- Email: [email protected]
421: The Neuroendocrine Effects of the TASER X26 Conducted Electrical Weapon as Compared to Oleoresin Capsicum
Research Forum Abstracts scientifically grounded. Our hospital was one of 3800 hospitals nationwide required to report statistics on these quality indicators. Patients who meet criteria for PN-5b and received antibiotics more than 4 hours after arrival are considered hospital quality failures. We sought to compare all patients who met criteria for PN-5b to determine if there is a difference in outcomes between those who received antibiotics in 4 hours and those who received antibiotics after 4 hours. Methods: This was a retrospective case series in a two-site university hospital: one site is a community ED, and the second a tertiary care ED. Data includes all patients eligible for inclusion on indicator PN-5b from January 1, 2006 to December 31, 2006. The control group was the subset of patients who received antibiotics within 4 hours of arrival. The experimental group was the subset of patients who received antibiotics more than 4 hours after arrival (hospital quality failures). The groups were compared on the following outcome endpoints: need for ICU admission, number of ICU days, need for intubation, overall length of stay (LOS), and inpatient death. Results: In 2006, there were 461 patients with either the admission or discharge diagnosis of pneumonia. Of these, 157 patients were excluded from the JCAHO Core Measure PN-5b based on the inclusion and exclusion criteria set forth in the Specifications Manual for National Hospital Quality Measures. Of the 304 patients left, 245 received antibiotics within 4 hours of arrival (control group) and 59 received antibiotics more than 4 hours after arrival (experimental group). The mean age in the control group was 70 with 53% males. The mean age in the experimental group was 66 with 56% males.
Conclusion: In patients eligible for the PN-5b indicator, we found no difference in outcomes between quality successes and quality failures, as defined by the JCAHOCMS. Compliance with PN-5b did not improve inpatient mortality, need for ICU, need for intubation, and overall LOS. The utility of PN-5b needs further validation.
420
Low Incidence of Pulmonary Embolism in Anticoagulated and Dialysis Patients: The Experience of an Urban Emergency Department
Allegra PC, Smith SW/Hennepin County Medical Center, Minneapolis, MN
Study Objectives: There is little data on the incidence of pulmonary embolism (PE) in emergency department (ED) patients who are 1) anticoagulated or 2) on dialysis. The authors hypothesized that there would be few patients with a therapeutic INR (⬎2) or on dialysis who have a new diagnosis of PE. Methods: Design: Retrospective analysis of an ED computerized database and hospital billing database. Setting: Urban ED with 100,000 annual visits. Participants: Consecutive patients with a diagnosis of “PE” seen by ED physicians from 10/2000 through 09/2005. Output criteria for review included medical record number, date, age, gender, presenting complaint, and the following, if they were done; INR, d dimer, CT angiogram and VQ scan. A second review of the hospital’s billing database performed two searches; the first for all patients in the above interval with a diagnosis code of “End Stage Renal Disease” (ESRD) and a second search for all patients with both a diagnosis of ESRD and PE. A single reviewer searched the hospital computerized medical record for the above results including the inpatient record to determine ultimate disposition. The gold standard was the determination of diagnosis of PE by the pulmonary staff as demonstrated by either diagnosis, dictated notes or management. Results: There were 307 PEs diagnosed in the ED over five years, 26 of which had an INR ⬎2 (range 2 to 8.2). Twelve of 26 had a prior PE diagnosis within the previous 6 months and 6 had a prior DVT diagnosis within 6 months; 8 were on lifelong warfarin for PE (5), Atrial Fibrillation (1), Antiphospholipid Antibody Syndrome (APLA) with prior DVT (1) and APLA with prior PE (1). Ultimately, only 2 of 26 patients had changes in their warfarin regimen, both of which had their regimen discontinued, as there was a false positive diagnosis on CT Angiogram (CTA) and V/Q Scan respectively, and they were six months since their prior PE diagnosis. Only one patient with an INR ⬎2 (3.4) had a PE confirmed; this patient had only been discharged from the hospital 2 days prior, after her initial DVT diagnosis and initiation of warfarin therapy. She was the only patient to receive an inferior vena cava filter. Of the 307 PEs initially identified over the five year period,
S132 Annals of Emergency Medicine
there were only two dialysis patients. Both had a hospital discharge diagnosis of fluid overload that did not include PE. During the same five year interval a separate review of hospital discharge coding revealed 9,722 patients were discharged with a diagnosis of ESRD. Only 2 of 9,722 admitted dialysis patients had PE as a final diagnosis; both had CTA’s, one had central PEs and the other had a segmental PE. Both were not captured by the initial search as the ED diagnosis did not include PE. Conclusions: These findings suggest that patients with therapeutic INRs, and also patients on dialysis, have a very low incidence of PE. These factors may serve as negative predictors of risk in suspected cases of PE.
