Volume 32 Number 3 March 2018

Uncivil Union
Intimate partner violence, which crosses all boundaries
of gender, age, race, and socioeconomic status, can
masquerade as a host of common acute complaints,
including stomach pain, substance abuse, or depression.
As such, this lethal cycle can be particularly difficult
to identify in the emergency department. Because most
patients will not readily admit to being victims of
domestic abuse, clinicians must be prepared to recognize
subtle clues and work with this vulnerable population to
construct a safety plan.

Gender Gap
Despite their absence from most educational curricula,
sex and gender disparities exist across a variety of
acute conditions. Evidence-based medicine of the past
assumed, without any direct evidence, that men and
women essentially were identical, with the exclusion of
their reproductive biologies. It has become increasingly
apparent, however, that the disease process can be affected
by significant gender differences — distinctions that must
be acknowledged when managing patients with acute
conditions.

THE OFFICIAL CME PUBLICATION OF THE AMERICAN COLLEGE OF EMERGENCY PHYSICIANS

IN THIS ISSUE
Lesson 5 n Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Critical Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Critical Decisions in Emergency Medicine is the official
LLSA Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 CME publication of the American College of Emergency
Physicians. Additional volumes are available.
Critical Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Critical ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 EDITOR-IN-CHIEF
Michael S. Beeson, MD, MBA, FACEP
Lesson 6 n Sex and Gender Differences . . . . . . . . . . . . . . . . . . . . . . . . . 15 Northeastern Ohio Universities,
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ISSN2325-0186(Print) ISSN2325-8365(Online)
 Uncivil Union
Intimate Partner Violence

LESSON 5

By Heather V. Rozzi, MD, FACEP; and Lisa E. Smale, DO

Dr. Rozzi is an emergency physician at Wellspan York Hospital in York,
Pennsylvania. Dr. Smale is an emergency physician at Beebe Healthcare in
Rehoboth Beach, Delaware.

Reviewed by Sharon E. Mace, MD, FACEP

OBJECTIVES
On completion of this lesson, you should be able to:
1. Recognize red flags that should raise clinical
suspicion for intimate partner violence (IPV).
2. Understand and utilize effective screening tools for
IPV.
3. Identify the important elements in a safety plan for
victims of domestic violence.
4. Describe how IPV affects special populations,
including pregnant patients and those in same-sex
relationships.
FROM THE EM MODEL
14.0 Psychobehavioral Disorders
14.6 Patterns of Violence/Abuse/Neglect
14.6.1.2 Intimate Partner
CRITICAL DECISIONS
n How should “intimate partner” and “intimate partner
violence” be defined in the acute setting?
n How and when should patients be screened for
intimate partner violence?
n What clues in a patient’s history and physical
examination should raise suspicion for IPV?
n How can I better understand a patient who refuses
to leave her abuser, and what can I do to help?
n What special considerations must be addressed
when managing pregnant victims of domestic
abuse?
n What unique concerns should be addressed when
managing patients in abusive same-sex relationships?

Intimate partner violence, which crosses all boundaries of gender, age, race, and socioeconomic status, can
masquerade as a host of common acute complaints, including stomach pain, substance abuse, or depression.
As such, this lethal cycle can be particularly challenging to identify and address in a busy emergency department,
where it can be difficult to find a quiet moment to connect with a reluctant or frightened patient.

March 2018 n Volume 32 Number 3 3

 CASE PRESENTATIONS
■ CASE ONE
A 34-year-old woman
presents with chief complaints
of headache and back pain. Her
initial screening for interpersonal
violence is negative, but she is
disheveled and avoids eye contact
with the triage nurse. Her physical
examination is notable for
hematoma of the posterior occiput,
bruising on her chin, abrasions on
the posterior neck, petechiae on the
lateral aspect of the neck, bruising
to the bilateral medial forearms,
and tenderness to palpation of the
midline lumbar spine.
■ CASE TWO
A 52-year-old woman presents
with neck pain and shortness of
breath after being strangled by
her ex-husband. She reports losing
consciousness at the scene, and says
she is having pain with swallowing.
Pertinent physical examination
findings include tenderness to
palpation and erythema over the
anterior neck bilaterally, bruising to
the chest, and abrasions and bruising
covering the posterior thorax. She
has bilateral breath sounds, no
carotid bruits, and no midline back
tenderness to palpation.
■ CASE THREE
A 27-year-old man presents with
dizziness and anxiety; he smells of alcohol
and says he has been fighting with his
boyfriend. His physical examination
is normal, with the exception of small,
linear abrasions noted on his left forearm.
Upon further questioning, he admits to a
year-long history of depression and self-
harm. The patient is highly distracted by
his cell phone, which has been buzzing
continuously with a flurry of text messages.
Without warning, he tells the clinician that
he “really should go” because his boyfriend
is waiting for him outside.

Ten million women and men in the
United States experience physical
violence each year at the hands of a
current or former intimate partner.1
Unfortunately, many clinicians are
uncomfortable addressing the sensitive,
emotionally loaded topic because of
a lack of applicable education and
experience. Furthermore, the individual
bias of providers can inadvertently
limit screening efforts to patients with
a perceived risk — an oversight that
can result in missed opportunities for
intervention.
It is crucial for frontline providers
to overcome these barriers by being
prepared to manage these often-fragile
cases and seeking out additional
education on intimate partner violence
(IPV), just as they would for any other
disease process.
CRITICAL DECISION
How should “intimate partner”
and “intimate partner violence”
be defined in the acute setting?
To properly identify victims of
intimate partner violence, it is important
to understand the relevant terminology.
An intimate partner is one with whom a
patient has a close personal relationship.
This dynamic can be characterized by
one or more of the following: emotional
connectedness, regular contact, ongoing
physical contact and sexual behavior,
identity as a couple, and familiarity and children and even pets. An estimated
knowledge about the other’s life. 2 IPV 50% to 70% of abused women own pets
includes physical, sexual, economic, that also have been mistreated or killed
emotional, or psychological abuse by a by their abusers. 3
current or former intimate partner. 2 Most clinicians have a good
Intimate partner violence is part understanding of what constitutes
of a spectrum of family violence that physical and sexual harm; however,
includes intimate partner abuse, child emotional, psychological, and economic
abuse, elder abuse, and animal abuse. abuse can be somewhat more difficult to
Unfortunately, particular forms of define and recognize. These latter forms
family violence rarely occur in isolation. of maltreatment can include threats
An abuser often harms not only of suicide/abandonment, threats to
the intimate partner, but also other children, blackmail, social isolation from
members of the household, including friends and family, control of money
TABLE 1. Types of Intimate Partner Violence5
Physical Hitting, slapping, shoving, grabbing, pinching, biting, hair pulling,
abuse etc., are types of physical abuse. This category also includes denying
a partner medical care or forcing alcohol and/or drug use upon the
victim.
Sexual abuse Coercing or attempting to coerce any sexual contact or behavior without
consent. Sexual abuse includes, but certainly is not limited to, marital
rape, attacks on sexual parts of the body, forcing sex after physical
violence has occurred, or treating one in a sexually demeaning manner.
Emotional Undermining an individual's sense of self-worth and/or self-esteem
abuse is abusive. This may include, but is not limited to, constant criticism,
diminishing the partner’s abilities, name calling, or damaging the
victim’s relationship with his or her children.
Economic Is defined as making or attempting to make an individual financially
abuse dependent by maintaining total control over financial resources,
withholding the partner’s access to money, or forbidding the victim’s
attendance at school or place of employment.
Psychological Elements of psychological abuse include, but are not limited to, causing
abuse fear by intimidation; threatening physical harm to self, partner, children,
or partner's family or friends; destruction of pets and property; and
forcing isolation from family, friends, or school and/or work.

