Take these steps if your trauma patient was assaulted or abused
Probe further if injuries are suspicious
(Editor's note: This is a three-part series on trauma care in the ED. This story will focus on violence-related trauma, including suspected abuse. Future issues will cover self-inflicted trauma and pediatric trauma cases.)
If a woman came to your ED with a black eye and swollen lip, you would suspect abuse or assault. But what if she had a liver or spleen injury? "Nurses who work in community EDs are very likely to see trauma cases involving violence; however, if they don't know what to look for, it can be easily missed," says Robin Ketchum, RN, MSN, nurse practitioner in the Division of Trauma and Critical Care and former emergency nurse at University of California — Irvine Medical Center.
An estimated 308,200 patients were hospitalized in the United States for violence-related trauma in 2005, which is 24,000 more patients than in 2002, according to a new report from the Agency for Healthcare Research and Quality (AHRQ).1 Pamela Owens, PhD, a senior research scientist at AHRQ, says, "Nearly 78% of these hospitalizations [238,855] initially began in the ED, which does not count the ED visits that do not result in hospitalization."
The number of violence-related trauma cases is increasing in EDs, report emergency nurses, and many involve abuse. Ketchum says, "We are seeing an increase in penetrating trauma that is reminiscent of the early 1990s when there was a high amount of gang-related violence in this area."
Additionally, the ED is seeing more assault victims brought by paramedics as designated traumas, she says. "I suspect the ED is also seeing an increased number of assault victims who are not necessarily classified as trauma patients but, nonetheless, suffered a minor injury as a result of violence," Ketchum says.
Don't underestimate seriousness
Often the patient's complaint is viewed as minor, when in fact it could be of far more significance, but the nurse doesn't probe further, says Jean M. Marso, RN, BSN, trauma coordinator at the University of Colorado Hospital in Aurora. If the injury was intentionally inflicted, then your patient is at risk for other violent acts, and you must take steps to intervene, she says.
Triage nurses might easily miss injuries from blunt trauma to the abdomen or flank areas if there isn't obvious bruising, says Ketchum. Also, a liver or spleen injury can have a delayed presentation. Without a certain level of suspicion, serial abdominal exams or studies such as CT scans may be overlooked, she adds.
"I encourage ED nurses to follow up if their instinct is telling them something isn't right," says Ketchum. "Often, one has to ask a patient several times in different ways before they feel safe to disclose abuse."
For example, you can ask a subtle question such as "Have you ever been concerned about safety for you or your children at home?" or "Are things OK for you at home?" or you can directly ask, "Did someone intentionally do this to hurt you?" or "Is someone abusing you?"
"Be observant to nonverbal clues, such as the patient avoiding eye contact," says Ketchum.
Reference
- Russo CA, Owens PL, Hambrick MM. Violence-related stays in U.S. hospitals, 2005. HCUP Statistical Brief, No. 48, March 2008. Agency for Healthcare Research and Quality, Rockville, MD.
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