EMF-5
Application of the Pulmonary Embolism Rule-Out Criteria in a Rural Population
Beam D, Brewer, K Kline JA/Brody School of Medicine at East Carolina University, Greenville, NC; Carolinas Medical Center, Charlotte, NC
Study Objective: Recent advances have shown pulmonary embolism can be safely ruled out in a very low-risk population of patients who met a subset of defined criteria based on history and clinical findings. The PE Rule-out Criteria (PERC) developed by Kline et. al. showed eight clinical variables, if negative, lowered the risk of developing a PE to less than 2.0%. PERC has been externally validated in three studies, in tertiary centers with a largely urban population. Here it was sought to validate the PERC rule in a rural population. Methods: Enrollment was done as in other validation studies, with prospective enrollment criteria consisting of testing for PE with either: CT scan, V/Q or a Ddimer. Patients were then followed for 45 days post enrollment for further development of PE. Over a period of seven months 189 patients were enrolled with follow-up. Diagnostic indeces and 95% CIs are reported. Results: Prevalence of PE in our population was 4.2% (2.2% to 8.1%), with 18.1% (13% to 24%) identified as PERC (⫺). All patients with PE or DVT were PERC (⫹) and all patients who were identified as PERC (⫺) were negative for PE and/or DVT at discharge and 45 days post discharge. Conclusions: In our population of rural patients, the PERC Rule was able to safely rule out patients who were PE negative. Further validation shows the PERC rule can be used by clinicians in rural populations. This validation centers on the utility for a clinical decision rule in a rural population to rule out PE, allowing for physicians in such locales the ability to safely eliminate PE in a very low risk population without the need for further testing that may not be readily available.
421
The Neuroendocrine Effects of the TASER X26 Conducted Electrical Weapon as Compared to Oleoresin Capsicum
Dawes DM, Ho JD, Miner JR, Johnson M/Lompoc District Hospital, Santa Barbara, CA; Hennepin County Medical Center, Minneapolis, MN; TASER International, Scottsdale, AZ
Study Objectives: Conducted electrical weapons (CEW) induce neuromuscular incapacitation and pain by the application of an electrical current. The electrical current stimulates both afferent sensory neurons causing pain and efferent motor neurons causing muscle tetany. There has been controversy in the lay press and medical literature with regard to the use of these weapons and sudden, unexpected in-custody death. There has been speculation that exposure to the discharge of a CEW may induce neuroendocrine effects (eg, a stress cardiomyopathy) which might predispose subjects to delayed malignant cardiac arrhythmias and sudden death. The objective of this study is compare the neuroendocrine effects of the TASER X26 CEW to oleoresin capsicum (O.C.), commonly referred to as pepper spray. The latter is a well accepted use of force alternative. Methods: Subjects were randomized to receive either a 5-second exposure from the TASER X26 CEW with the probes fired into the back from about 7 feet or a 2second spray of O.C. to the eyes. Subjects had salivary samples collected by passive drool through a straw 10-15 minutes before the exposure, and at 10, 20, and 60 minutes after the exposure. Salivary samples were analyzed for quantitative measures of alpha-amylase (surrogate for sympathetic-adrenal-medulla (SAM) axis stimulation, peak at 10 minutes) and cortisol (surrogate for hypothalamic-pituitary-adrenal (HPA) axis stimulation, peak at 20 minutes). Data were analyzed using descriptive statistics. Results: 10 subjects were randomized to the O.C. exposure, and 5 subjects were randomized to the CEW exposure. There was a 173% (confidence interval 37.3308.6) increase in alpha-amylase in the O.C. group at 10 minutes compared to an 8% (⫺33.0-31.3) decrease in the CEW group. Non-significant results included: 1) at one hour, alpha-amylase was 44% (11.8-75.6) over baseline in the O.C. group and
Volume , . : September