4 Critical Decisions in Emergency Medicine

and resources, and other manipulative
behaviors (Table 1).4-6 FIGURE 1. Power and Control Wheel
The Power and Control Wheel COERCION
(Figure 1), which represents the AND THREATS
Making and/or carrying out
experience of women who live with threats to do something

M ook s tu g s . r t y s pl
a k s , r e D . A ay
t:
to hurt her. Threatening

IN e r o n s a s h y i n n g
l e in e Di s .
abusive intimate partners, offers a

in ac s. es t bu ing
an

TI a f r , a i n g h
g
to leave her, commit

E
rv

g
th cisi g a er LE E

M
h ti m ro s i
G
d e k i n n g h IV AL

le s t c t ig e
more precise explanation of the tactics suicide, or report

ID a i d d g e r
s

t h ro t s . pon
st a a b a

w n’s de eing f th like

m ati PR M

AT by
I
her to welfare.

ca e “m ons l th ike

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IO u s
men use to batter women. Battering

e
m e to ” b e r o i n g
l l
Making her

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p e
p
e
ro me a nd ine t h
drop charges.

n
w
is one form of IPV based on gender

,
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e
do illegal
and characterized by the pattern of

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Tr
a

,
things.

s. ’s
actions used to intentionally control

n
n
e
o

Putting her down. Making

e
or dominate one’s partner. “Power

job. Making her ask for

her feel bad about herself.

money. Giving her an

Calling her names.

Power

Making her think

know
getting or keeping a

Taking

she’s crazy. Playing

and control” constitute the center of

Preventing her from

about or have

mind games.
her money. Not
ECONOMIC

Humiliating

EMOTIONAL
her. Making
and

her feel
ABUSE
the wheel. The spokes, which contain

income.
access to
her

guilty.

ABUSE
e.

family
the systemic behaviors used by men Control

allowanc

letting
who batter, include specific threats, Wheel
intimidation, and coercions that instill

m vis r. ak re s it.
a
t c

y.
Us o j u t i o n

t e it T e n he
h to i l d i n g d
M a bo e c s a g tion rea he wa

c h S ay u s e
fear in the partner. Physical and sexual i in
L v n s s

a
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ca
caused it.

CH r f e h i l d o r g s s
g t h r . U h in
t o n d i t l ve j e a y

a
violence, which comprise the rim of the

ld s o n
a k u t h i e t te
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t
Saying she
C o w ho , w w h ing me lou

U I LD l g e n l a y
n
nt s hat e r he nt . s y

N RE i l U
behavior.
wheel, hold the dysfunctional system

e r e

t
h
.
ro he s e s r o the abusive

t
lli s e he he ut

e
together. u

a
n e r s responsibility for
IS g w s a e a d g o e i d e

s
O h n happen. Shifting
L A at d t s, s .
e
TI s h e a l k the abuse didn’t
CRITICAL DECISION

h
S I

O
N do s
n
about it seriously. Saying
i
es not taking her con­cerns
How and when should patients
,
Making light of the abuse and

be screened for intimate partner DENYING, AND BLAMING

MINIMIZING,
violence?
Adapted from the National Center on Domestic and Sexual Violence.
In some emergency departments,
screening begins with the nursing staff; physician during handoff. Physicians Ideally, screening should be
however, it is important to note that should remain attuned to aspects of conducted in a private place in the
IPV can be missed during triage for a the history and physical examination absence of visitors. To help gain the
multitude of reasons, including severe that increase the potential for domestic patient’s trust, clinicians should refrain
medical illness necessitating immediate abuse.7 from using a condescending tone
stabilization, altered mental status, Although there are multiple tools or judgmental body language. The
intoxication, or the presence of visitors. that can be used to guide the secondary physician should be mentally prepared
If suspicion for IPV persists despite a screening, clinicians should develop for a positive screen and ready with a
negative initial screening, the physician their own set of questions tailored to comforting response such as “I’m sorry
should conduct a secondary screening fit the specific concerns of each case this happened to you,” or “This is not
during the visit. If this is not possible (Table 2). A positive answer to any your fault.”7,8
due to ongoing medical or social issues, screening question should prompt the
it is critical to relay the need for IPV development of a patient safety plan CRITICAL DECISION
screening to the subsequent treating prior to discharge.8 What clues in a patient’s history
and physical examination should
TABLE 2. Common IPV Screening Protocols raise suspicion for IPV?
Universal Have you been in a relationship with a partner in the past year? If yes,
Red flags that might indicate
Violence within the past year, has a partner:
potential IPV include a delay in seeking
Prevention • Slapped, kicked, pushed, choked, or punched you?
Screening • Forced or coerced you to have sex?
care (eg, a patient who reports a fall
Protocol17 • Threatened you with a knife or gun to scare or hurt you? that occurred a week prior to her
• Made you afraid that you could be physically hurt? emergency department visit), multiple
• Repeatedly used words, yelled, or screamed in a way that frightened visits for chronic or seemingly minor
you, threatened you, put you down, or made you feel rejected? complaints, and trauma during
Partner • Have you been hit, kicked, punched, or otherwise hurt by someone in pregnancy.8 Emergency practitioners
Violence the past year? If so, by whom? should be sensitive to patients who
Screen18 • Do you feel safe in your current relationship? seem apprehensive about speaking in
• Is there a partner from a previous relationship who is making you feel
front of their partner. A dominating
unsafe now?
partner who attempts to control the

