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Emergency and Acute Medicine – Domestic Violence
Basics
Description
Intimate partner violence (IPV) is physical, sexual, or psychological abuse by a current or former partner. It occurs in adult and adolescent intimate relationships across all socioeconomic groups.
Etiology
Most victims are women injured by male perpetrators, but men and individuals in same-sex relationships may also be victims. Risk factors include female sex, young age (20–24 years), and separation from a partner or spouse.
Diagnosis
Directly asking about IPV increases identification of victims.
Signs and symptoms
Traumatic injuries include a wide range of presentations. Unwitnessed head, neck, and facial injuries are common. Forearm bruises or fractures may suggest defensive posture. Injuries may be in various stages of healing.
Psychiatric and medical associations include chronic pain syndromes, depression, somatization, anxiety, suicidality, and substance abuse.
Alert
Clinical clues include discrepancies between history and physical findings, a partner refusing to leave the patient alone with the provider, delay in seeking care, any injury during pregnancy, concerning patient–partner interactions, and multiple symptoms without clear physical findings.
History
Screening questions can identify IPV. Evidence is mixed regarding improved outcomes, but IPV screening is required by the Joint Commission and supported by some professional organizations. Screening should be direct, nonjudgmental, supportive, and private. Computer-based ED screening may be effective. Consider IPV in patients with substance abuse or intoxication, who may be at higher risk and under-identified.
Physical examination
Perform a careful examination for traumatic injuries and a mental status assessment.
Essential workup
After IPV identification, perform a directed evaluation for traumatic injuries and acute medical or behavioral health conditions. Assess risk for future injury or victimization.
Differential diagnosis
Maintain a high index of suspicion for IPV in patients with traumatic injuries, behavioral health complaints, and medical presentations such as genitourinary or gynecologic complaints and multiple somatic symptoms.
Treatment
Prehospital
Provide standard trauma evaluation and treatment. Incorporate accurate EMS descriptions into the medical record.
Initial stabilization and therapy
Provide timely medical care and ongoing emotional support throughout evaluation and treatment.
Emergency department treatment and procedures
Interview the patient privately without family members present. Use a professional medical interpreter when needed. Document thoroughly using the patient’s exact words; careful documentation is admissible in court. Record extent and location of injuries; diagrams or photographs are helpful.
If stable for discharge, assess lethality risk, including escalating violence, threats of homicide or suicide, and access to lethal weapons. Collaborate with the patient to create a discharge plan aligned with their wishes. Arrange referrals for victim services, emergency shelter information, hotlines, restraining order information, and legal services.
Mandatory reporting varies by state and may increase risk or pose ethical challenges. Inform patients of reporting requirements and potential outcomes.
Medication
Acetaminophen 650–975 mg PO.
Morphine sulfate 0.1 mg/kg/dose IV or IM.
Follow-up and disposition
Admission criteria
Use standard admission guidelines based on injury severity. Medically stable patients with imminent safety risk may require hospitalization until a safe plan is established.
Discharge criteria
Patients whose safety is ensured and whose injuries are manageable as an outpatient may be discharged.
Issues for referral
Advocacy services availability varies by region.
Follow-up recommendations
Provide information on outpatient services and emergency shelter options.
Pearls and pitfalls
Failure to consider IPV in the differential diagnosis. Inadequate, nonobjective documentation of assault details and exam findings. Failure to assess discharge safety and arrange appropriate referrals. Mandatory reporting laws remain controversial and may have unintended consequences.
Basics
Description
Intimate partner violence (IPV) is physical, sexual, or psychological abuse by a current or former partner. It occurs in adult and adolescent intimate relationships across all socioeconomic groups.
Etiology
Most victims are women injured by male perpetrators, but men and individuals in same-sex relationships may also be victims. Risk factors include female sex, young age (20–24 years), and separation from a partner or spouse.
Diagnosis
Directly asking about IPV increases identification of victims.
Signs and symptoms
Traumatic injuries include a wide range of presentations. Unwitnessed head, neck, and facial injuries are common. Forearm bruises or fractures may suggest defensive posture. Injuries may be in various stages of healing.
Psychiatric and medical associations include chronic pain syndromes, depression, somatization, anxiety, suicidality, and substance abuse.
Alert
Clinical clues include discrepancies between history and physical findings, a partner refusing to leave the patient alone with the provider, delay in seeking care, any injury during pregnancy, concerning patient–partner interactions, and multiple symptoms without clear physical findings.
History
Screening questions can identify IPV. Evidence is mixed regarding improved outcomes, but IPV screening is required by the Joint Commission and supported by some professional organizations. Screening should be direct, nonjudgmental, supportive, and private. Computer-based ED screening may be effective. Consider IPV in patients with substance abuse or intoxication, who may be at higher risk and under-identified.
Physical examination
Perform a careful examination for traumatic injuries and a mental status assessment.
Essential workup
After IPV identification, perform a directed evaluation for traumatic injuries and acute medical or behavioral health conditions. Assess risk for future injury or victimization.
Differential diagnosis
Maintain a high index of suspicion for IPV in patients with traumatic injuries, behavioral health complaints, and medical presentations such as genitourinary or gynecologic complaints and multiple somatic symptoms.
Treatment
Prehospital
Provide standard trauma evaluation and treatment. Incorporate accurate EMS descriptions into the medical record.
Initial stabilization and therapy
Provide timely medical care and ongoing emotional support throughout evaluation and treatment.
Emergency department treatment and procedures
Interview the patient privately without family members present. Use a professional medical interpreter when needed. Document thoroughly using the patient’s exact words; careful documentation is admissible in court. Record extent and location of injuries; diagrams or photographs are helpful.
If stable for discharge, assess lethality risk, including escalating violence, threats of homicide or suicide, and access to lethal weapons. Collaborate with the patient to create a discharge plan aligned with their wishes. Arrange referrals for victim services, emergency shelter information, hotlines, restraining order information, and legal services.
Mandatory reporting varies by state and may increase risk or pose ethical challenges. Inform patients of reporting requirements and potential outcomes.
Medication
Acetaminophen 650–975 mg PO.
Morphine sulfate 0.1 mg/kg/dose IV or IM.
Follow-up and disposition
Admission criteria
Use standard admission guidelines based on injury severity. Medically stable patients with imminent safety risk may require hospitalization until a safe plan is established.
Discharge criteria
Patients whose safety is ensured and whose injuries are manageable as an outpatient may be discharged.
Issues for referral
Advocacy services availability varies by region.
Follow-up recommendations
Provide information on outpatient services and emergency shelter options.
Pearls and pitfalls
Failure to consider IPV in the differential diagnosis. Inadequate, nonobjective documentation of assault details and exam findings. Failure to assess discharge safety and arrange appropriate referrals. Mandatory reporting laws remain controversial and may have unintended consequences.
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