All genitourinary and hip bruising were found in
abuse cases but too few for significance


Bruising in child less than 4 months old rare
14
15
Bruises

Sugar N, Taylor JA, Feldman KY. Bruises in infants
and toddlers: those who don’t cruise rarely bruise.
Arch Ped Adol Med. 1999;153(4):399-403



Landmark study of 1000 children less than 36 months old
well child care visits at clinic
Bruises on pre-cruisers rare
Bruises on the hands and buttocks were not observed at any
age
16
Bruising Blunt Object
3/12/2016
17
Bruise Patterns
3/12/2016
18
Bruise Patterns
3/12/2016
19
Bruise Patterns
3/12/2016
20
Bruise Patterns
3/12/2016
21
Bruise Patterns
3/12/2016
22
Bruise Patterns
3/12/2016
23
Bruise Patterns
3/12/2016
24
Case 2




18 month old female with pain in right leg,
refusing to walk, father states that she was
playing on picnic table, fell off
Injury happened about 20 minutes prior to
presentation
Discussion
Xray
25
Spiral Fracture Tibia (Toddler’s)
3/12/2016
26
Fractures in Children



Fractures are very common in children 60% of
boys and 40% of girls will have a fracture by
their 15th birthday. Children who are abused
represent a very small number of childhood
fractures.
Are there characteristics of fractures that may
represent abuse?
Discuss
27
Fractures



Kemp, Dunstan, Harrison et al from Cardiff,
Wales, published a systematic review in BMJ
2008 on patterns of fractures in child abuse
Questioned what features differentiate fractures
sustained from abuse from those sustained from
other causes.
Included 32 studies
28
Fractures

Kemp et al conclusions
Most common abuse fractures were in infants and
toddlers
 80% of all fractures from abuse were seen in < 18
month old children
 Multiple fractures were more common in abuse
 After excluding major trauma rib fractures had the
highest probability of abuse

29
Fractures

Fractures due to abuse in children
Age < 18 months 1 in 9 fractures
 Age 19 months and 5 yrs 1 in 250 fractures
 Age > 5 years old none



When infants and toddlers present with a
fracture consider abuse
No fracture on its own can distinguish abuse
from non abusive causes
30
Fractures


Metaphyseal fractures (bucket handle) thought
to be strong predictors of abuse. This systematic
review did not find any evidence to support or
refute this hypothesis.
The most comprehensive studies on
metaphyseal fractures were descriptions of
radiologic findings of metaphyseal lesions in
case series of a group of fatally abused children.
31
Fractures




Kleinman PK, Marks SC Jr. A regional approach to the classic
metaphyseal lesion in abused infants: the proximal humerus. AJR
Am J Roentgenol 1996;167:1399-403.
Kleinman PK, Marks SC Jr. A regional approach to classic
metaphyseal lesions in abused infants: the distal tibia. AJR Am J
Roentgenol 1996;166:1207-12.
Kleinman PK, Marks SC Jr. A regional approach to the classic
metaphyseal lesion in abused infants: the distal femur. AJR Am J
Roentgenol 1998;170:43-7.
Kleinman PK, Marks SC Jr. A regional approach to the classic
metaphyseal lesion in abused infants: the proximal tibia. AJR Am
J Roentgenol 1996;166:421-6.
32
3/12/2016
33
Metaphyseal Fracture Shoulder
3/12/2016
34
3/12/2016
35
Metaphyseal Fracture Elbow
3/12/2016
36
3/12/2016
37
Metaphyseal Fracture Distal
Femur
3/12/2016
38
3/12/2016
39
Metaphyseal FractureS Tibia
3/12/2016
40
3/12/2016
41
Rib Fractures
3/12/2016
42
Fractures Old and New
3/12/2016
43
Fracture callus in Radius, Ulna
3/12/2016
44
Case 3



2 year old female with burn to buttocks from
exposure to hot bath water
See image
Discuss
45
3/12/2016
46
Burns





James-Ellison, Barnes, Maddocks et al. Social
health outcomes following thermal injuries: a
retrospective matched co-hort study. Arch Dis
Child. 2009 Sep;94(9): 663-7
Swansea Wales
Retrospective Cohort study
145 children age of 3 years admitted for burns
Matched against controls for age, sex,
enumeration district.
47
Burns



Followed until age of six
Results: 89% of burns were deemed accidental
and 2.8 % non accidental at initial event
By 6th birthday burn cases were more likely to be
referred to social services with 9.7% of cases vs
1.4% of controls having been abused or
neglected. 32% of cases vs 18% of controls were
defined as in need (Social services referral)
48
Burns

