Basics
Description
- Intimate partner violence (IPV) is the physical, sexual, or psychological abuse by a current or former partner.
- Occurs in adult and adolescent intimate relationships across the socioeconomic spectrum.
Etiology
- Most victims are women injured by male perpetrators
- Men and individuals in same-sex relationships may also be victims.
- Risk factors for IPV include female sex, young age (20-24) and being separated from partner/spouse.
Diagnosis
Asking specifically about IPV increases likelihood of identifying victims.
Signs and Symptoms
- Traumatic injuries:
- Wide variety of presentations
- Unwitnessed head, neck, facial injuries are common
- Forearm bruises or fractures suggesting a defensive posture
- Injuries in various stages of healing
- Psychiatric:
- Chronic pain syndromes
- Depression
- Somatization
- Anxiety
- Suicidality
- Substance abuse
Clinical clues:
- Discrepancy between history and physical findings
- Partner refusing to allow patient to be alone with provider
- Delay in seeking care
- Any injury during pregnancy
- Interaction between patient and partner that suggests interpersonal problems
- Multiple symptoms without obvious physical findings
History
- Screening questions for IPV may be useful in identifying victims of domestic violence.
- Controversial as to whether available evidence demonstrates that screening improves health outcomes.
- IPV screening is required by the Joint Commission and supported by some professional medical organizations.
- Screening should be direct, nonjudgmental, supportive, and private.
- There is some evidence for effectiveness of computer-based screening of ED patients for IPV.
- Consider IPV in patients with substance abuse/intoxication as they may be at greater risk and less likely to be identified.
Physical Exam
- Careful exam for traumatic injuries
- Mental status exam
Essential Workup
- After identification of IPV, a directed workup for traumatic injuries and acute medical or behavioral health illnesses is warranted.
- Assess patients risk for future injury/victimization
Differential Diagnosis
Important to maintain high index of suspicion for IPV in patients with traumatic injuries, behavioral health problems, and medical complaints (e.g., GU, GYN, multiple somatic complaints)
Treatment
Pre-Hospital
- Customary trauma evaluation and treatment
- An accurate description of events by EMS should be incorporated into the medical record.
Initial Stabilization/Therapy
- Provide timely and appropriate medical attention.
- Provide appropriate emotional support throughout workup and treatment
Ed Treatment/Procedures
- Interview the patient in a private, secure location without any family members present
- Use a medical interpreter (not family members) to conduct in an interview when there is a language barrier.
- Provide complete, careful documentation including use of the patients exact words, as they are admissible in court.
- Carefully document extent and location of injuries. Diagrams or photographs are particularly useful.
- If stable for discharge, assess situation for lethality
- Risk factors include violence that is increasing in frequency and severity, threats of homicide or suicide by the partner, or the availability of a lethal weapon.
- Work with the patient to develop optimal discharge plan that is consistent with his/her wishes.
- Arrange referrals and follow-up:
- Outpatient victim services
- Emergency shelter information
- Hotlines
- Restraining order information
- Legal services
- Mandatory reporting requirements vary among states:
- Reporting requirements for IPV vary by state.
- Mandatory reporting may place the victim in more danger and create ethical dilemmas for the physician when the victim does not want the case reported to police or social service agencies.
- Inform victims of any requirement to report to authorities and possible outcomes of reporting.
Medication
- Acetaminophen: 650-975 mg PO
- Morphine sulfate: 0.1 mg/kg/dose IV or IM
Follow-Up
Disposition
Admission Criteria
- Use appropriate admission guidelines depending on degree of trauma sustained.
- A patient who is medically stable for discharge but whose safety is at imminent risk may require hospitalization until a safe discharge plan is developed.
Discharge Criteria
A victim whose safety is ensured and whose injuries can be managed as an outpatient may be discharged.
Issues for Referral
Availability of advocacy services varies considerably.
Followup Recommendations
Provide information regarding outpatient services and emergency shelter information.
Pearls and Pitfalls
- Failure to consider IPV in the differential diagnosis of the patients chief complaint.
- Failure to provide thorough, objective documentation of the details of the assault and physical exam findings.
- Failure to adequately assess patient's safety upon discharge and provide appropriate referrals
- Mandatory reporting laws remain controversial and may cause unintended consequences for the patient.
Additional Reading
- Hancock M. Intimate partner violence and abuse. In: Tintinalli J, Stapczynski J, John Ma O, Cline D, eds. Tintinallis Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, NY: The McGraw Hill Companies, Inc; 2011. http://www.accessmedicine.com/content.aspx?aID=6368860. Accessed March 3, 2013.
- Houry D. Interpersonal violence. In: Harwood Nuss' Clinical Practice of Emergency Medicine. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
- Klevens J, Kee R, Trick W, et al. Effect of screening for partner violence on women's quality of life: A randomized controlled trial. JAMA. 2012;308:681-689.
- Rhodes KV. Taking a fresh look at routine screening for intimate partner violence: What can we do about what we know? Mayo Clin Proc. 2012;87(5):419-423.
- Schrager JD, Smith LS, Heron SL, et al. Does stage of change predict improved intimate partner violence outcomes following an emergency department intervention? Acad Emerg Med. 2013;20(2):169-177.
See Also (Topic, Algorithm, Electronic Media Element)
Codes
ICD9
- 995.81 Adult physical abuse
- 995.82 Adult emotional/psychological abuse
- 995.83 Adult sexual abuse
ICD10
- T74.11XA Adult physical abuse, confirmed, initial encounter
- T74.21XA Adult sexual abuse, confirmed, initial encounter
- T74.31XA Adult psychological abuse, confirmed, initial encounter
SNOMED
- 406137001 Adult victim of abuse (finding)
- 237451000119100 Adult victim of physical abuse (finding)
- 288681000119103 Adult victim of physical abuse by male partner (finding)
- 288671000119101 Adult victim of physical abuse by female partner (finding)
- 149141000119102 Adult victim of sexual abuse (finding)
- 207871000119100 Adult victim of emotional abuse (finding)