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Intimate Partner Violence

Jamie Hope, MD and Anand Swaminathan, MD FAAEM

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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EM:RAP 2019 July Written Summary 289 KB - PDF

Intimate Partner Violence

Anand Swaminathan MD and Jaime Hope MD

Take Home Points

  • Domestic violence is common. It affects people of every race, religion and gender. It occurs in all socioeconomic groups.
  • Strangulation is a significant predictor of lethal violence.
  • Victims with disability, who are pregnant or postpartum and those in the process of leaving their abuser are at particular risk.
  • Know your local resources.


  • We deal with a lot of horrible things in the ED; child abuse, human trafficking and domestic violence.
  • How common is domestic violence? Every single minute, 24 people are the victims of rape or physical violence in the United States. This amounts to 12 million people per year. 1 in 3 women and 1 in 7 men have been the victims of severe physical violence by an intimate partner in their lifetime.
  • Are there specific injury patterns that can indicate domestic violence? Keep this on your radar. Recognize that men can be victims. This occurs with patients in every zip code, race, gender, religion and socioeconomic status. Look for injury patterns; pattern type bruises, whip marks, cigarettes burns and hand marks. Less obvious are patients who present with recurrent abdominal pain and an injury pattern that doesn’t fit the story or those who won’t make eye contact or have a partner who won’t leave the room.
  • Strangulation is a significant predictor for future lethal violence.If an abuser has strangled their victim, the victim’s chance of death by violence is 10 times higher. This is like a sentinel bleed for subarachnoid hemorrhage. This is your chance to intervene. This is your opportunity to recognize this particular injury pattern and connect the patient to help. If they go back into that home, they are substantially more likely to die.
    • Patients with strangulation may not have significant injuries or findings. It is more obvious in patients with bruising or ligature marks around the neck. Look for bruising on the neck and behind the ears in patients presenting with complaints of sore throat, neck pain, hoarse voice and drooling. Bruising behind the ears may occur if they are lifted while they are strangulated. Look at the tongue for discoloration or injury. Look for petechial hemorrhages on the face or subconjunctival hemorrhage. Patients might complain of dizziness or headache. They may have head injury, loss of consciousness or seizure from anoxia. The post-effects are similar to a traumatic brain injury.
  • There are specific times when a victim is at increased risk. These include pregnancy, childbirth and the postpartum period. Violent partners may try to induce miscarriage by punching the patient, pushing them down the stairs or other acts of violence. There are also much higher rates of violence in the postpartum period, including both physical and sexual violence. Abstinence from intercourse is recommended in the immediate postpartum period as the cervix is not closed, which places the patient at higher risk of air embolism, endometritis, bleeding and tears.
    • Victims are at increased risk when they attempt to leave the abuser. Abuse is about control. When a victim tries to establish control and leave for safety, it often escalates the violence and the victim is more likely to be killed.
  • Why don’t they just leave? If it were simple, no one would be in an abusive situation. There may be fear. Some may believe the abuse is normal. There is a lot of embarrassment and shame associated with being a victim. They may be threatened by the abuser and their children may be threatened. They may love or have loved the perpetrator. Perpetrators may hold onto the victims money, passport and financial or identification documents making it impossible for them to leave.
  • Victims with a disability are at higher risk. Perpetrators may withhold their assistive devices, medications or access to care.
  • We need to be a place of support. “How can I help you get out of this situation?”
  • What reporting laws apply to emergency clinicians? All states mandate reporting child abuse. 47 states mandate reporting of elder abuse. Domestic violence is murkier. Most states have reporting of injuries due to firearms or deadly weapons. Some states have provisions for “severe injuries” or injuries resulting from a criminal act that necessitate reporting. There is substantial variation. There are some ethical questions involved in reporting to the police without consent. Victims may avoid seeking future care. They may experience retribution. They may be at increased risk for
    • “A review of the literature to date fails to isolate any substantial data to support the premise that mandatory reporting laws improve the situation for those it intends to protect.”
    • Sachs, CJ. Mandatory reporting of injuries inflicted by intimate partner violence. Virtual Mentor. 2007 Dec 1;9(12):842-5. PMID: 23228649
  • What should emergency physicians do when providing care to victims of domestic violence?
  1. Be a safe and nonjudgmental place so they can get good medical care and not fear the system. If they aren’t ready to leave the situation that day, you are still opening the door for them to return in the future.
  2. Keep strangulation on your radar. Look for the obvious and subtle signs. This is an extremely dangerous act.
  3. Know your local resources. Every community has places for victims of domestic violence to go but there is a lot of variation. There is a national domestic violence hotline that has a comprehensive list of resources and ways for victims to get help.


Paul Z., M.D. -

At AAEM 2018, there was a presentation on strangulation; data for increased risk of carotid artery complications; argued for considering CT angio. Not mentioned; thoughts?

Jaime H., MD -

Paul, great point! CTA is definitely worth consideration in patients who have been injured with strangulation.

Josh D., MD -

Thank you for this piece. It would be helpful to have a reference for the statement that strangulation carries a 10x risk of death at the hands of the same abuser. I'm sure it's true, but I'd love to see where that came from. Many thanks!

Anand S., M.D. -

From Dr. Hope:

During the course of my research, in addition to other sources, I found valuable information on the National Domestic Violence Hotline (, including an article they published on the dangers of strangulation ( They cite multiple sources (

But what first brought this to my attention was seeing a patient who had a severe strangulation injury as the result of Intimate Partner Violence. Our outreach team mentioned how common that was in lethal events and I realized I did not have that on my radar enough! I started asking all of my IPV patients and found it was more common than I expected. It is an opportunity to educate our patients who are being victimized and help them seek support when they are ready.

Another great thing about, they have warnings about how to exit the site quickly and clear browser history as a way to help keep information-seekers safe.

Thank you for listening and helping support victims of IPV!

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EM:RAP 2019 July Full episode audio for MD edition 192:37 min - 268 MB - M4AEM:RAP 2019 July German Edition Deutsche 103:01 min - 142 MB - MP3EM:RAP 2019 July Aussie Edition Australian 10:50 min - 15 MB - MP3EM:RAP 2019 July Farsi Edition Farsi 164:39 min - 226 MB - MP3EM:RAP 2019 July Canadian Edition Canadian 20:02 min - 28 MB - MP3EM:RAP 2019 July Spanish Edition Español 61:20 min - 84 MB - MP3EM:RAP 2019 July French Edition Français 24:38 min - 34 MB - MP3EM:RAP 2019 July Board Review Answers 237 KB - PDFEM:RAP 2019 July Board Review Questions 111 KB - PDFEMRAP 2019 July Individual MP3 250 MB - ZIPEM:RAP 2019 July Written Summary 289 KB - PDF

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