Children with a burn requiring admission appear
to be at higher risk of further abuse or neglect
compared with controls.
49
Case 4



5 year old girl presents with itching and foul
discharge in the vaginal area for past two days.
No dysuria or hematuria.
How do you approach the history and physical
exam in this child?
Discuss
50
Child Sexual Abuse
 85%
Child sexual abuse cases presenting to
ED are for:
disclosure of the abuse
 or because of other GU tract symptoms

 Behavioral
Disturbances
 Excessive
masturbation, genital fondling,
regression, nightmares, encopresis, or other
sexually oriented or provocative behavior
3/12/2016
51
Child Sexual Abuse

How do we manage a case of suspected
pediatric sexual abuse ?
3/12/2016
52
Child Sexual Abuse

Question child directly about what happened

Write EXACTLY what they say
Document the degree of sexual development



The genital exam should be confined to a careful
inspection of the genitalia and perianal area
Use frog-leg position and document labia and hymen
condition
3/12/2016
53
Child Sexual Abuse

Watch for signs of STD’s

Once the diagnosis is suspected consult pediatric
sexual assault team

Consult social services

Ensure child has safe environment
54
Red flags for abuse







History inconsistent with nature or extent of
injuries
Story changes
Caregiver and child discrepancies in history
Injuries in siblings
Unusual parental behaviour
Intoxicated caregivers, or use of street drugs
Boyfriend in the home not related to the child
55
Red flags for abuse

Bruises


Fractures




Number, age, pattern, region of body
Number, plausible explanation, prompt medical
attention
Burns
Sexual assault
Neglect
56
Management





Treat injuries
Further work up may include skeletal survey
Head CT if altered LOC
Trauma blood work
Ultrasound if abdominal pain or vomiting
57
Management




Document well, write the child’s responses verbatim
on the chart as they may be admissible as evidence
Contact hospital child protection team or Family
Services
Be firm but non judgmental with parents, they may be
innocent and concerned
DO NOT be fearful of legal battle if you are wrong.
BE fearful of misdemeanor charge potential of failure
to report a case.
58
Adult Sexual Assault

Clinical Definition:
3/12/2016
59
Female rape Examination

Assault history:
Who ? How many ?
 What happened ? Physical assault too ?
 When ?
 Where ?
 Douche, shower, or change clothes ?


Medical History:
LMP
 Birth control method
 Last intercourse
 Allergies and prior medical history

3/12/2016
60
Adult Sexual Assault

Document bruises, lacerations, or other signs of trauma.
Pay special attention for “submissive injuries”

Pelvic exam





Use a rape kit
Or make smears from the vagina and cervix and allow to air
dry. Make a wet mount and look for sperm
Take 10 ml of sterile water and do vaginal aspirate
GC and chlamydia swabs
Pre moistened rectal or buccal swab for sperm
61
Treatment of Sexual Assault






Treat injuries
Consider Td prophylaxis
Pregnancy test and repeat in 10 day
 Plan B
Blood Tests:
 HIV- baseline and repeat in 6 months
 HbsAg, core antibody (anti-HBc), and surface antibody
(anti-HBs) and repeat at 3 months
 Consider HepC in high risk and repeat at 6 months if
drawn
Swabs for GC, chlamydia, and trichomonas
Follow up counseling established, follow up medical care
3/12/2016
62
Sexual Assault

Sexually Transmitted Disease Prophylaxis

HIV transmission rates for unprotected sex









Receptive anal
Receptive vaginal
Insertive vaginal
Insertive anal
1-30/1000
1-2/1000
1/1000
3-9/1000
HIV - prophylaxis offered based on case by case basis
Hepatitis B - if antibody level low, then start vaccination
series. Consider passive immunization in high risk patient.
Needs follow-up.
Syphilis – benzathine penicillin 18 mil units im (high risk)
Chlamydia – Azithromycin 1 g po (all patients)
Gonorrhoea – Ceftriaxone 250mg im or Cefixime 400mg
3/12/2016
63
Intimate Partner Violence



Treatment of victims of intimate partner
violence is the same as for other victims of
sexual and physical assault
Need to address ongoing safety of the patient
Screening
Identifies women exposed to violence
 Most women do not find screening problematic
 It is unclear whether screening leads to appropriate
referral or use of service that will benefit the victim

3/12/2016
64
Intimate Partner Violence

Wathen, Jamieson, MacMillan et al. Who is identified
by screening for intimate partner violence? Women’s
Health Issues. 2008;18:423-32

