Trauma-Informed Examination, Injury Identification, Strangulation, and Medical Stability
Trauma-informed practice
Safety, trustworthiness, choice, collaboration, and empowerment. Explain each step before doing it, ask permission at each step, offer a support person, allow the patient to stop or pause, offer alternative positions, and never narrate findings in a way that implies judgment. The patient's control over the examination is itself therapeutic.
Injury identification and description
Name the lesion: erythema, abrasion, contusion, laceration, incised wound, bite mark, petechia, ligature mark, pattern injury. Describe location (body region and clock face for genital findings), size in centimeters, color, shape, and margins. Photograph with and without a scale, and supplement with body-map diagrams. Aging a bruise or wound is unreliable - do not assign a time frame. Alternative light sources can highlight fluorescence but do not by themselves establish injury or its cause.
Strangulation
Ask every patient directly about hands, arms, ligature, or objects to the neck, and about loss of consciousness, incontinence, voice change, difficulty breathing or swallowing, neck pain, and vomiting. Signs include petechiae of the face, eyes and oral mucosa, subconjunctival hemorrhage, neck swelling, hoarseness, and ligature marks - but external marks are frequently absent. Symptoms may be delayed hours to days, and carotid or vertebral artery injury can occur without visible trauma. Document findings and symptoms precisely; strangulation is a strong lethality indicator and often a felony enhancement.
Medical stability first
Airway, breathing, circulation, neurologic status, and bleeding before any forensic step; transfer to emergency care for altered mental status, respiratory compromise, severe pain, heavy bleeding, or pregnancy complications.
Traps
- Equating no visible marks with no strangulation.
- Assigning an age to a bruise.
- Failing to ask about strangulation at all.
Rule of thumb: Ask about the neck every time, and treat "looks fine" as compatible with a life-threatening mechanism.