Research Forum Abstracts 9% (⫺31.5-49.8) over baseline in the CEW group, 2) there was a 89% (41.9-135.3) increase in cortisol in the O.C. group at 20 minutes and a 90% (⫺61.3-242.0) increase in the CEW group, 3) at one hour, cortisol was 15% (⫺44.7-75.2)over baseline in the O.C. group and 68% (⫺114.4-242.0) over baseline in the CEW group. Conclusion: The results suggest a significant greater level of activation of the SAM cascade with O.C. compared to the CEW. Overlapping confidence intervals preclude a definitive statement about the other measurements, but do not suggest a greater activation of the stress cascade by the CEW than O.C. Given that the CEW is generally considered more efficacious in the control of subjects with impaired nocioception secondary to drug intoxication or an excited delirium, and that it induces a smaller or equal stress response, it maybe the use of force of choice in certain settings.
422
Anogenital Injury Following Sexual Assault in Women After Recent Consensual Intercourse
Stacey J, Bush C, Rossman L, Jones JS, Rossman P/Grand Rapids MERC/ Michigan State University, Grand Rapids, MI
Study Objectives: Rape Shield Laws are present in 49 states and limit the use of a victim’s prior sexual history as an attempt to undermine the credibility of the victim’s testimony. During a recently well-publicized case in Colorado, the judged ruled that the defense can present evidence about the woman’s sexual activities in the three days before a hospital exam, saying it is relevant to help determine the cause of her injuries, the source of DNA evidence and her credibility. The purpose of this study was to compare the frequency and types of anogenital trauma in rape victims as a function of the time interval between the assault and recent (⬍72 hours) consensual sexual intercourse. Methods: This retrospective cohort trial evaluated consecutive female patients, age 13 years or older, presenting to a community-based nurse examiner clinic (NEC) during a 4-year study period. Sexual assault victims presenting directly to four downtown emergency departments were routinely referred to the NEC for evaluation after triage and initial assessment. The NEC facility is staffed by forensic nurses trained to perform medical-legal examinations using colposcopy with nuclear staining and digital imaging. Assault victims who refused forensic examination, had no history of prior sexual intercourse experience (virgins), had multiple assailants, or could not estimate the time of assault, were excluded. Eligible patients were classified into four different groups based on the time interval from the last consensual intercourse to the forensic examination (⬍24 hrs, 24-48 hrs, 48-72 hrs, ⬎72 hrs). Patient demographics, assault characteristics, and injury patterns were recorded using a standardized classification system. Comparative data were analyzed using chi-square, ANOVA tests, and Pearson correlation. Results: A total of 582 cases of sexual assault met the inclusion criteria and were divided into four groups. The age range was 13 to 87 years (mean, 23 ⫹ 9 years); 77% (448/582) were examined within 24 hours following sexual assault. The four study groups were comparable in terms of demographics, assault history, and incidence of non-genital injuries. The overall frequency of anogenital injury did not vary significantly between groups and ranged between 64 - 67% (P⫽.77). Similarly, there were no significant differences in the type or location of anogenital injuries. Variables that did correlate with the degree of anogenital injury were victim age and alcohol consumption, time to forensic examination, history of anal penetration, and the number of non-genital injuries. Conclusion: This is the first clinical study to systematically compare the frequency and type of anogenital injuries in sexual assault victims who have had consensual intercourse within three days before a forensic exam. The frequency or location of anogenital lacerations and abrasions did not vary significantly based on the time interval from last consensual intercourse to the forensic examination.
