Rosen & Barkin's 5-Minute Emergency Medicine Consult (223 page)

• 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.
  

• Careful exam for traumatic injuries
  
• Mental status exam
  

• After identification of IPV, a directed workup for traumatic injuries and acute medical or behavioral health illnesses is warranted.
  
• Assess patient’s risk for future injury/victimization
  

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

• Customary trauma evaluation and treatment
  
• An accurate description of events by EMS should be incorporated into the medical record.
  

• Provide timely and appropriate medical attention.
  
• Provide appropriate emotional support throughout workup and treatment
  

• 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 patient’s 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.
    

• Acetaminophen: 650–975 mg PO
  
• Morphine sulfate: 0.1 mg/kg/dose IV or IM
  

FOLLOW-UP

• 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.
  

A victim whose safety is ensured and whose injuries can be managed as an outpatient may be discharged.

Availability of advocacy services varies considerably.

Provide information regarding outpatient services and emergency shelter information.

• Failure to consider IPV in the differential diagnosis of the patient’s 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.
  

• Hancock M. Intimate partner violence and abuse. In: Tintinalli J, Stapczynski J, John Ma O, Cline D, eds.
  Tintinalli’s 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)

• Elder Abuse
  
• Trauma
  

CODES

• 995.81 Adult physical abuse
  
• 995.82 Adult emotional/psychological abuse
  
• 995.83 Adult sexual abuse
  

BASICS

• Definitions:
  
  • Drowning: “A process resulting in primary respiratory impairment from submersion or immersion in a liquid medium”
    
    • Fatal drowning: Death at any time as a result of drowning
      
    • Nonfatal drowning: If the victim is rescued at any time and the process of drowning is interrupted
      
  • Water rescue: Any submersion or immersion incident without evidence of respiratory impairment
    
• Scenario of drowning:
  
  • Now thought all drowning victims aspirate some amount of liquid
    
  • Previously classified as “wet” and “dry” drowning:
    
    • “Wet” drowning (90%): Aspiration of small amount of liquid into the lungs
      
    • “Dry” drowning (10%): Laryngospasm secondary to the presence of liquid in the oropharynx or larynx
      
  • End result: Hypoxia
    
  • No significant difference between freshwater and saltwater submersion
    
• Pathophysiology:
  
  • Aspiration:
    
    • Small volume of water
      
    • Decreased lung compliance causing ventilation/perfusion mismatch and intrapulmonary shunting
      
    • No significant electrolyte changes
      
    • Grossly contaminated water: Risk for pulmonary infection
      
  • Hypoxemia:
    
    • Metabolic lactic acidosis
      
    • Multisystem organ dysfunction
      
    • Noncardiogenic pulmonary edema
      
    • Myocardial dysfunction (arrhythmias)
      
    • Coagulation abnormalities (disseminated IV coagulation)
      
    • Renal failure (usually acute tubular necrosis)
      
    • Cerebral hypoxia: Cerebral edema, increased intracranial pressure
      

• Hypothermia:
  
  • More common in young children
    
  • Larger body surface-to-mass ratio
    
  • Decreases the metabolic rate
    
  • Survival with full recovery is possible (neuroprotective)
    
• Diving reflex:
  
  • Young children are more susceptible
    
  • Triggered by submersion of face in cold water
    
  • Bradycardia ensues: Redistribution of blood flow to the heart and brain
    
  • Delays onset of hypoxia-related damage