March 2018 n Volume 32 Number 3 5

 FIGURE 2. Bruising Caused by a Broom Handle
PHOTO COURTESY OF ELIZABETH JENKINS, RN
visit or consistently speaks for the
patient should raise concerns.8
Victims may present with
complications from chronic illnesses
or demonstrate noncompliance with
medications and office visits. For
example, a patient presenting in diabetic
ketoacidosis may have had difficulty
remembering to take insulin due to
personal safety concerns. It is important
to recognize that noncompliant patients
may be being prevented from taking
proper care of themselves.4,8
During the physical examination,
it is important to consider the victim’s
injury patterns. These include defensive
wounds to the forearms or patterned
injuries such as ligature marks, linear
markings from a broom handle
(Figure 2), or imprints from the sole of
a shoe. Contusions, among the most
common manifestations of abuse,
can be used to help determine the
mechanism of trauma, but should not
be used to estimate the age or force of
an injury. Bruising is unique to each
patient; multiple variables can influence
the appearance of bruises, including
their location on the body and the
patient’s overall health status.
Lacerations (Figure 3), slicing
or cutting wounds, and penetrating
wounds also can suggest the mechanism
of injury. Any injury that appears
6 Critical Decisions in Emergency Medicine
FIGURE 3. Linear Lacerations from a Boxcutter
PHOTO COURTESY OF TRACY HUNTER RN, SANE-A, SANE-P
to have been caused by a wielded
object (Figure 4) should be examined
closely. The hand, the most commonly
used weapon in IPV, has a distinct
injury pattern usually evidenced by
linear contusions with central areas
of clearing. Bites and burns also can
be identified by their characteristic
appearance. A human bite wound may
contain saliva that could be useful in
later legal proceedings.4
The majority of injuries incurred
during an intimate partner assault
are craniofacial. Blunt force trauma
to the face can result in characteristic
injuries secondary to the patient’s
own accessories. For example,
periorbital contusions or lacerations
can result from contact with the
victim’s eyeglasses.4 Strangulation
(Figure 5) can result in subconjunctival
hemorrhages and petechiae around the
eyes, nose, mouth, and oral mucosa.
Patients may present with abrasions,
erythema, ligature marks to the chin
or neck, or subcutaneous emphysema;
however, a normal examination
does not rule out a serious injury
such as carotid dissection.4 Positive
examination findings, in addition
to other factors such as dysphonia,
difficulty swallowing, dyspnea,
positive loss of consciousness, and
visual changes, should prompt further
imaging to assess the structures of
the neck. CT angiography of carotid/
vertebral arteries is the gold standard
for the evaluation of vessels and bony/
cartilaginous structures.9
While craniofacial trauma is the
most commonly seen injury in cases of
domestic violence, it is crucial to have
the patient undress fully and examine
the entire body for additional wounds.
Injuries frequently are discovered in
regions separate from those specific to
the patient’s complaints.4
CRITICAL DECISION
How can I better understand
a patient who refuses to leave
her abuser, and what can I do
to help?
It can be very difficult for those
who have not experienced IPV to
understand why victims decline
help and/or return to their abusers.
This frequent reality can frustrate
caregivers; however, the goal should
be to work with the patient to develop
a safety plan, regardless of whether
those steps include leaving the abuser.
Victims of IPV choose to remain
in the abusive relationship for many
reasons, and it is important to
understand that any patient seeking
help for IPV is taking a significant
risk. According to the Bureau of Justice
Statistics, one-third of female murder
victims are killed by their intimate
partners. These homicides often occur
after the victim attempts to leave the
relationship.8 In addition, patients may
fear for the wellbeing of their children,
pets, or other family members.
Oftentimes, the victim of homicide is
not the intimate partner, but rather
a family member, friend, neighbor,
intervening person, first responder, or
bystander.10,11
Patients also may choose to
remain in abusive relationships out of
economic concern. They might fear
homelessness or the inability to provide
for themselves and their children.
Immigrant women may be unsure of
their legal rights or fear deportation.
In addition, patients can feel pressure
from family, peers, or cultural norms
to remain with their abusive partners.
Some victims simply choose to stay
because they are still in love with their
abusers and harbor hope that things
will change. Because many victims feel
these forces outweigh the danger of
staying in the relationship, a safety plan
must be put into place.4,7,8
A social worker or advocate
from an IPV organization should
be involved if the patient’s domestic
abuse screen is positive or obvious
FIGURE 4. Patterned Injury Caused by an Unknown
Wielded Object
PHOTO COURTESY OF MICHELLE FREY, RN-BC
signs of abuse are revealed during
the examination. A social worker is
essential to the safety planning process
and will help ensure the patient has
support following the emergency
department visit. The social worker
can help arrange emergency shelter,
assist with services for children, and
provide resources for legal advocacy
and emotional support. If the patient
refuses to leave the abuser, the
physician or social worker can help her
develop a simple safety plan.
The plan should start with
identifying a point person that the
patient can call in the event of danger.
This could be a relative, friend, or other
close contact. The victim should have
a hidden emergency bag containing
extra clothes, necessary keys, and an
accessible source of money. Important
numbers and documents also should
be readily available, including the
patient’s social security number, birth
certificate, driver’s license, bank
account numbers, insurance policies,
and important phone contacts.4,8
Reporting laws pertaining to intimate
partner violence vary from state to
state; it is important for clinicians to
understand the requirements of the
jurisdictions in which they practice.
Mandatory reporting laws for IPV are
controversial. If a victim knows that
FIGURE 5. Strangulation Injury
PHOTO COURTESY OF ELIZABETH JENKINS, RN
her physician is required to report, she
may be less likely to seek health care.
Victims also may fear retaliation by the
perpetrator.
Patients who show signs of abuse but
do not admit to being in danger should
be reminded to return to the emergency
department at any time for help. This
can be conveyed in statements such as,
“Should your situation ever change, I
want you to know that we’ll always be
available to talk to you about it.”4,8
CRITICAL DECISION
What special considerations must
be addressed when managing
pregnant victims of domestic
abuse?
Homicide is the leading cause of
traumatic death among pregnant and
postpartum women in the United
States.8,12 Men may attempt to induce
miscarriage by inflicting direct trauma
to the abdomen or genitalia. Fathers
of the newborn children may harbor
jealously or resentment that can result
in physical violence to the mother or
child. When the relationship is abusive,
the stress of pregnancy can exacerbate
an already tenuous situation.8,13 Nearly
90% of women who suffer abuse during
pregnancy have a history of IPV prior to
becoming pregnant.4
March 2018 n Volume 32 Number 3 7
 be arranged, and the patient’s safety
should be evaluated by a social worker.
Resources for housing and shelter
should be discussed, and information
about advocacy groups specific to
n Any patient who presents to the emergency department should be pregnant patients should be provided
screened for intimate partner violence. prior to discharge.4,8
n A secondary screening should be performed if a patient’s history or physical
CRITICAL DECISION
examination is suspicious for signs of abuse.
n Be prepared with an appropriate response and management plan in What unique concerns should
the event a victim of domestic violence is identified in the emergency be addressed when managing
department. patients in abusive same-sex
n Prior to discharge, victims should receive information about local relationships?
emergency shelters and identify a point person who can be called if they
feel in danger. While heterosexual women are
most likely to be the target of IPV
screening in the emergency department,
IPV is associated with direct fetal be placed in the left lateral decubitus it is vital to consider the possibility of
injury, abruption, premature labor, and position to maintain venous return relationship violence when assessing
stillbirth. Life-threatening maternal and prevent uterine compression of lesbian, gay, bisexual, and transgender
trauma results in fetal loss in 40% the inferior vena cava. An evaluation (LGBT) patients. A study comparing
to 50% of cases; nonlife-threatening of the fetus should occur after the lesbian and heterosexual women
trauma results in fetal loss in 1% to mother has been stabilized, but it is showed that lesbians are more likely
5% of patients. 5 The physiological important to note that significant fetal to experience nonsexual physical
changes in pregnancy demand special injury can be present even with only violence.8,16 Unlike the heterosexual
considerations when managing minor trauma to the mother. community, in which women are
patients with traumatic injuries. Heart Complaints of extreme uterine victimized far more often than men,
rate increases by 15% in normal tenderness or vaginal bleeding victims in the LGBT community are
pregnancy; due to expanded maternal may be signs of uterine rupture equally likely to be male.4
blood volume, patients can tolerate or abruption. The fetal heart rate It can be particularly difficult for
about 1,500 mL of blood loss before should be evaluated as a general victims to discuss IPV with healthcare
becoming hypotensive. These changes indicator of fetal wellbeing. If professionals. Patients may not have
make it difficult to use vital signs the fetus has reached at least 20 disclosed their sexual orientation
as a predictor for shock. Moreover, weeks’ gestation, the mother should to friends and family; homophobia
acute blood loss is disproportionately undergo contraction monitoring for a and a lack of family and community
detrimental to the fetus. In cases of minimum of 4 to 6 hours. Kleihauer- support can result in severe feelings of
hemorrhage, maternal blood pressure Betke testing may be helpful to detect isolation and a reluctance to seek help.
is maintained by shunting blood away concealed maternal-fetal bleeding. In Furthermore, LGBT patients who do
from the fetus, a process that results in such cases, rho(D) immune globulin reach out for help may have difficulty
fetal hypoxia.4,14 should be administered.4,14,15 finding resources that accommodate
By the second trimester, the uterus As with any other type of IPV, those in same-sex relationships. For
has risen into the abdominal cavity, appropriate follow-up care should example, many shelters segregate
and minor blows to the abdomen can
cause uterine rupture or abruption.
The enlarging uterus further displaces
intraabominal structures, and bowel
injuries are more common with
penetrating trauma to the upper
abdomen. Slowed gastric emptying
and increased intraabdominal n Assuming the patient does not need to be screened for IPV based on gender,
pressure confers an increased risk of race, age, or socioeconomic status.
aspiration.4,14 n Failing to address your concerns with the patient because you are
uncomfortable discussing the topic of abuse.
Stabilization of the mother must
n Becoming frustrated with patients who will not leave their abusers, and failing
take precedence and follow the
to provide them with appropriate resources.
normal trauma mantra of airway, n Failing to use your ancillary staff to help the patient develop an individualized
breathing, circulation, disability, and safety plan.
environment. Pregnant patients should

