Evaluation and Management of Intimate Partner Violence in the Emergency Department - Trauma EXTRA Supplement (Trauma CME, Domestic Violence CME, and Ethics CME)

Table of Contents

 

About This Issue

When patients who have experienced intimate partner violence (IPV) present to the ED for medical care, the immediate priority for the emergency clinician is the stabilization of the patient and the treatment of acute traumatic injuries. However, there are unique considerations associated with the evaluation and management of these patients. Emergent medical needs must be balanced with concerns for the patient’s emotional well-being; the need for advocacy and social services; issues of privacy and consent; and protocols for forensic evidence collection. In this issue, you will learn:

The most common physical and psychosocial injuries associated with IPV

Why human trafficking must be on the differential

Why a patient-centered care approach is imperative for patients who have experience IPV

The trauma-informed care resources for victims of interpersonal violence that can be utilized in the ED

The role of SAFEs and SANEs in cases of sexual assault related to IPV

The laboratory tests and imaging most likely to be needed in the evaluation of injuries in IPV

Treatment strategies for traumatic injuries commonly seen in IPV

Recommendations for emergency contraception and post-exposure prophylaxis for STIs in cases of sexual assault

Why social services and domestic and sexual violence advocates should be engaged early and through disposition

Special considerations for minors, LGBTQ+ patients, pregnant patients, and undocumented immigrants

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Etiology and Pathophysiology
   1. Traumatic Injuries
   2. Psychosocial Issues
6. Differential Diagnosis
   1. Human Trafficking
7. Prehospital Care
8. Emergency Department Evaluation
   1. Primary Survey
   2. Screening for Intimate Partner Violence
   3. Patient-Centered and Trauma-Informed Care
   4. History
   5. Physical Examination
      1. External Examination
      2. Forensic Examination
9. Diagnostic Studies
   1. Laboratory Testing
   2. Imaging
      1. Imaging Considerations in Pregnant Patients
10. Treatment
    1. Physical Injuries
       1. Ocular and Orbital Injuries
       2. Facial Lacerations
       3. Ear Lacerations
       4. Bite Wounds
       5. Genitourinary Injuries
    2. Postexposure Prophylaxis and Emergency Contraception After Sexual Assault
    3. Psychiatric Care
    4. Social Services
    5. Domestic and Sexual Violence Advocacy
    6. Documentation and Privacy
11. Special Populations
    1. Patients Aged <18 Years
    2. Pregnant Patients
    3. LGBTQ+ Patients
    4. Undocumented Patients
12. Disposition
13. Summary
14. Risk Management Pitfalls in Emergency Department Management of Patients Who Have Experienced Intimate Partner Violence
15. Case Conclusions
16. Clinical Pathway for Emergency Department Management of Patients Who Have Experienced Intimate Partner Violence
17. Tables and Figures
18. References

Abstract

Intimate partner violence (IPV) and emergency medicine intersect when individuals experiencing IPV present to emergency departments for medical care, either on their own or when brought in by law enforcement authorities for medical evaluation and social services. Coordination of care is required, with particular attention paid to the sensitive nature of the patient’s presentation and with an emphasis on trauma-informed care. Emergent medical needs must be balanced with concerns for the patient’s emotional well-being and the need for advocacy and social services. This supplement reviews best practices and evidence-based recommendations for the evaluation and management of patients who have experienced IPV, with a focus on the considerations for traumatic injuries in these patients.

Case Presentations

A 23-year-old woman with no past medical history presents to the ED with a complaint of neck pain…

• During the history, the patient first states that she fell down the stairs, then a few minutes later says that large boxes fell on her neck. You note these conflicting details regarding the etiology of her neck pain.
• On examination, the patient has an occipital scalp hematoma, but no other cranial deformity, periorbital ecchymosis, or facial trauma. Bilateral neck ecchymosis is noted, along with edema that is worse on the right side.
• She has full range of motion of the neck. Cranial nerves are intact, and pulses to bilateral upper extremities are full and equal.
• The patient becomes tearful during the exam and discloses that her husband hit her on the head with a heavy book and wrapped his hands around her neck during an argument. She denies sexual assault or other injuries but states she does not feel safe at home. She denies active suicidal and homicidal ideations.
• You order lab work, urinalysis, noncontrast CT of the brain, and a CT angiogram of the head and neck. While you wait for lab and imaging results, you consider the best next steps for this patient…

A 36-year-old transgender woman presents to the ED with complaints of rectal pain and discharge...

