Supplement: Intimate Partner Violence-Related Head and Neck Trauma

Supplement: Intimate Partner Violence-Related Head and Neck Trauma

Supplement: Intimate Partner Violence-Related Head and Neck Trauma

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Contributors: Michael Ellis, Michelle Ward, Halina (Lin) Haag, Karen Mason, Paul Van Donkelaar, Carrie Esopenko

The medical care of adolescents who sustain head and neck trauma as a result of intimate partner violence (IPV) requires special consideration. This supplement provides important background regarding IPV, the different types of cranial and extracranial injuries that can result from IPV and outlines special considerations for providing initial medical assessment, follow-up and multi-disciplinary management of adolescents with acute IPV-related head and neck trauma.

Background:

 Intimate partner violence (IPV) is an important public health issue that can impact adolescents and includes physical, sexual or emotional abuse or controlling behaviors inflicted by a current or former intimate partner1. It is estimated that approximately 1 in 3 women worldwide experience physical and/or sexual forms of IPV or non-partner sexual violence during their lifetime1. Teen dating is a common cause of physical and sexual violence, however adolescents involved in human trafficking or the sex trade industry can also be at risk of gender-based violence. Risk factors for experiencing IPV may include younger age, female sex, lower socioeconomic status and previous exposure to child abuse as well as disability 2,3,4. Intimate partner violence can result in acute physical injuries and medical conditions but can also contribute to the development of mental health conditions. The most common physical injuries that occur in the context of IPV include those to the head, face and neck5,6. Head trauma can lead to a spectrum of traumatic brain injuries that range from concussion to more severe structural brain injuries and result in physical, cognitive, sleep and emotional symptoms and in more severe cases deficits in sensory, motor or language functioning and seizures. Trauma to the face can lead to facial fractures that commonly involve the nasal bones, zygomatic complex and mandible7,8 and can result in bruising, deformity or facial numbness but can also include injury to the orbit and its contents9,10 resulting in periorbital bruising, subconjunctival hemorrhage, extraocular muscle entrapment and globe rupture. Neck trauma due to blunt trauma or strangulation can lead to hoarseness and difficulty swallowing as well as blunt cerebrovascular injury and hypoxic-ischemic brain injury. Orthopedic injuries can include strains, sprains, and fractures that often occur in defensive locations including the hands, wrists and ulna7,11. Intimate partner violence can also result in injuries to solid organs and can take the form of co-occurring sexual assault, which together can result in pelvic injuries, sexually transmitted and blood borne infections and pregnancy-related complications12. Those who experience IPV can be at an elevated risk of developing mental health outcomes including depression, anxiety, post-traumatic stress disorder and substance misuse13,14. Beyond the medical impacts of IPV survivors can also present with complex housing, safety or legal needs. When caring for survivors of IPV it is important that medical providers use a trauma-informed approach that includes open-ended questions and limits technical terms. They should provide a safe environment and listen to patients; remain non-judgmental; demonstrate empathy, concern and kindness; provide empowerment and validation and give patients multiple opportunities to disclose IPV15. Taken together, IPV exposure in adolescence can have diverse medical and social consequences that require an organized approach to identify and address. Physicians and nurse practitioners must apply an intersection lens to ensure that patients receive the equitable, trauma-informed, multi-disciplinary and multi-sectoral care they deserve.  

This table presents important considerations for the initial medical assessment and follow-up care of adolescents who present with acute IPV-related head and neck trauma.

Initial Medical Assessment (physician/nurse practitioner)

Objectives:

  1. Identify, classify, and diagnose existing traumatic brain injuries
  2. Identify and diagnose co-existing traumatic injuries and/or mental health/medical conditions
  3. Develop an individually-tailored management plan

Components:

Informed consent: outline purpose of medical assessment and limits of confidentiality and duty to report

Clinical history: Collect demographics, injury details (including relationship to perpetrator, setting of assault, injury mechanisms- head trauma, strangulation, sexual assault), previous care, past medical history (including previous IPV, mental health conditions, substance use, pregnancy status), social history, current symptoms and red flags and danger assessment16 and screen for human trafficking