8 Critical Decisions in Emergency Medicine

 CASE RESOLUTIONS
■ CASE ONE
After evaluating the woman’s
injuries, the emergency physician
conducted a secondary intimate
partner violence screening. When
asked if she felt safe at home, the
patient replied, “I am now.” The
clinician discussed the physical
examination findings with her and
expressed concern that she was
being hurt by someone. The patient
reluctantly revealed a story of both
physical and emotional abuse by her
boyfriend.
Her story and physical
examination were meticulously
documented in a forensic medical
record, and the patient worked with
ancillary staff to develop a safety
plan. The plan included identifying a
support person and a safe place to go;
in addition, the victim was provided
with information about counseling
and support groups in the area. The
patient’s brother agreed to stay with
her, and arrangements were made
by gender — a dynamic that poses a
unique risk to members of the LGBT
community. In such cases, same-sex
abusers potentially could gain entry to
the shelter.4
Summary
Intimate partner violence, which
includes any behavior used to control
or manipulate a partner, affects
all genders, races, ages, sexual
orientations, and socioeconomic
strata. Special consideration should
be made when screening pregnant
patients for domestic abuse, as they
are at particular risk. IPV can be
an uncomfortable topic to discuss
with patients, but it is the duty of
the emergency physician to help
protect this vulnerable population.
Ongoing education and preparation
for a positive IPV screen are key. The
effective use of ancillary staff is crucial
when managing and developing a safety
plan for any suspected victim of abuse.
for her to appear in court the following
Monday to file for a temporary
protective order.
■ CASE TWO
Because the young woman had lost
consciousness and exhibited symptoms
of odynophagia and anterior neck
tenderness, the clinician ordered CT
angiography to evaluate the vessels and
bony/cartilaginous structures of the
patient’s neck. The imaging ultimately
was negative. Ancillary staff was called
in to assist with the case.
Safety planning, including
identifying a support person and a
safe place to go, was conducted prior
to discharge. The patient made plans
to stay in a hotel that night, and then
call ACCESS (Assault Care Center
Extending Shelter and Support) in
the morning. ACCESS helps find safe
temporary shelter for victims and their
children; provides counseling; and helps
victims navigate legal, medical, or social
service systems. She also was provided
with a list of local counseling and
REFERENCES
1. Breiding MJ, Smith SG, Basile KC, et al. Prevalence
and characteristics of sexual violence, stalking, and
intimate partner violence victimization – national
intimate partner and sexual violence survey, United
States, 2011. MMWR Surveil Summ. 2014;63(8):1-18.
2. Breiding M, Basile K, Smith S, et al. Intimate
partner violence surveillance uniform definitions
and recommended data elements version
2.0. 2015. Available at https://www.cdc.gov/
violenceprevention/pdf/intimatepartnerviolence.pdf.
Accessed July 20, 2016.
3. Ascione F, Weber C, Wood, D. The Abuse of Animals
and Domestic Violence: A National Survey of Shelters
for Women Who Are Battered. Society and Animals.
1992;5(3).
4. Markowitz J, Polsky S. Color Atlas of Domestic
Violence. St. Louis, MO: Mosby; 2004.
5. Domestic Violence. The United States Department of
Justice. October 31, 2016. Available at https://www.
justice.gov/ovw/domestic-violence. Accessed July 3,
2016.
6. Power and Control Wheel. Domestic Abuse
Intervention Project. Available at http://www.ncdsv.
org/images/powercontrolwheelnoshading.pdf.
Accessed October 10, 2016.
7. Choo EK, Houry DE. Managing intimate partner
violence in the emergency department. Ann Emerg
Med. 2015;65(4):447-451.
8. Kaplan C, Lovelace D, Pittard A, et al. Domestic
violence and intimate partner violence. Emergency
Medicine Reports. 2006.
9. Recommendations for the Medical Radiographic
Evaluation of Acute Adult, Non-fatal strangulation.
The Training Institute for Strangulation
Prevention. Available at https://www.
strangulationtraininginstitute.com/wp-content/
uploads/2015/07/Recommendations-for-Medical-
Radiological-Eval-of-Non-Fatal-Strangulation-
v17.9.pdf. Accessed January 17, 2017.
support groups, and was encouraged
to file a temporary protection from
abuse order at the courthouse.
■ CASE THREE
Concerned for the young man’s
safety, the emergency physician tried
to engage him by asking open-ended
questions about his relationship with
his partner. When asked to explain
more about the fight that precipitated
his emergency department visit, he
readily accepted blame by saying that
he had been “playing mind games”
with his partner. He admitted that
his boyfriend “goes off on [him]
sometimes,” but only because they
“love each other so much.”
The anxious patient rebuffed
the clinician’s attempts to counsel
him about domestic violence. After
returning several text messages, he
abruptly gathered his belongings and
said, “Sorry, but I just need to go.”
10. Smith SG, Fowler KA, Niolon PH. Intimate partner
homicide and corollary victims in 16 states: National
Violent Death Reporting System, 2003-2009. Am J
Public Health. 2014;104(3):461-466.
11. National Statistics. National Coalition Against
Domestic Violence. Available at http://ncadv.org/
learn-more/statistics. Accessed October 10, 2016.
12. Chang J, Berg CJ, Saltzman LE, Herndon J.
Homicide: a leading cause of injury deaths
among pregnant and post-partum women in the
United States, 1991-1999. Am J Public Health.
2005;95(3):471-477.
13. Bacchus L, Bewley S, Mezey G. Domestic violence in
pregnancy. Fetal Matern Med Rev. 2001;12:249-271.
14. Lavin JP Jr, Polsky SS. Abdominal trauma during
pregnancy. Clin Perinatol. 1983;10(2):423-428.
15. Coleman MT, Trianfo VA, Rund DA. Nonobstetric
emergencies in pregnancy: trauma and surgical
conditions. Am J Obstet Gynecol. 1997;177(3):497-
502.
16. Baum R, Moore K. Lesbian, gay, bisexual and
transgender domestic violence: 2003 supplement.
New York: National Coalition of Anti-Violence
Programs; 2004:42.
17. Heron, S. Thompson, M. Jackson, E., et al. Do
responses to an intimate partner violence screen
predict scores on a comprehensive measure of
intimate partner violence in low income black
women? Ann Emerg Med. 2003;42(4):483-491.
18. Feldhaus KM, Koziol-McLain J, Amsbury HL, et
al. Accuracy of 3 brief screening questions for
detecting partner violence in the emergency
department. JAMA. 1997;277(17):1357-1361.
March 2018 n Volume 32 Number 3 9
 The Critical
Procedure
By Steven Warrington, MD, MEd
Dr. Warrington is director of the Emergency Medicine
Residency Program and academic chair of the
Department of Emergency Medicine at Orange Park
Medical Center in Orange Park, Florida.