423
Breathing Parameters, Venous Blood Gases, and Serum Chemistries With Exposure to a New Wireless Projectile Conducted Electrical Weapon in Human Volunteers
Dawes DM, Ho JD,Johnson MA, Lundin E, Miner J/Lompoc District Hospital, Lompoc, CA; Hennepin County Medical Center, Minneapolis, MN; TASER International, Scottsdale, AZ
Study Objectives: The TASER X26 conducted electrical weapon (CEW) has a maximum range of 35 feet, limiting its effectiveness in some tactical situations. TASER International has developed a non-tethered CEW that is fired from a 12-
Volume , . : September
gauge shotgun that has a longer range. A previous study showed that the TASER X26 had no significant effect on tidal volume, respiratory rate, PETCO2, and PETO2. The purpose of this study was to study the effects of this new CEW on respiration, venous blood gases, and certain blood chemistries. Methods: Subjects had venipuncture prior to the application of the CEW and immediately after the exposure, and venous samples were analyzed to obtain venous pH, pCO2, HCO3, lactate, as well as Na and K. Breathing data was collected by a breath by breath gas-exchange system. All subjects were exposed for a minimum of 15 seconds. Exposure was thoraco-abdominal with one lead over the pectoralis major muscle, and the other in the upper abdomen. In 27 subjects, the device was programmed for a 45-second exposure. The subjects could terminate the exposure with a “tap out” button after 15 seconds. In 23 subjects, the exposure was fixed at 20 seconds. In 4 of these subjects, the device was programmed to deliver 2 exposures. The first exposure was the standard thoraco-abdominal exposure, and the second was between the contra-lateral abdomen and the thigh. Results: Fifty (50) subjects completed the study. The analysis was separated into two groups. The first was the self-terminating group (variable time exposure). In this group, respiratory rate and minute ventilation increased significantly during the exposure. End-tidal CO2 decreased significantly during exposure. Venous pH decreased by 0.023, pO2 increased by 13.4, HCO3 decreased by 2.8, lactate increased by 2.4, and potassium decreased by 0.13. The second group was the fixed 20-second exposure (including the 4 with the “double” exposure). In this group, respiratory rate and minute ventilation increased significantly during the exposure. End-tidal CO2 decreased and end-tidal O2 increased significantly during exposure. Venous pH did not significantly change. pCO2 decreased by 4.0, p O2 increased by 16.3, HCO3 decreased by 3.4, and lactate increased by 2.7. Chemistries had no significant change. Conclusion: This study demonstrates that the new CEW has no important deleterious effects on respiratory parameters, blood chemistries, or venous blood gases. These results are consistent with previous results for the TASER X26 CEW.
424
Comparative Analysis of Incapacitated Versus Forcible Sexual Assault in a Community-Based Population
Woolley B, Jones JS, Rossman L, Bush C/Grand Rapids MERC/Michigan State University, Grand Rapids, MI; YWCA of Grand Rapids, Nurse Examiner Program, Grand Rapids, MI
Study Objectives: Although women’s substance use is believed to contribute to sexual assault vulnerability, few studies have compared the characteristics of rape that occurs through incapacitation or intentional intoxication from those that are due to perpetrator physical aggression. The current study compares the prevalence, epidemiology, and injury patterns of these two forms of rape in a community-based population. Methods: This case-series analysis evaluated consecutive female patients presenting to a sexual assault clinic over a seven-year study period. Sexual assault victims presenting directly to four downtown emergency departments were routinely referred to the sexual assault clinic for evaluation after triage and initial assessment. The clinic is associated with a university-affiliated emergency medicine residency program and is staffed by forensic nurses trained to perform medicolegal examinations using colposcopy with digital imaging. Patient demographics, assault characteristics, and injury patterns were recorded using a standardized classification system. Comparative data from the two patient groups (incapacitated vs. forcible rape) were analyzed using chi-square, t-test, and multivariate analysis. Results: Case files of 1786 cases of sexual assault were reviewed; 19% (339/1276) of the victims were documented as incapacitated. Alcohol consumption in the hours prior to the assault was reported by 90% of incapacitated victims; 19% described recreational drug use and 9% reported using prescription medications. A total of 28% (95/339) of these women reported rape due to covert drug administration by the perpetrator. Incapacitated rape incidents differed from forcible rape on several contextual variables, including relationship to perpetrator, location and time of assault, history of childhood sexual abuse, and frequency of non-genital injuries. Incapacitated victims had significantly fewer anogenital injuries (39% vs. 73%, P ⬍.001), although the overall injury pattern was not statistically different (P ⫽ .79). Incapacitated victims also had a longer delay to treatment (26 hours vs. 17 hours, P ⬍0.001), and were less likely to consent to a forensic examination or file a police report. Conclusion: Findings suggest that one-fifth of sexual assault victims are mentally incapacitated through alcohol and/or drug use. The epidemiology of sexual trauma in
Annals of Emergency Medicine S133
Conclusion: In patients eligible for the PN-5b indicator, we found no difference in outcomes between quality successes and quality failures, as defined by the JCAHOCMS. Compliance with PN-5b did not improve inpatient mortality, need for ICU, need for intubation, and overall LOS. The utility of PN-5b needs further validation.