Physical examination: Vital signs, complete neurological exam, vision/oculomotor/otological exam, head and neck exam and focused exam for other extracranial injuries as needed

Supplemental tests (as needed): plain film (e.g extremity fractures), computerized tomography (rule out structural brain or spine injuries), blood work (e.g for sexually-transmitted or blood borne infections)

Management Plan:

  • Provide verbal and written information on IPV TBI.
  •  Provide return to school, work or sport documentation as needed.
  • Provide information and guidance about how to develop a safety plan.
  • Provide information on mental health crisis and IPV support resources, family counseling, victim and legal services and organizations that can provide culture- and gender-specific support and healing.
  • Consider additional tests or referrals as needed.
  • Consider referral to a multi-disciplinary TBI clinic or program.
  • Arrange medical follow-up with patient in 1-2 weeks.
  • Assess need for mandatory reporting to police or child protective services.

Medical Follow-up

(physician/nurse practitioner)

  • Reassess housing status, safety and new injuries.
  • Reassess clinical symptoms and return to activity status (work, school, sport).
  • Screen for features of mental health conditions.
  • Perform focused physical examination as needed.
  • Provide return to school, work or sport documentation as needed.
  • Provide information on mental health crisis and IPV support resources, family counseling, victim and legal services and organizations that can provide culture- and gender-specific support and healing.
  • Consider additional tests or referrals as needed.
  • Arrange medical follow-up as needed or consider discharge based on individual patient needs.

 

This table outlines medical and allied health professionals who may need to be consulted to optimize the multi-disciplinary care of patients with acute IPV-related head and neck trauma.041880

Medical sub-specialist 

Reason for referral

Emergency medicine physician

Cranial or extra-cranial injuries requiring urgent assessment in the emergency department

Radiologist

Need to arrange diagnostic imaging

Neurosurgeon

Structural brain or spine injury

Maxillofacial/plastic surgeon

Facial fractures and injuries

Ophthalmologist

Suspected or diagnosed structural eye injury

Orthopedic surgeon

Traumatic orthopedic injuries

ENT surgeon

Suspected or diagnosed injuries to ears, nose, or throat including hearing deficits and temporal bone pathology

Oral surgeon/dentist

Oral or dental injuries

Psychiatrist

Suspected or diagnosed mental health conditions, addictions, sleep disorders or suicidal ideation

Neuro-ophthalmologist

Suspected or diagnosed cranial neuropathy or visual field defect

Primary care physician

General medical care and follow-up

Neurologist

Persistent post-traumatic headaches, migraines, facial pain, cerebrovascular injury, seizures or stroke

Obstetrician/gynecologist

Pregnancy or gynecological concerns

Allied health sub-specialist 

Reason for referral

Social worker

Assistance with social needs, housing, victim and legal services

Patient advocate/navigator

Assistance with accessing and coordinating patient care and support

Forensic nurse examiner

Acute sexual and domestic assault

Clinical psychologist

Suspected or diagnosed mental health conditions, addictions, sleep disorders or suicidal ideation

Neuropsychologist

Persistent mood or cognitive symptoms

Vestibular physiotherapist

Suspected or diagnosed vestibular disorders

Neuro-physiotherapist

Neurological deficits requiring rehabilitation

Musculoskeletal physiotherapist

Diagnosed whiplash and other musculoskeletal injuries requiring rehabilitation

Occupational therapist

Neurological and cognitive challenges or mental health needs requiring rehabilitation, or environmental modifications and support

Speech language pathologist

Deficits in speech, language or swallowing

Chiropractor

Diagnosed whiplash-type injury

Traditional healer

Patients who wish to receive culturally-based traditional healing and support

Clinical child protection service

Children impacted by IPV or family violence

Tables adapted from: Abused & Brain Injured Toolkit; Supporting Survivors of Abuse and Brain Injury Through Research; Concussion Awareness Training Tool: Intimate Partner Violence Traumatic Brain Injury Medical Provider Resource (Version 1.0), February 2023.