ESOPHAGEAL BOUGIENAGE
In select patients, esophageal bougienage is a safe, effective, method for dislodging and advancing
certain foreign bodies from the esophagus into the stomach. This simple alternative to endoscopy,
which requires no sedation or general anesthesia, can be a valuable emergency department tool
for the management of uncomplicated ingestions such as coins.

Contraindications
n Unknown duration of esophageal
foreign body
n Known esophageal pathology
n Sharp foreign body
n Respiratory distress
n Large foreign body unlikely to pass
through the rest of the GI tract
Benefits and Risks
Unlike endoscopy, esophageal
bougienage does not require sedation.
Other benefits include a shorter time
to discharge and lower cost.
In the appropriate population (see
Special Considerations), esophageal
bougienage is a relatively safe
technique. The most common risks
include gagging and vomiting, failure
of the procedure itself, and an ongoing
sensation of foreign body post-
procedure. Rare, but more serious,
complications include aspiration,
injury to the oral/esophageal mucosa/
tissue, perforation, and infection of
damaged tissue.
Special Considerations
It is important to note that support
from existing literature comes from
specific patient selection. The procedure
is safe in those who meet all of the
following criteria: 1. single and smooth
esophageal foreign body lodged <24
hours; 2. no respiratory distress; 3. no
history of esophageal disease; 4. no prior
esophageal foreign bodies or esophageal
surgery; 5. single foreign body; and
6. foreign body likely to pass beyond
stomach without complications. The
classic scenario in such cases is the child
with a recent witnessed ingestion of a
coin that can be visualized on imaging to
be in the distal esophagus.
A post-procedure x-ray generally
is recommended to ensure successful
passage of the foreign body into the
stomach. Depending on the nature of
the object, a follow-up x-ray and/or
monitoring of the stool may be indicated.
Follow-up care is recommended for
adult patients, who have a high rate of
underlying esophageal pathologies.
TECHNIQUE
1. Measure and mark the length of the
bougie from the tip of the nose, to
the ear, to the epigastrium (the length
that the bougie should be expected to
advance). Consider topical anesthesia
of the posterior pharynx.
2. Lubricate the dilator tip with water-
soluble gel, and place a bite block. For
pediatric patients, consider instructing
the parent to hold the child in a bear
hug, or use a sheet for stability during
the procedure.
3. Advance the lubricated tip to the
posterior pharynx, and ask the patient
to swallow. Consider extending the
head, and continue to advance to
the premeasured distance. Abort the
procedure if significant resistance or
pain is noted.
4. Withdraw the bougie after the single
pass. Obtain a repeat x-ray to identify
the location of the foreign body.
5. Instruct the patient and/or family on
follow-up and return precautions.

10 Critical Decisions in Emergency Medicine


Although the emergency department
diagnosis of elder abuse remains
elusive, it has important implications
for both health care professionals
and patients. Previous national
surveys estimate that elder abuse affects
approximately 9% to 10% of the United
States population; however, because
these figures rely on self-reporting and
exclude individuals who cannot reliably
participate, they likely underestimate
the magnitude of the problem. In
addition to acute injuries, victims are at
increased risk of death, hospitalization,
and placement in a nursing home.
In addition, the long-term effects of
elder abuse include increased rates of
depression and anxiety.
Although the definition of elder abuse
has been much debated and continues to
adapt, a consensus has arisen about the
inclusion of fiver major types.
• Physical abuse: Acts carried out with
the intention to cause physical pain or
injury
• Psychological or verbal abuse: Acts
carried out with the aim of causing
emotional pain or injury
• Sexual abuse: Nonconsensual sexual
contact of any kind
• Financial exploitation: Misappro­
priation of an older person’s money or
property
• Neglect: Failure of a designated
caregiver to meet the needs of a
dependent older person
Critical Decisions in Emergency Medicine’s series of LLSA reviews features articles articles from ABEM’s 2018 Lifelong Learning and
Self-Assessment Reading List. Available online at acep.org/llsa and on the ABEM website.
The LLSA
Literature Review
Elder Abuse
By Andrew Goldsmith MD, MBA; and Andrew Eyre MD, MHPEd
Departments of Emergency Medicine at Massachusetts General Hospital,
Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA
Lachs MS, Pillemer KA. Elder abuse. N Engl J Med. 2015;373(20):1947-1956.
As with any disease state, clinicians
should consider a number of risk factors
that may increase or decrease the
likelihood of elder abuse, including:
• A “younger” older adult (increased
likelihood of living with a spouse or
adult children)
• Shared living environment
• Low income
• Lack of social support
Aside from dementia, no specific
conditions or diseases have been
identified as conferring a greater
danger of abuse. Chronic disease and
functional limitations, however, are risk
factors, regardless of the specific cause.
Unfortunately, many chronic conditions
place patients at risk for a wide variety of
associated problems such falls, fractures,
skin breakdown, and bruising, just to
name a few.
Although it can be extremely
challenging to identify victims of abuse,
emergency physicians are in a unique
position to recognize and intervene on
behalf of this vulnerable population.
There are strategies and services that
can help providers assess and intervene
if necessary. Potential victims should
be interviewed alone; it’s important to
understand that the relative caregiver
may be the abuser, and patients may be
hesitant to reveal mistreatment. Both
direct questions (eg, “Do you feel safe at
home?”) and indirect questions (eg,“Has
someone not helped you when you
needed help?”) can be used as screening
tools. In every state but New York, even
suspected cases of elder abuse must be
reported to Adult Protective Services
(APS).
There have been no large-scale
randomized trials focused on
interventions for elderly victims of abuse;
therefore, recommendations are based
on suggested best practices. The most
promising response to this problem has
been the development of multidisciplinary
teams consisting of physicians, social
workers, law-enforcement personnel,
and community workers. Emergency
department screening may be the first step
in identifying these victims and enacting
a multidisciplinary response, which can
improve efficiency, coordination, and
professional patient support.
KEY POINTS
n The prevalence of elder abuse
among emergency department
patients may be higher than 10%.
n Older adults are susceptible to
many types of maltreatment,
including neglect, and physical,
emotional, sexual, financial abuse.
n Physicians are mandated to report
elder abuse to APS in every state,
except New York.
n A multidisciplinary approach
appears to be the best strategy for
successful intervention.
March 2018 n Volume 32 Number 3 11
 The Critical Image
A 95-year-old man with chronic lymphocytic leukemia (CLL) on rituximab By Joshua S. Broder, MD, FACEP
therapy presents with several days of left facial swelling and purulent Dr. Broder is an associate professor and the
residency program director in the Division
drainage from his left external auditory canal. The patient has dementia of Emergency Medicine at Duke University
and denies complaints; he has no history of headache or fever. His family Medical Center in Durham, North Carolina.

