Summary

Sexual Assault

This talk was full of amazing information. Here are some of the key messages:

• There are forensic registrar positions at VIFM which are accredited for ACEM. These jobs are fantastic - please contact Nicola for more information.

• Sexual offences are significantly under-reported. Sexual offenders are known to their victim in up to 75% of cases. There is often no physical signs of an offence. Severe vaginal injuries are rare. Injuries are subtle, easily missed and heal rapidly.

• In terms of photographing injuries, Nicola’s suggestion is that the patient should take the photos themselves on their own phone which they can then hand over to the police. This makes the chain of evidence far simpler.

• In patients who presents to the ED with sexual assault:

  • The immediate care of the patient in the ED should not differ when the triage note states “sexually assaulted”.

  • Consider STI testing and prophylaxis as well as emergency contraception

  • Medical treatment takes priority over forensic integrity, just do your best to preserve evidence

• If we have a patient with suspected sexual assault and want advice - call VIFM. We may also need to call local police - they will need to be involved if VIFM are going to perform a forensic examination. There are various Centres against sexual assault (CASAs) across Melbourne. They provide social support and follow up for the victim. They also run the space where VIFM can attend to assess a patient so also need to be involved. However, the CASAs are not able to provided specific advice on investigation or management.

Documenting injuries

Documenting injuries is really important in the ED for a number of reasons. If we are ever required to attend court our documentation is critical.

Sexual Health

sti.guidelines.org.au and therapeutic guidelines have up to date treatment suggestions

Testing for chlamydia and gonorrhoea in females

• Endocervical swabs are the gold standard tests

• Urine PCR and endocervical swabs are both > 95% sensitive for chlamydia

• Urine PCR is only 56-70% sensitive for gonorrhoea compared to 94% for an endocervical swab

• A self-collected low vaginal swab is superior to urine PCR

• Urine PCR should only be used if endocervical or self-collected vaginal swab is not possible

In males, send a first pass urine sample

Which swab to use at St V ED?

Gas of the Week

Thanks Khalid for the gas this week.

A 32 yo male BIBA from prison with poor oral intake and vomiting for the past three days.. No known medical history. Vital signs on arrival” GCS 13, HR 110, BP 95/60, RR 30, SPO2 98% RA,

This patient has a severe metabolic acidosis with low pH and base excess.

Fencl-Stewart

• SID = 36 therefore hyperchloraemic acidosis contributing -6 to the base excess

• Lactate effect -1

• Albumin effect -2

• The sum effect is -9 but the measured base excess is -25 so there must be another significant effect of weak acids - in this case, likely ketones.

Traditional

AG = 27 (or 30 if you include K)

Delta ratio = (27-12)/(24-5) = 15/19

Therefore there is a HAGMA and mild NAGMA

Other things to note include hyperglycaemia and a relative hypokalaemia (expected K = 7 for this pH, alternatively you could say the corrected K is 1.5)

Corrected Na for glucose = 145

Clinical interpretation

There is a likely ketoacidosis - ? new DKA. Could this be alcohol or starvation ketosis? Glucose can be high in all three of these conditions.

The hyperchloraemia could have been caused by excess sodium chloride if this was given as part of his resuscitation or by renal tubular acidosis given the abnormal renal function. Note that in alcohol ketosis there is usually hypochloraemia due to vomiting. The patient’s hyperalbuminaemia is likely from contraction (poor water intake, vomiting and water loss from glycosuria).

This patient requires treatment for DKA including potassium replacement. A thorough drug and alcohol history is required. Is this patient withdrawing precipitating this event?