Good medical practice obligates health care providers in the
ED to serve as an interface between patients and the state within
the context of the public health, legal, and justice systems. To
comply with these additional responsibilities, clinicians must be aware
of local public health and legal obligations and must be able to
recognize patterns of injury. Document observations appropriately
and process evidence in a manner consistent with legal standards.1
Local and public health responsibilities also include the recognition
of potential epidemics or bioterrorist events. ED patients fall
under medical examiner jurisdiction if they die suddenly and unexpectedly
without a clear diagnosis. Examples of surveillance originating
in an ED include West Nile encephalitis in New York2 and
the anthrax deaths in 2001.3 Any death that results
from the deliberate dissemination of an otherwise natural disease
is also a homicide and must be reported to the medical examiner
or coroner. Other examples of unexplained deaths include the series
of cyanide-laced acetaminophen deaths.
Each ED should provide its physicians with a standard protocol for
responding to state-imposed legal and public health requirements. As
an example, all states impose an obligation to report certain infectious
diseases,4 and many states also require reporting
of certain injuries to state social services or law enforcement agencies.
Generally, these reporting requirements are centered on vulnerable
patients such as children,5 the elderly, and victims
of domestic violence. Reporting laws for other types of injuries
vary from state to state. There may be obligations to report gunshot
wounds, knife wounds, assaults, and burns.
When evaluating a patient with injuries that have potential forensic
implications, take a proper history from the patient and other reporting
witnesses, and include information about the origin of the injury.
Document the statements verbatim, if possible, in case contradictions
arise later on, and because such statements are of legal significance
and are admissible in subsequent legal proceedings.
Examine the injury and document the state of the injury
before the injury is altered by healing or medical treatment. Other
diagnostic and documentary tools, such as photographs and radiographs,
should supplement the physical examination.
Injuries may be classified in a variety of ways: mode of production,
circumstances of infliction, or by injury pattern. Mode
of production includes blunt force, sharp force, missile, heat,
electricity, and chemicals. Circumstances of infliction are accidental,
suicidal, or homicidal. Wounds may be characterized as surgical
or ritual, depending on the setting in which these wounds are sustained.
The most useful classification is based on the components of the
injury pattern. Injuries consist of one or a combination of several
types of tissue damage (Table 263.2-1).
Table 263.2-1 Types of Tissue
Damage from Injury
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Table 263.2-1 Types of Tissue
Damage from Injury
An abrasion is the damage inflicted on the superficial
layers of the skin (epidermis) by friction or pressure (Figure 263.2-1). An abrasion may be sustained
by sliding on a rough carpet, producing what is commonly called
a rug burn. A much more extreme version of an abrasion
is the injury produced when a pedestrian is knocked to the pavement
by an automobile, sustaining extensive friction injuries to the
skin on various parts of the body (Figure 263.2-2).
Such injuries are commonly called road burn or road
rash. Although many abrasions do not have a specific enough
pattern to identify the instrument of causation, imprint abrasion
patterns may be very specific. Imprint abrasions may include the
abrasions resulting from a rope used as a ligature
around the neck or extremities and rubbed against the skin, called ligature
marks. Abrasions can also be caused by the irregular surface
of the shoe sole or by an electrical cord used as a whip (Figure 263.2-3).
Abraded knuckles with surrounding bruise.
Imprint abrasion in a pedestrian impacted by a vehicle.
Imprint abrasions from double stranded wire cord.
An external bruise represents bleeding beneath
the skin. If sufficient bleeding occurs to create a lump, this is
called a hematoma. Bruises and hematomas result
from direct force applied to the skin surface, resulting in the
tearing of subcutaneous blood vessels. The pattern of bleeding may
be circular, surrounding a central bleeding point where the blow
has stretched and torn a blood vessel wall. When multiple blood
vessels are torn because of the use of a specific instrument, the
bleeding pattern may conform to the outline of that instrument.
For example, a blow inflicted with a human fist can produce multiple
circular bruises in a pattern that conforms to the tips of the knuckles.
Similarly, pressure from fingertips, such as occurs when someone
grabs another by the arm, may produce several circular to oval bruises.
In contrast, a strike with a baton can produce parallel linear bruises conforming
to the diameter of the baton similar to imprint abrasions but without
removing the epidermis (Figure 263.2-4).
Linear bruises from police baton impacts. (Reproduced
with permission from Knoop KJ, Stack LB, Storrow AB, Thurman RJ: The
Atlas of Emergency Medicine, 3rd ed. © 2010, McGraw
Hill, New York.)
When sufficient force is applied to the surface of the body,
the combination of friction or pressure and tearing of ...