explains that he has had chronic infections of the left ear for more than 1 year
for which he has been receiving long-term oral amoxicillin-clavulanic acid.
His vital signs are blood pressure 153/74, heart rate 69, respiratory rate 16, temperature 36.6°C (97.9°F), and oxygen
saturation 95% on room air. The patient does not appear to be in distress. His examination is unremarkable, with the
exception left facial swelling, loss of the left nasolabial fold, and purulent discharge from the left external auditory canal.
His glucose level is normal, and his white blood cell count is 9.7.
A computed tomography (CT) scan is performed to assess for soft-tissue fluid collection, bony involvement, or intracranial
extension.
A and B.
A B Photographs
of the patient
from frontal
(A) and lateral
(B) positions.
Left facial swelling
and purulent
discharge from
the external
auditory canal
are visible.

KEY POINTS
CASE RESOLUTION
n Malignant otitis externa is classically described as an infection in elderly
diabetic patients caused by Pseudomonas aeruginosa. However, a recent Culture revealed multidrug-
analysis found that only 22.7% of cases occur in patients with these resistant Proteus mirabilis.
characteristics.1 Other organisms also may be present, and susceptible hosts The patient was treated with
include pediatric patients and those with comorbidities such as CLL, as in intravenous ceftriaxone, and
this case. a peripherally-inserted central
n A chronic infection, malignant otitis externa causes osteomyelitis of the skull catheter was placed for long-
base and eventually can result in intracranial abscess formation, meningitis, term outpatient intravenous
and dural sinus thrombosis. antibiotic therapy.
n The location makes surgical debridement particularly challenging. Cranial
nerves also are commonly affected, including the facial nerve (VII) in 6% to 1. Sylvester MJ, Sanghvi S, Patel VM, et al. Malignant
otitis externa hospitalizations: analysis of patient
30% of cases, as suggested in the photographs of this patient.1,2 characteristics. Laryngoscope. 2017;127:2328-2336.
2. Chandler JR. Malignant external otitis: further
n Imaging techniques include CT and magnetic resonance imaging (MRI). considerations. Ann Otol Rhinol Laryngol.
1977;86:417-428.
Uncertain cases may benefit from hybrid imaging such as positron emission 3. van Kroonenburgh A, van der Meer WL, Bothof RJP,
tomography (PET)-CT or PET-MRI; however, these tests are not commonly et al. Advanced imaging techniques in skull base
osteomyelitis due to malignant otitis externa. Curr
initiated in the emergency department.3 Radiol Rep. 2018;6:3.

12 Critical Decisions in Emergency Medicine

 C and D.
C D External Axial CT
auditory
canal images, bone
windows.
Destruction of
the mastoid
region and
erosion of the
temporal bone
are seen.

Normal
mastoid Destruction
air cells of mastoid

E. Coronal CT
image, bone E
windows. The thin
Temporal bone demonstrates
remaining layer of
evidence of destruction
bone preventing
intracranial
extension is seen.
The bone appears
to be eroded when
compared with
the contralateral
(right) normal side.
(Brain windows
[not shown] did
not demonstrate
intracranial
abscess).

F and G.
F G 3D recon-
structions
from CT
show the
degree
of bony
destruction.

Normal skull base

in region of external Destruction
auditory canal of skull base

March 2018 n Volume 32 Number 3 13

 A 77-year-old man found unconscious at home.

The Critical ECG

Sinus rhythm, rate 64, left anterior fascicular block, left ventricular hypertrophy, By Amal Mattu, MD, FACEP
prolonged QT interval, T-wave abnormality suggestive of diffuse cardiac Dr. Mattu is a professor, vice chair, and
director of the Emergency Cardiology
ischemia versus intracranial hemorrhage. The most prominent abnormality is the
Fellowship in the Department of
presence of giant T-wave inversions in the precordial leads. T-wave inversions of this Emergency Medicine at the University
magnitude in patients with a depressed level of consciousness are highly suggestive of Maryland School of Medicine in
Baltimore.
of a large intracranial hemorrhage, and in fact are often referred to as “cerebral
T-wave patterns.” These T-wave abnormalities may be present in the setting of non-hemorrhagic cerebral disorders as well
(eg, cerebral edema, ischemic stroke), but less commonly. They may be present in the limb leads, although they tend to be
most prominent in the precordial leads, where their magnitude may be 20 mm or more. A prolonged QT interval typically is
associated with these “cerebral T waves.” Rarely, T-wave inversions of this magnitude occur in the setting of cardiac ischemia,
but those patients are likely to have a normal mental status. The exact
reason why cerebral disorders can cause these unusual T waves is
uncertain. This patient did, in fact, have a large intracranial hemorrhage
and died within two days. See figure at right.

CNS disasters can produce a range of ECG abnormalities. à

In this instance, the patient demonstrates deeply inverted T waves.
The QT interval also is prolonged, another manifestation of a significant
CNS event. Determination of the QT interval can be performed via
several different methods, including Bazett’s formula or a comparison
of the QT interval relative to the R-R interval. In this simple bedside
determination, the QT interval is compared to the R-R interval; in sinus For this rate, the QT interval >
rhythm with rates between 60 and 100/minute, a normal QT interval one-half the R-R interval — the QT
interval is prolonged for this rate.
should be less than one-half the related R-R interval for that rate.

From Mattu A, Brady W, ECGs for the Emergency Physician 2. London: BMJ Publishing; 2008:11,23. Reprinted with permission.