420
Low Incidence of Pulmonary Embolism in Anticoagulated and Dialysis Patients: The Experience of an Urban Emergency Department
Allegra PC, Smith SW/Hennepin County Medical Center, Minneapolis, MN
Study Objectives: There is little data on the incidence of pulmonary embolism (PE) in emergency department (ED) patients who are 1) anticoagulated or 2) on dialysis. The authors hypothesized that there would be few patients with a therapeutic INR (⬎2) or on dialysis who have a new diagnosis of PE. Methods: Design: Retrospective analysis of an ED computerized database and hospital billing database. Setting: Urban ED with 100,000 annual visits. Participants: Consecutive patients with a diagnosis of “PE” seen by ED physicians from 10/2000 through 09/2005. Output criteria for review included medical record number, date, age, gender, presenting complaint, and the following, if they were done; INR, d dimer, CT angiogram and VQ scan. A second review of the hospital’s billing database performed two searches; the first for all patients in the above interval with a diagnosis code of “End Stage Renal Disease” (ESRD) and a second search for all patients with both a diagnosis of ESRD and PE. A single reviewer searched the hospital computerized medical record for the above results including the inpatient record to determine ultimate disposition. The gold standard was the determination of diagnosis of PE by the pulmonary staff as demonstrated by either diagnosis, dictated notes or management. Results: There were 307 PEs diagnosed in the ED over five years, 26 of which had an INR ⬎2 (range 2 to 8.2). Twelve of 26 had a prior PE diagnosis within the previous 6 months and 6 had a prior DVT diagnosis within 6 months; 8 were on lifelong warfarin for PE (5), Atrial Fibrillation (1), Antiphospholipid Antibody Syndrome (APLA) with prior DVT (1) and APLA with prior PE (1). Ultimately, only 2 of 26 patients had changes in their warfarin regimen, both of which had their regimen discontinued, as there was a false positive diagnosis on CT Angiogram (CTA) and V/Q Scan respectively, and they were six months since their prior PE diagnosis. Only one patient with an INR ⬎2 (3.4) had a PE confirmed; this patient had only been discharged from the hospital 2 days prior, after her initial DVT diagnosis and initiation of warfarin therapy. She was the only patient to receive an inferior vena cava filter. Of the 307 PEs initially identified over the five year period,
S132 Annals of Emergency Medicine
there were only two dialysis patients. Both had a hospital discharge diagnosis of fluid overload that did not include PE. During the same five year interval a separate review of hospital discharge coding revealed 9,722 patients were discharged with a diagnosis of ESRD. Only 2 of 9,722 admitted dialysis patients had PE as a final diagnosis; both had CTA’s, one had central PEs and the other had a segmental PE. Both were not captured by the initial search as the ED diagnosis did not include PE. Conclusions: These findings suggest that patients with therapeutic INRs, and also patients on dialysis, have a very low incidence of PE. These factors may serve as negative predictors of risk in suspected cases of PE.