• The patient states that she was sexually assaulted by her partner 2 days ago.
• She says that during a confrontation with her partner about concerns of infidelity, the partner offered the patient an alcoholic beverage. The patient drank the beverage and has no recollection of the events that followed, but awakened later with complaints of rectal pain and bloody drainage.
• You order lab work including CBC, type and screen, basic metabolic panel, and HIV serology. Given her report of sexual assault, you consider how to proceed with the evaluation of this patient…

An 18-year-old woman presents to the ED with abdominal pain...

• The patient is accompanied by a man who identifies himself as her boyfriend.
• When you ask the patient about her chief complaint, the man interrupts her reply and says the patient believes she has a urinary tract infection.
• You note that the patient is avoiding eye contact with you. When you ask her to describe her symptoms, the man interrupts again and requests a “quick test and antibiotics.”
• You are concerned that this patient does not seem to feel free to speak for herself…

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathway for Emergency Department Management of Patients Who Have Experienced Intimate Partner Violence

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * Weil A, Elmore J, Kunins L. Intimate partner violence: epidemiology and health consequences. UpToDate. 2020. Updated August 24, 2022. Accessed April 1, 2023. (Review)

7. * Wu V, Huff H, Bhandari M. Pattern of physical injury associated with intimate partner violence in women presenting to the emergency department: a systematic review and meta-analysis. Trauma Violence Abuse. 2010;11(2):71-82. (Systematic review & meta-analysis; 7 articles) DOI: 10.1177/1524838010367503

8. International Labor Organization. Forced labour, modern slavery and human trafficking. 2022. Accessed April 1, 2023. (International Labor Organization statistics)

11. * Yau RK, Stayton CD, Davidson LL. Indicators of intimate partner violence: Identification in emergency departments. J Emerg Med. 2013;45(3):441-449. (Retrospective chart review; 5514 patients) DOI: 10.1016/j.jemermed.2013.05.005

12. * Caponnetto P, Maglia M, Pistritto L, et al. Family violence and its psychological management at the emergency department: a review. Health Psychol Res. 2019;7(2):8558. (Review) DOI: 10.4081/hpr.2019.8558

13. * Vonkeman J, Atkinson P, Fraser J, et al. Intimate partner violence documentation and awareness in an urban emergency department. Cureus. 2019;11(12):e6493. (Retrospective chart review; 2736 patients) DOI: 10.7759/cureus.6493

18. * Choo EK, Houry DE. Managing intimate partner violence in the emergency department. Ann Emerg Med. 2015;65(4):447-451.e441. (Review) DOI: 10.1016/j.annemergmed.2014.11.004

20. * Rasmussen V, Steel Z, Spangaro J, et al. Investigating the prevalence of intimate partner violence victimisation in women presenting to the emergency department in suicidal crisis. Emerg Med Australas. 2021;33(4):703-710. (Cross-sectional study; 563 patients) DOI: 10.1111/1742-6723.13714

21. Ramaswamy A, Frederiksen B, Rae M, et al. Out-of-pocket charges for rape kits and services for sexual assault survivors. Updated November 1, 2022. Accessed April 1, 2023. (Policy brief)

23. Ladd M, Seda J. Sexual assault evidence collection. StatPearls [Internet]. Updated September 26, 2022. Accessed April 1, 2023. (Online textbook chapter)

24. * US Centers for Disease Control and Prevention. Sexual assault and abuse and STIs - STI treatment guidelines. Updated July 22, 2021. Accessed April 1, 2023. (Treatment guidelines)

29. Sletten Z. Preventing scarface: pearls for complicated facial lacerations – eyelid lacerations. November 12, 2020. Accessed April 1, 2023. (Case study)

31. Dominguez KL, Smith DK, Vasavi T, et al. Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV—United States, 2016. April 18, 2016,. Updated May 23, 2018. Accessed April 1, 2023. (Guidelines)

34. Substance Abuse and Mental Health Services Administration. Use of medication-assisted treatment in emergency departments. National Mental Health and Substance Use Policy Laboratory; 2021. (Government report)

38. Futures Without Violence. Child abuse & mandatory reporting: a complex matter. November 20,2022. Accessed April 1, 2023. (Policy guidance)

43. National Domestic Violence Hotline. Survivors of domestic violence report feeling less safe after contacting law enforcement. Accessed April 1, 2023. (Press release)

Subscribe to get the full list of 43 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: intimate partner violence, domestic violence, IPV, human trafficking, abuse, sexual assault, forensic examination, sexual assault nurse examiner, SANE, sexual assault forensic examiner, SAFE, orbital wall fracture, strangulation, ear laceration, facial laceration, bite wound, social services, advocate, trauma-informed care, PEARR tool, CUES intervention, post-exposure prophylaxis, PEP, emergency contraception