Resources

For more information:

Websites:

References

  1. Internet- World Health Organization, Violence Against Women. March 9 2021. https://www.who.int/news-room/fact-sheets/detail/violence-against-women
  2. Abramsky, T., Watts, C. H., Garcia-Moreno, C., Devries, K., Kiss, L., Ellsberg, M., Jansen, H. A., & Heise, L. (2011). What factors are associated with recent intimate partner violence? findings from the WHO multi-country study on women’s health and domestic violence. BMC Public Health, 11, 109. https://doi.org/10.1186/1471-2458-11-109
  3. Capaldi, D. M., Knoble, N. B., Shortt, J. W., & Kim, H. K. (2012). A Systematic Review of Risk Factors for Intimate Partner Violence. Partner Abuse, 3(2), 231-280. https://doi.org/10.1891/1946-6560.3.2.231
  4. Breiding M. J. & Armour B. S. (2015). The association between disability and intimate partner violence in the United States. Ann Epidemiol, 25(6), 455-457. https://doi.org/10.1016/j.annepidem.2015.03.017
  5. Sheridan, D. J., & Nash, K. R. (2007). Acute injury patterns of intimate partner violence victims. Trauma Violence Abuse, 8(3), 281-289. https://doi.org/10.1177/1524838007303504
  6. Wu, V., Huff, H., & Bhandari, M. (2010). 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, 11(2), 71-82. https://doi.org/10.1177/1524838010367503
  7. Alessandrino, F., Keraliya, A., Lebovic, J., Mitchell Dyer, G. S., Harris, M. B., Tornetta, P., 3rd, Boland, G. W. L., Seltzer, S. E., & Khurana, B. (2020). Intimate Partner Violence: A Primer for Radiologists to Make the “Invisible” Visible. Radiographics, 40(7), 2080-2097. https://doi.org/10.1148/rg.2020200010
  8. Arosarena, O. A., Fritsch, T. A., Hsueh, Y., Aynehchi, B., & Haug, R. (2009). Maxillofacial injuries and violence against women. Arch Facial Plast Surg, 11(1), 48-52. https://doi.org/10.1001/archfacial.2008.507
  9. Clark, T. J., Renner, L. M., Sobel, R. K., Carter, K. D., Nerad, J. A., Allen, R. C., & Shriver, E. M. (2014). Intimate partner violence: an underappreciated etiology of orbital floor fractures. Ophthalmic Plast Reconstr Surg, 30(6), 508-511. https://doi.org/10.1097/IOP.0000000000000165
  10. Cohen, A. R., Renner, L. M., & Shriver, E. M. (2017). Intimate partner violence in ophthalmology: a global call to action. Curr Opin Ophthalmol, 28(5), 534-538. https://doi.org/10.1097/ICU.0000000000000397
  11. Bhandari, M., Dosanjh, S., Tornetta, P., 3rd, Matthews, D., & Violence Against Women Health Research, C. (2006). Musculoskeletal manifestations of physical abuse after intimate partner violence. J Trauma, 61(6), 1473-1479. https://doi.org/10.1097/01.ta.0000196419.36019.5a
  12. Intimate partner violence. Committee Opinion No. 518. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012; 119:412–7
  13. Beydoun, H. A., Williams, M., Beydoun, M. A., Eid, S. M., & Zonderman, A. B. (2017). Relationship of Physical Intimate Partner Violence with Mental Health Diagnoses in the Nationwide Emergency Department Sample. J Womens Health (Larchmt), 26(2), 141-151. https://doi.org/10.1089/jwh.2016.5840
  14. Dillon, G., Hussain, R., Loxton, D., & Rahman, S. (2013). Mental and Physical Health and Intimate Partner Violence against Women: A Review of the Literature. Int J Family Med, 2013, 313909. https://doi.org/10.1155/2013/313909
  15. Feder, G. S., Hutson, M., Ramsay, J., & Taket, A. R. (2006). Women exposed to intimate partner violence: expectations and experiences when they encounter health care professionals: a meta-analysis of qualitative studies. Arch Intern Med, 166(1), 22-37. https://doi.org/10.1001/archinte.166.1.22
  16. Messing, J. T., Campbell, J. C., & Snider, C. (2017). Validation and adaptation of the danger assessment-5: A brief intimate partner violence risk assessment. J Adv Nurs, 73(12), 3220-3230. https://doi.org/10.1111/jan.13459