EMF-5
Application of the Pulmonary Embolism Rule-Out Criteria in a Rural Population
Beam D, Brewer, K Kline JA/Brody School of Medicine at East Carolina University, Greenville, NC; Carolinas Medical Center, Charlotte, NC
Study Objective: Recent advances have shown pulmonary embolism can be safely ruled out in a very low-risk population of patients who met a subset of defined criteria based on history and clinical findings. The PE Rule-out Criteria (PERC) developed by Kline et. al. showed eight clinical variables, if negative, lowered the risk of developing a PE to less than 2.0%. PERC has been externally validated in three studies, in tertiary centers with a largely urban population. Here it was sought to validate the PERC rule in a rural population. Methods: Enrollment was done as in other validation studies, with prospective enrollment criteria consisting of testing for PE with either: CT scan, V/Q or a Ddimer. Patients were then followed for 45 days post enrollment for further development of PE. Over a period of seven months 189 patients were enrolled with follow-up. Diagnostic indeces and 95% CIs are reported. Results: Prevalence of PE in our population was 4.2% (2.2% to 8.1%), with 18.1% (13% to 24%) identified as PERC (⫺). All patients with PE or DVT were PERC (⫹) and all patients who were identified as PERC (⫺) were negative for PE and/or DVT at discharge and 45 days post discharge. Conclusions: In our population of rural patients, the PERC Rule was able to safely rule out patients who were PE negative. Further validation shows the PERC rule can be used by clinicians in rural populations. This validation centers on the utility for a clinical decision rule in a rural population to rule out PE, allowing for physicians in such locales the ability to safely eliminate PE in a very low risk population without the need for further testing that may not be readily available.
421
The Neuroendocrine Effects of the TASER X26 Conducted Electrical Weapon as Compared to Oleoresin Capsicum
Dawes DM, Ho JD, Miner JR, Johnson M/Lompoc District Hospital, Santa Barbara, CA; Hennepin County Medical Center, Minneapolis, MN; TASER International, Scottsdale, AZ
Study Objectives: Conducted electrical weapons (CEW) induce neuromuscular incapacitation and pain by the application of an electrical current. The electrical current stimulates both afferent sensory neurons causing pain and efferent motor neurons causing muscle tetany. There has been controversy in the lay press and medical literature with regard to the use of these weapons and sudden, unexpected in-custody death. There has been speculation that exposure to the discharge of a CEW may induce neuroendocrine effects (eg, a stress cardiomyopathy) which might predispose subjects to delayed malignant cardiac arrhythmias and sudden death. The objective of this study is compare the neuroendocrine effects of the TASER X26 CEW to oleoresin capsicum (O.C.), commonly referred to as pepper spray. The latter is a well accepted use of force alternative. Methods: Subjects were randomized to receive either a 5-second exposure from the TASER X26 CEW with the probes fired into the back from about 7 feet or a 2second spray of O.C. to the eyes. Subjects had salivary samples collected by passive drool through a straw 10-15 minutes before the exposure, and at 10, 20, and 60 minutes after the exposure. Salivary samples were analyzed for quantitative measures of alpha-amylase (surrogate for sympathetic-adrenal-medulla (SAM) axis stimulation, peak at 10 minutes) and cortisol (surrogate for hypothalamic-pituitary-adrenal (HPA) axis stimulation, peak at 20 minutes). Data were analyzed using descriptive statistics. Results: 10 subjects were randomized to the O.C. exposure, and 5 subjects were randomized to the CEW exposure. There was a 173% (confidence interval 37.3308.6) increase in alpha-amylase in the O.C. group at 10 minutes compared to an 8% (⫺33.0-31.3) decrease in the CEW group. Non-significant results included: 1) at one hour, alpha-amylase was 44% (11.8-75.6) over baseline in the O.C. group and
Volume , . : September
Research Forum Abstracts 9% (⫺31.5-49.8) over baseline in the CEW group, 2) there was a 89% (41.9-135.3) increase in cortisol in the O.C. group at 20 minutes and a 90% (⫺61.3-242.0) increase in the CEW group, 3) at one hour, cortisol was 15% (⫺44.7-75.2)over baseline in the O.C. group and 68% (⫺114.4-242.0) over baseline in the CEW group. Conclusion: The results suggest a significant greater level of activation of the SAM cascade with O.C. compared to the CEW. Overlapping confidence intervals preclude a definitive statement about the other measurements, but do not suggest a greater activation of the stress cascade by the CEW than O.C. Given that the CEW is generally considered more efficacious in the control of subjects with impaired nocioception secondary to drug intoxication or an excited delirium, and that it induces a smaller or equal stress response, it maybe the use of force of choice in certain settings.
