When Injuries Speak: Differentiating Between Accidental and Intentional Injuries

1
When Injuries Speak Differentiating Between
Accidental and Intentional Injuries

• Daniel J. Sheridan, PhD, RN
• Assistant Professor
• Johns Hopkins University School of Nursing
• Forensic Clinical Nurse Specialist
• Johns Hopkins Hospital Department of Emergency
  Medicine

2
4N6 RN

• Forensic Nurse
• Forensic Pertaining to the Law
• International Association of Forensic Nursing
• www.iafn.org
• 1-856-256-2425

3
Abrasion

• A wound caused by rubbing or scraping the skin or
  mucous membrane.

4
Avulsion

• The tearing away of a structure or part. Often
  seen as a partial avulsion.

5
Bruise

• Blunt force trauma that results in a superficial
  discoloration due to hemorrhage into the tissue
  from ruptured blood vessels from beneath the skin
  surface without the skin itself being broken
• also called a contusion.

6
Contusion

• A bruise
• Traumatic injury of tissue without breakage of
  skin blood accumulates in the surrounding tissue
  producing pain, swelling, tenderness, and
  discoloration.

7
Cut

• See incision.

8
Ecchymosis

• A hemorrhagic spot or blotch, larger than
  petechia, in the skin or mucous membrane forming
  a non-elevated, rounded, or irregular blue or
  purplish purpuric patch.
• Ecchymosis is not injury from blunt force trauma.
  It is NOT a bruise or contusion.
• Ecchymosis is purpura usually in the skin or
  mucous membranes.

9
At Risk Meds

• Aspirin - antiplatelet
• Warfarin (Coumadin) - anticoagulant
• Ibuprofen, ketorolac - NSAIDs
• Heparin - anticoagulant
• Valproic acid - Depakote (thrombocytopenia)
• Prednisone - steroids

10
At Risk Supplements

• There are over 40 supplements that can effect
  bleeding and/or clotting
• Bilberry - may prolong coagulation times
• Garlic - reduces coagulation
• Ginger - increases risk of bleeding when used
  concurrently with anticoagulants, bilberry, or
  aspirin
• Ginko - increases risk of bleeding when used
  concurrently with anticoagulants or bilberry

11
Basic Labs

• Look for baseline lab data (pre-injury)
• Get the health provider to order the following
• CBC with Platelets
• Basic chemistries CHEM 7 albumin
  malnutrition BUN/Creatinine dehydration)
• Liver function
• Coagulation panel (PT/PTT)
• Urinalysis

12
Hematoma

• A localized collection of blood

13
Hemorrhage

• The escape of blood from a ruptured vessel. It
  can be internal, external, or into the skin or
  other tissue.

14
Incision

• A cut.
• A wound made by a sharp instrument or object
  (scalpel, knife, razor, paper).

15
Laceration

• The act of tearing or splitting. A wound produced
  by the tearing or splitting of body tissue often
  from blunt impact, usually over a bony surface,
  that is distinguished from a cut or incision.

16
Lesion

• Any pathological or traumatic discontinuity of
  tissue or loss of function of a part.
• Broad term, including wounds, sores, ulcers,
  tumors, or other tissue damage.

17
Patterned Injury

• An injury where one is reasonably certain an
  object caused the injury, or certain which object
  caused the injury and/or by what mechanism an
  injury was caused.

18
Pattern of Injury

• Injuries in various stages of healing, including
  new and old scars, contusions, fractures, wounds.

19
Petechia

• Minute, pin-point, non-raised, perfectly round,
  purplish-red purpuric spots caused by intradermal
  or sub-mucous hemorrhage, which later turns blue
  and yellow.

20
Puncture

• The act of piercing or penetrating with a pointed
  object or instrument.

21
Purpura

• A hemorrhagic rash with leakage of blood into the
  tissue often associated with a bleeding or
  clotting disorder. Diffuse purpura under the skin
  or mucous membrane is ecchymoses while pinpoint
  purpura is petechiae.
• Thrombocytopenic purpura
• non-thrombocytopenic purpura

22
Wound

• A bodily injury caused by physical means, with
  disruption of the normal structures
• contused w. - one which skin is unbroken
• incised w. - one caused by cutting instrument
• lacerated w. - one in which tissues are torn
• open w. - one having free outward opening
• penetrating w. - one caused by a sharp, slender
  object that passes through the skin into tissue

23
Clinical Assessment

• Types of injuries
• Proximal versus distal
• Patterned injuries
• Patterns of injuries
• Hidden injuries
• Treatment delays

24
Daniel J. Sheridan, RN, PhD

• sheridan_at_quixnet.net
• Home Office 6210 Fairbourne Ct.
• Hanover, MD 21076
• 410-379-8577 410-379-8572 fax
• Johns Hopkins University
• School of Nursing, Room 467
• 525 N. Wolfe St
• Baltimore, MD 21205 410-614-5301
• 410 - 955 - 7463 fax dsheridan_at_son.jhmi.edu