5,607 women recruited from 12 primary care, 11 acute
care and 3 specialty care sites in Ontario
65
Intimate Partner Violence

The screened group completed both a brief IPV
screening tool (WAST-Woman Abuse Screening
Tool 8 items) before their clinical visit and CAS
(Composite Abuse Scale 30 items) after the visit

Non screened group completed both the WAST
and CAS after the clinic visit
66
Intimate Partner Violence

Screening (WAST) identified 22.1% of women
as experiencing past year abuse, in contrast to
the criterion standard (CAS) which identified
14.4%

Implications of over identifying women as
having been exposed to IPV
67
Red Flags for IPV








Partner with drug or alcohol problem
Patient with alcohol problem
Women age < 30
Lower income
Never or currently married,
Depression
Somatization
No relationship to pregnancy
68
Intimate Partner Violence



MacMillan, Wathen, Jamieson et al. Screening for
intimate partner violence in Health Care settings. A
randomized trial. JAMA. 2009;302(5): 493-501
6743 women aged 18-64 years seen in 11 emergency
departments, 12 family practices and 3 obs/gyne clinics
in Ontario
There was no difference in screened and non screened
women in the use of referral services, in increased or
decreased violence, in depression, PTSD, Alcohol or
drug use, or quality of life
69
Domestic Violence Treatment



Treat injury
Assess risk for suicide or homicide.
If discharge:





How safe is home?
Is there pattern of escalating violence?
Was batterer arrested? Do they know where he is now?
Does he have access to weapons?
Does she have somewhere safe to go? Would she feel safer
in a battered woman’s shelter
If she wishes to go home, have a plan if the violence
erupts again.
3/12/2016
70
Domestic Violence Treatment

REFFERAL Woman’s shelter, Legal Aid, and Social
Services.

Children involved, consult to Family Services child
protection services

Documentation of events and statements are critical

Potential legal charges: Restraining orders, assault child
custody, separation, and divorce.
71
Knife wounds
3/12/2016
72
Bruise pattern
3/12/2016
73
Wound pattern
3/12/2016
74
Principle of the chain of evidence


All evidence collected must be appropriately
labeled and placed in secure area
Collected items must be delivered to the police
without anyone else having access to the
contents
75
Legal Documentation

What cases go to court
 Sexual
assaults
 Physical assaults
 Child protection cases
 Alcohol related driving arrests/ MVC’s
3/12/2016
76
Legal Documentation

Document well
Draw and explain in detail the appearance of
findings
 Include lab and xray findings in your documentation.
 If well documented, may not have to attend court.


In cases of disclosure


the person to whom the disclosure was first made
gets the subpoena
DWI cases are the most common cases
77
Ethanol Blood Test

New driving while impaired (DWI) laws introduced by
the conservative government’s Tackling Violent Crime
Act in 2008

DWI cases require either a refusal of a breath test or a
positive breath test with documented alcohol level

Need to obtain consent from the patient before
drawing blood for the police. Let police get consent
first, then you (saves time)
3/12/2016
78
Ethanol Blood Test




Clean the skin with iodine and avoid alcohol
swabs.
Draw blood in the presence of the officer and
initialed by both the officer and medical staff.
You may designate this duty to a nurse if they
are willing.
The sample is sealed and in the hands of the
police officer to take to the crime lab for testing.
79
Ethanol Blood Test

Timing of samples becomes important

4 hour degradation table (zero order kinetics) as
a standing acceptance

Collection time beyond 4 hrs requires expert
testimony of a toxicologist to establish a
reasonably accurate alcohol level at the time in
question
80
Role of the Medical Expert
Witness

Request to testify as a witness on any medical grounds,
most often declared an expert witness

Credibility as an expert
Very important to the choose your words wisely and to
comment only on what you are sure of


Any mistakes or statements in error may be grounds for
dismissal of the case
81
Preparation for Court





Your best preparation is a well documented
patient interaction
Most subpoenas come long after the patient has
been seen in the Emergency Department
Pull your records and review all your data
Make briefing notes to refer to in court
Take a copy of the chart with you
82
Learning Objectives
1.
2.
3.
4.
5.
6.
7.
8.
Define abuse and assault
Discuss the extension of abuse to all ages
Sexual assault in adults and in children
Risk factors for abuse, red flags
Principle of the chain of evidence
Consent for blood ethanol testing for legal purposes
The role of the medical expert witness
Preparation for provision of evidence in court
83