422
Anogenital Injury Following Sexual Assault in Women After Recent Consensual Intercourse
Stacey J, Bush C, Rossman L, Jones JS, Rossman P/Grand Rapids MERC/ Michigan State University, Grand Rapids, MI
Study Objectives: Rape Shield Laws are present in 49 states and limit the use of a victim’s prior sexual history as an attempt to undermine the credibility of the victim’s testimony. During a recently well-publicized case in Colorado, the judged ruled that the defense can present evidence about the woman’s sexual activities in the three days before a hospital exam, saying it is relevant to help determine the cause of her injuries, the source of DNA evidence and her credibility. The purpose of this study was to compare the frequency and types of anogenital trauma in rape victims as a function of the time interval between the assault and recent (⬍72 hours) consensual sexual intercourse. Methods: This retrospective cohort trial evaluated consecutive female patients, age 13 years or older, presenting to a community-based nurse examiner clinic (NEC) during a 4-year study period. Sexual assault victims presenting directly to four downtown emergency departments were routinely referred to the NEC for evaluation after triage and initial assessment. The NEC facility is staffed by forensic nurses trained to perform medical-legal examinations using colposcopy with nuclear staining and digital imaging. Assault victims who refused forensic examination, had no history of prior sexual intercourse experience (virgins), had multiple assailants, or could not estimate the time of assault, were excluded. Eligible patients were classified into four different groups based on the time interval from the last consensual intercourse to the forensic examination (⬍24 hrs, 24-48 hrs, 48-72 hrs, ⬎72 hrs). Patient demographics, assault characteristics, and injury patterns were recorded using a standardized classification system. Comparative data were analyzed using chi-square, ANOVA tests, and Pearson correlation. Results: A total of 582 cases of sexual assault met the inclusion criteria and were divided into four groups. The age range was 13 to 87 years (mean, 23 ⫹ 9 years); 77% (448/582) were examined within 24 hours following sexual assault. The four study groups were comparable in terms of demographics, assault history, and incidence of non-genital injuries. The overall frequency of anogenital injury did not vary significantly between groups and ranged between 64 - 67% (P⫽.77). Similarly, there were no significant differences in the type or location of anogenital injuries. Variables that did correlate with the degree of anogenital injury were victim age and alcohol consumption, time to forensic examination, history of anal penetration, and the number of non-genital injuries. Conclusion: This is the first clinical study to systematically compare the frequency and type of anogenital injuries in sexual assault victims who have had consensual intercourse within three days before a forensic exam. The frequency or location of anogenital lacerations and abrasions did not vary significantly based on the time interval from last consensual intercourse to the forensic examination.