14 Critical Decisions in Emergency Medicine

 Gender Gap
Sex and Gender
Differences in the Treatment
of Acute Conditions

LESSON 6

By Tracy E. Madsen, MD, ScM, FACEP; Lauren Walter, MD,

FACEP; and Alyson J. McGregor, MD, MA, FACEP
Dr. Madsen is an assistant professor in the Department of Emergency Medicine,
and associate director of the Division of Sex and Gender in Emergency Medicine
at the Alpert Medical School of Brown University/Rhode Island Hospital in
Providence, Rhode Island. Dr. Walter is an associate professor and member
of the core educational faculty in the Department of Emergency Medicine at
the University of Alabama at Birmingham. Dr. McGregor is the director of the
Division of Sex and Gender in Emergency Medicine (SGEM) and director of the
SGEM Fellowship at the Alpert Medical School of Brown University/Rhode Island
Hospital in Providence, Rhode Island.
Reviewed by Walter L. Green, MD, FACEP

OBJECTIVES
On completion of this lesson, you should be able to: CRITICAL DECISIONS
1. Name sex- and gender-related differences in the acute
n How should sex and gender differences affect the
management of patients with suspected acute coronary
syndrome. acute management of ischemic heart disease and
2. Describe the sex-specific risk factors for acute ischemic other cardiac abnormalities?
stroke, and identify gender-related disparities in treatment of n What sex and gender differences should be
the disease.
3. List common emergency department medications that may considered when managing a patient with an
require sex-dependent dose adjustments. ischemic stroke?
4. Describe the common differences in injury patterns between n What important sex and gender differences should
women and men.
be considered when prescribing a medication?
5. Explain several ways to reduce gender disparities and
improve outcomes when managing patients in cardiac arrest. n What sex-specific factors influence sports-related
injuries?
FROM THE EM MODEL
n How can sex and gender affect the treatment and
20.0 Other Core Competencies
20.2 Practice-Based Learning and Improvement outcomes of patients in cardiac arrest?
20.2.1.1 Evidence-Based Medicine

The discipline of emergency medicine continues to evolve as a reflection of science and society. Interestingly,
traditional evidence-based medicine assumed without any direct proof that — other than their reproductive
organs — women essentially were identical to men. Over the last two decades, however, it has become apparent
that disease can manifest quite differently depending on a patient’s sex. Unfortunately, much of the current medical
science and practice of clinical medicine has failed to account for these significant disparities.

