Rosen & Barkin's 5-Minute Emergency Medicine Consult (645 page)

• Involvement of the airway
  
• Relapse of symptoms and signs after initial steroids
  
• Immunosuppression
  
• Concomitant serious disease
  
• Sociologic considerations
  

Stable; most cases are self-limiting.

Skin testing with heterologous antisera is performed routinely to avoid anaphylaxis to future administration of heterologous serum.

Primary care follow-up

• Identification and cessation of the offending antigen is crucial in the treatment of serum sickness.
  
• Significant morbidity comes from a failure to diagnose when the serum sickness is not considered on the differential.
  

• Chen S. Serum sickness (emergency medicine). Emedicine. Available at
  Emedicine.medscape.com/article/756444-overview
  .
  
• Gamarra RM,
  McGraw SD, Drelichman
  VS, et al. Serum sickness-like reactions in patients receiving intravenous infliximab.
  J Emerg Med
  . 2006;30(1):41–44.
  
• Piessens WF. Systemic immune complex disease. In: Ruddy S ed.
  Kelley’s Textbook of Rheumatology.
  6th ed. Philadelphia, PA: Saunders; 2001.
  
• Pilette C, Coppens N, Houssiau FA, et al. Severe serum sickness-like syndrome after omalizumab therapy for asthma.
  J Allergy Clin Immunol
  . 2007;120(4):972–973.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Anaphylaxis
  
• Vasculitis
  

CODES

• 999.51 Other serum reaction due to administration of blood and blood products
  
• 999.52 Other serum reaction due to vaccination
  
• 999.59 Other serum reaction
  

BASICS

Specific legal definition varies from state to state:

• Nonconsensual completed or attempted penetration between the penis and vulva or penis and anus
  
• Nonconsensual contact between the mouth and the penis, vulva, or anus
  
• Nonconsensual penetration of the anal or genital opening with a finger, hand, or object
  
• Nonconsensual intentional touching, directly or through clothing, of the genitalia, vagina, anus, groin, inner thigh, or buttocks
  

• Lifetime prevalence of sexual assault in US is 18% in women, 5% in men
  
• 72% of female rape victims are raped by someone they know; however, men are primarily raped and physically assaulted by strangers and acquaintances, not intimate partners.
  
• Women who are disabled, pregnant, or attempting to leave their abusers are at increased risk of intimate partner rape.
  
• Prevalence of sexual assault in men is higher in those who are gay, bisexual, veterans, prison inmates or seeking mental health services
  
• Nearly 25% of women and 7% of men have been raped or sexually assaulted by a current or former partner.
  

DIAGNOSIS

• Victims might not disclose assault:
  
  • Most will reveal the history only in response to direct questions.
    
• Tachycardia or pounding heart beat
  
• Headaches
  
• Nausea
  
• Back pain
  
• Skin problems
  
• Menstrual symptoms
  
• Sudden weight change
  
• Sleeping disorders
  
• Abdominal pain
  
• Trouble breathing
  
• Associated injuries:
  
  • Of those with injuries, 70% report no injury at presentation.
    
  • Lacerations of perineum
    
  • Vulvar trauma
    
  • Laceration of vaginal wall (more common in younger patients, near introitus)
    
  • Multiple contusions
    
  • Abrasions
    
  • Human bite
    
  • Lacerations or puncture wound to extremity
    
  • Burns
    
  • Depressed skull fracture
    

• ∼54% of rapes of women occur before the age of 18.
  
• Must follow state laws regarding child abuse
  
• Most of the physical exams in child sexual abuse cases are normal
  
• In prepubertal children, an exam will most likely not require a speculum exam. If a speculum exam is warranted, it should be done under sedation; consider involving a sexual assault examiner.
  
• In interviewing the child, ask open-ended questions.
  
• Use toys and dolls to have the child explain what happened.
  
• Early psychiatric intervention is necessary.
  

Women who are pregnant have higher rates of abuse/assault

• Obtain complete history even if patient does not wish to file charges, including:
  
  • Date, time, and place of assault
    
  • Physical description of assailants
    
  • Number of assailants
    
  • Types of penetration: Vaginal, oral, rectal
    
  • Assailant ejaculation: Ask if assailant used condom
    
  • Any bodily fluid exchange
    
  • Use of force, weapons, restraints, drugs, or alcohol
    
  • Ask if victim has memory loss or loss of consciousness
    
  • Victim’s activity since assault:
    
    • Changed clothes
      
    • Douched
      
    • Bathed
      
    • Urinated
      
    • Defecated
      
    • Eaten
      
    • Tampon use
      
  • Full gynecologic history
    
  • Last voluntary intercourse
    
  • Sperm may be mobile up to 5 days in cervix and 12 hr in vagina
    
• Address all physical complaints.
  

• Use local evidence kit even if victim is unsure of reporting to police.
  
• Female chaperone required if male physician
  
• If clothes soiled, photograph prior to undressing, with patient’s consent.
  
• Note emotional state of victim.
  
• Note general appearance of clothes:
  
  • Staining
    
  • Tears
    
  • Mud
    
  • Leaves
    
  • Wood lamp for seminal stains
    
  • Have patient disrobe while standing on sheet and place all clothes in paper bag.
    
• Plastic causes mold and increases bacterial counts.
  
• Only the patient should handle the clothing.
  
• Arrange for change of clothes.
  
• Complete physical exam should be done with emphasis on:
  
  • Abrasions
    
  • Lacerations
    
  • Bites
    
  • Scratches
    
  • Foreign bodies
    
  • Ecchymosis
    
  • Dried semen on skin
    
• Forensic collection:
  
  • Fingernail scrapings
    
  • Scalp or pubic hair samples
    
  • If oral penetration, swab between teeth for acid phosphatase (assay for semen) and sperm.
    
  • Throat culture for
    Gonococcus
    and
    Chlamydia
    if oral sex
    
• Gynecologic exam:
  
  • Explain all steps and allow patient to pace exam.
    
  • Comb and collect pubic hair per local protocol.
    
  • Lubricate speculum with water (not lubricant).
    
  • Look for genital trauma even in asymptomatic patients.
    
  • May use toluidine blue to identify small pelvic lacerations from traumatic intercourse:
    
    • Best applied to vaginal mucosa at introitus
      
  • Special attention to hymen as 1 of the most common places for trauma
    
  • Lacerations to vaginal wall near introitus more common in younger patients
    
  • Aspirate secretions pooled in posterior fornix and place in sterile container to be examined for sperm and acid phosphates:
    
    • If no secretions in posterior fornix, wipe with cotton tip.
      
    • Swab and microscopically examine for sperm and acid phosphates.
      
  • Swab for
    Gonococcus
    and
    Chlamydia
    :
    
    • Controversial; evidence can be used by defense to show promiscuity.
      
  • Colposcope allows visualization of small lesions and enables photography of findings (performed by many sexual assault nurse examiner [SANE] programs)
    
  • Rectal exam and cultures for
    Gonococcus
    and
    Chlamydia
    if there was penetration or attempted penetration
    

• Obtain written consent prior to any exam, test, or treatment.
  
• Allow patient to pause and proceed at comfortable pace.
  
• Allow advocate to stay with patient during exam with patient’s consent.