423
Breathing Parameters, Venous Blood Gases, and Serum Chemistries With Exposure to a New Wireless Projectile Conducted Electrical Weapon in Human Volunteers
Dawes DM, Ho JD,Johnson MA, Lundin E, Miner J/Lompoc District Hospital, Lompoc, CA; Hennepin County Medical Center, Minneapolis, MN; TASER International, Scottsdale, AZ
Study Objectives: The TASER X26 conducted electrical weapon (CEW) has a maximum range of 35 feet, limiting its effectiveness in some tactical situations. TASER International has developed a non-tethered CEW that is fired from a 12-
Volume , . : September
gauge shotgun that has a longer range. A previous study showed that the TASER X26 had no significant effect on tidal volume, respiratory rate, PETCO2, and PETO2. The purpose of this study was to study the effects of this new CEW on respiration, venous blood gases, and certain blood chemistries. Methods: Subjects had venipuncture prior to the application of the CEW and immediately after the exposure, and venous samples were analyzed to obtain venous pH, pCO2, HCO3, lactate, as well as Na and K. Breathing data was collected by a breath by breath gas-exchange system. All subjects were exposed for a minimum of 15 seconds. Exposure was thoraco-abdominal with one lead over the pectoralis major muscle, and the other in the upper abdomen. In 27 subjects, the device was programmed for a 45-second exposure. The subjects could terminate the exposure with a “tap out” button after 15 seconds. In 23 subjects, the exposure was fixed at 20 seconds. In 4 of these subjects, the device was programmed to deliver 2 exposures. The first exposure was the standard thoraco-abdominal exposure, and the second was between the contra-lateral abdomen and the thigh. Results: Fifty (50) subjects completed the study. The analysis was separated into two groups. The first was the self-terminating group (variable time exposure). In this group, respiratory rate and minute ventilation increased significantly during the exposure. End-tidal CO2 decreased significantly during exposure. Venous pH decreased by 0.023, pO2 increased by 13.4, HCO3 decreased by 2.8, lactate increased by 2.4, and potassium decreased by 0.13. The second group was the fixed 20-second exposure (including the 4 with the “double” exposure). In this group, respiratory rate and minute ventilation increased significantly during the exposure. End-tidal CO2 decreased and end-tidal O2 increased significantly during exposure. Venous pH did not significantly change. pCO2 decreased by 4.0, p O2 increased by 16.3, HCO3 decreased by 3.4, and lactate increased by 2.7. Chemistries had no significant change. Conclusion: This study demonstrates that the new CEW has no important deleterious effects on respiratory parameters, blood chemistries, or venous blood gases. These results are consistent with previous results for the TASER X26 CEW.
424
Comparative Analysis of Incapacitated Versus Forcible Sexual Assault in a Community-Based Population
Woolley B, Jones JS, Rossman L, Bush C/Grand Rapids MERC/Michigan State University, Grand Rapids, MI; YWCA of Grand Rapids, Nurse Examiner Program, Grand Rapids, MI
Study Objectives: Although women’s substance use is believed to contribute to sexual assault vulnerability, few studies have compared the characteristics of rape that occurs through incapacitation or intentional intoxication from those that are due to perpetrator physical aggression. The current study compares the prevalence, epidemiology, and injury patterns of these two forms of rape in a community-based population. Methods: This case-series analysis evaluated consecutive female patients presenting to a sexual assault clinic over a seven-year study period. Sexual assault victims presenting directly to four downtown emergency departments were routinely referred to the sexual assault clinic for evaluation after triage and initial assessment. The clinic is associated with a university-affiliated emergency medicine residency program and is staffed by forensic nurses trained to perform medicolegal examinations using colposcopy with digital imaging. Patient demographics, assault characteristics, and injury patterns were recorded using a standardized classification system. Comparative data from the two patient groups (incapacitated vs. forcible rape) were analyzed using chi-square, t-test, and multivariate analysis. Results: Case files of 1786 cases of sexual assault were reviewed; 19% (339/1276) of the victims were documented as incapacitated. Alcohol consumption in the hours prior to the assault was reported by 90% of incapacitated victims; 19% described recreational drug use and 9% reported using prescription medications. A total of 28% (95/339) of these women reported rape due to covert drug administration by the perpetrator. Incapacitated rape incidents differed from forcible rape on several contextual variables, including relationship to perpetrator, location and time of assault, history of childhood sexual abuse, and frequency of non-genital injuries. Incapacitated victims had significantly fewer anogenital injuries (39% vs. 73%, P ⬍.001), although the overall injury pattern was not statistically different (P ⫽ .79). Incapacitated victims also had a longer delay to treatment (26 hours vs. 17 hours, P ⬍0.001), and were less likely to consent to a forensic examination or file a police report. Conclusion: Findings suggest that one-fifth of sexual assault victims are mentally incapacitated through alcohol and/or drug use. The epidemiology of sexual trauma in
Annals of Emergency Medicine S133