March 2018 n Volume 32 Number 3 15

 CASE PRESENTATIONS
■ CASE ONE
A 62-year-old woman presents
with fatigue and shortness of breath
with exertion; her symptoms began
2 weeks ago and have progressively
worsened. She denies chest pain, but
complains of occasional “pressure”
near her jaw. The patient smokes
and has a history of noninsulin-
dependent diabetes mellitus.
Her electrocardiogram (ECG)
demonstrates nonspecific T-wave
inversions in the inferolateral leads,
and her laboratory results, including
troponin tests, are within normal
limits. Her chest x-ray likewise is
unremarkable.
■ CASE TWO
A 65-year-old woman with
a history of atrial fibrillation,
hypertension, and migraines
arrives via ambulance after being
found collapsed on the floor. She
is confused, disoriented, and has a
right-sided hemiparesis; her NIH
stroke scale score is 22. The patient,
who lives alone, was last seen about
5 hours prior to presentation, at
which time she appeared normal.
Computed tomography(CT)/
computed tomography angiography
(CTA) tests are positive for a left-
sided infarct secondary to a large
Sex- and gender-based medicine
embraces the influences that sex (a
biological construct) and gender (a social
construct) have on patient presentations,
diagnostic testing, treatment responses,
and outcomes (Figure 1). A recent US
National Institutes of Health requirement
[NOT-OD-15-102], which expects
research design, analysis, reporting, and
generalizability to account for the role of
sex as a biological variable in vertebrate
and human studies, will unleash an
unimaginable quantity of new evidence
that can be incorporated into clinical
practice.
Additionally, terms lesbian, gay,
bisexual, and transgender (LGBT)
attempt to represent a broad group by
emphasizing the diversity that exists
16 Critical Decisions in Emergency Medicine
vessel occlusion of the left middle
cerebral artery (MCA). Although her
delayed presentation rules out the
administration of intravenous tissue
plasminogen activator (tPA), the patient
is deemed an appropriate candidate for
endovascular intervention.
■ CASE THREE
A 70-year-old woman with a history
of hypertension and diabetes presents
with a fever of 38.9°C (102°F), altered
mental status, and hypotension. She is
tachycardic with a heart rate of 115 and
blood pressure of 70/40. Her Glasgow
coma scale (GCS) is 12. The patient
is moaning in pain and intermittently
vomiting, but seems to have no focal
abdominal tenderness. Her workup
is remarkable for an elevated white
blood cell count (16.6) and a positive
urinalysis; a CT of the abdomen and
pelvis reveal stranding around the left
kidney, consistent with pyelonephritis.
The patient’s ECG shows sinus
tachycardia, a corrected QT interval
(QTc) of 500, and no evidence of
ischemia. Broad-spectrum antibiotics
and intravenous fluid are administered;
however, her systolic blood pressure
remains in the 80s with a progressive
decline in mental status. She is intubated
and vasopressors are initiated.
with respect to gender identity, gender
expression, and sexual orientation.
Adding to the complexity, no longer can
patients simply be categorized as either
male or female; instead, gender has
evolved into a continuum upon which
sexual identity is modified by behavior
and subjected to the use of exogenous
hormones.
It is incumbent upon emergency
physicians to take patient sex and gender
into account when interpreting clinical
manifestations of disease, potential
limitations in diagnostic imaging,
sex-specific thresholds for biomarkers
and laboratory value references, and
medication dosing – not to mention
mitigating potential and often-
unconscious gender bias.
■ CASE FOUR
An 81-year-old man presents with
right hip pain, which began 1 week
ago after he fell while getting out of
bed. X-rays taken by the patient’s
primary care doctor on the day
of the injury reportedly revealed
no acute fractures. His symptoms
have not been alleviated with pain
medications, and is worse when
bearing weight. On examination, he
is noted to have a pronounced limp.
■ CASE FIVE
An unconscious elderly
woman arrives via ambulance.
Cardiopulmonary resuscitation
(CPR) is in process, and paramedics
report that the patient initially
was in asystole, and has not
responded to multiple rounds of
epinephrine administered in the
field. The monitor indicates that
she is in ventricular fibrillation.
After undergoing two shocks
and orotracheal intubation, the
patient has a return of spontaneous
circulation (ROSC) but remains
minimally responsive with a GCS of
3T. A post-ROSC ECG is equivocal
for ST-elevation myocardial
infarction, and also reveals an old
left bundle branch block. Cardiology
is consulted.
CRITICAL DECISION
How should sex and gender
differences affect the acute
management of ischemic heart
disease and other cardiac
abnormalities?
Ischemic Heart Disease
Coronary artery disease (CAD)
remains the most common killer of
adults in the United States.1 While
men with CAD present 10 to 15 years
earlier than their female counterparts,
the incidence of the disease actually has
increased among women between 35
and 54 years old, and mortality rates
have declined at a slower rate in women.2
In addition, women who present with
chest pain are treated less aggressively
than male patients, and are less likely
to undergo stress testing, angiography,
coronary revascularization, and other
standard medical treatments, including
aspirin, statins, heparin, glycoprotein IIb/
IIIa inhibitors, and thrombolytics.3
The 2012 American College of
Cardiology (ACC) and American Heart
Association (AHA) guidelines advocate
approaching each potential CAD patient
with their sex and gender in mind as
independent factors. While both men
and women with CAD most commonly
present with chest pain, women (younger
women, in particular) are more likely
to present with shortness of breath,
profound fatigue, weakness, nausea, and/
or referred pain (jaw/shoulder), with or
without chest pain (Table 1).4-7
A sex-related discrepancy in cardiac
risk factors also plays an important
role when considering risk stratification
(Table 2). Diabetes, a traditional risk
factor for CAD, appears to double the
risk of myocardial infarction (MI) in
women.8,9 Similarly, women who smoke
are 25% more likely to suffer from
CAD than male smokers.10 On the flip
side, hypertension and dyslipidemia
disproportionally increase the risk of
CAD in men.11 Nontraditional risk
factors associated with MI, including
depression, migraines, lupus, vasculitis,
and metabolic syndrome, also are more
commonly seen in female patients.12,13
Finally, there is a sex-specific increased
risk of CAD in women with pregnancy-
related complications.
A conventional troponin assay, tested
serially, remains the recommended
diagnostic test for suspected cases
of acute coronary syndrome (ACS).
TABLE 1. CAD Symptoms
More Common in Women6
Excessive, unusual fatigue
Sleep disturbance
Shortness of breath
Generalized weakness
Nausea
Jaw or shoulder pain
Note: May be prodromal, >1 month prior
to presentation.
FIGURE 1. Defining Sex- and Gender-Specific Medicine
Women’s
Reproductive Health:
Sex Exclusive
Sex and
Gender-Based
Health
Men’s Reproductive
Health: Sex
Exclusive
Adapted from Jenkins, MR. Chapter 14: Sex and Gender in Medical Education: The Next Chapter. In:
AJ McGregor (Ed.), Sex and Gender in Acute Care Medicine (p. 233). 2016. New York, NY: Cambridge
University Press
Data suggests, however, that the 99th
percentile serum levels for troponin
assays (ie, the “MI cutoff”) are
consistently lower for women than
they are for men, who benefit from a
lower heart muscle mass. Adjusting
this diagnostic threshold to a sex-
specific standard likely would increase
the precision of the ACS diagnosis in
women.
Provocative testing results are affected
by pretest probability; since women
generally have a lower prevalence of CAD
and single vessel disease, their exercise
tolerance/treadmill tests are less accurate
(roughly 60% sensitivity versus 70% in
men). Improvements in nuclear perfusion
studies and stress echocardiography
have made the accuracy of the tests
comparable in all patients. Coronary
CT angiography is an alternative in
non-obese patients; however, in young
women, there is a noteworthy and
attributable lifetime risk of cancer that
must be considered.14
The pathophysiology underlying ACS
in men and women also differs frequently.
Classic plaque rupture resulting in ST-
elevation myocardial infarction is more
common in men, whereas 1 in 8 women
demonstrate endovascular dysfunction/
erosion, coronary artery dissection or
spasm, or Takosubo cardiomyopathy
— alternatives to the typical thrombo­
embolic mechanism.12,15 This is further
evidenced when women undergo
Ovarian cancer
Vaginal atrophy
Pregnancy
Menopause
Asthma
Autoimmune disease
Depression
Drug metabolism
Irritable bowel syndrome
Cardiovascular disease
Prostate cancer
Testicular cancer
Erectile dysfunction
Benign prostatic hypertrophy
coronary angiography; they are more
likely than men to have nonobstructive
CAD (<50% stenosis of one or more
coronary arteries).16
Despite these differences, the current
ACC/AHA guidelines for treating MI/
ACS are similar for both male and
female patients. Anticoagulants should
be weight-adjusted to reduce the risk of
bleeding, a complication more frequently
encountered in women. The optimization
of cardiac risk factors, given known
sex-specific discrepancies, also should be
taken into account.
Gender Factors
A recent study that assessed factors
affecting outcomes after ACS in young
patients (18-55 years old) determined
that feminine roles and personality traits
(assessed via questionnaire) may be
associated with higher rates of recurrent
ACS and major adverse cardiac events
compared with masculine characteristics,
regardless of patient sex.17
Other Cardiac Diseases
Heart failure (HF), a complex
clinical syndrome that is a major cause
of cardiac death in the US and the
reason for an ever-increasing number
of emergency department visits, also
should prompt sex-related adjustments
in clinical management. Women are
more likely to develop concentric
remodeling with pathological cardiac
stress (due to myocardial injury or
March 2018 n Volume 32 Number 3 17
 and may affect the applicability of
TABLE 2. Differentially Weighted Sex-Associated CAD/AMI Risk Factors8,10 acute treatments such as IV tPA and
Confer increased risk to men Confer increased risk to women endovascular intervention. 22
(as compared to women) (as compared to men)
Some data indicate that women are
• Hypertension • Type 2 diabetes
• Dyslipidemia • Smoking
more likely than men to call 911 when
• Metabolic syndrome experiencing stroke symptoms, but
• Nontraditional risk factors (eg, depression, this propensity varies by race; white
autoimmune conditions) more common in women women are most likely to use EMS. 23
• Pregnancy and pregnancy-related factors Women are more likely than men to
(eg, eclampsia, gestational diabetes, and report nontraditional symptoms such as
gestational hypertension)
pain, altered mental status, and non-
neurological symptoms. 24,25 Women also
pressure/volume overload), resulting and diagnosis of patients with acute
are more likely to present with stroke
in left ventricular (LV) diastolic ischemic stroke (AIS), it is important to
mimics, including atypical migraines and
dysfunction and diastolic heart failure be aware of sex and gender differences conversion disorder; these mimics make
with a preserved ejection fraction. in the way the disease presents. Women diagnostic and therapeutic decisions more
Men tend to develop eccentric left tend to be 6 years older at the time difficult, including the determination to
ventricular remodeling from similar of their incident stroke and are more administer IV tPA. Emergency physicians
stresses, resulting in increased LV mass likely to be living alone, a factor that should be cognizant, however, that
and dilated ventricular cavities.18,19
may affect whether or not symptoms symptomatic intracranial hemorrhage
These alternative, often sex-specific,
are witnessed. While most research following the administration of IV tPA
models of pathological cardiac muscle
has not shown a significant difference for the treatment of stroke mimics is
remodeling result in distinct acute and
in the time between symptom onset rare and occurs even less frequently than
chronic presentations with subsequent
and emergency department arrival, spontaneous intracranial hemorrhage
implications for their acute management.
the presence of a witness often is key among those with an ultimate diagnosis
Atrial fibrillation (AF), the most
common arrhythmia encountered in to obtaining an accurate time history of AIS. 26
clinical practice, is associated with the
same risk factors in both sexes; however, FIGURE 2. Q-Angle Differences
women are more likely to suffer from
valvular heart disease, and men more
frequently have associated hypertension
and myocardial infarction. 20 The
treatment for AF is the same for any
adult. However, women generally have
higher resting heart rates and longer
corrected QT intervals, and are at 13° 18°
greater risk for torsades de pointes in Q angle
response to certain antiarrhythmic
medications. In addition, female patients
appear to be at significantly greater risk
for major bleeding events while taking
warfarin. These potentially dangerous
side effects warrant careful selection and
medication monitoring, particularly in
women.

CRITICAL DECISION
What sex and gender differences
should be considered when
managing a patient with an
ischemic stroke?
Small Q angle Large Q angle
Symptoms/Presentation (typical male) (typical female)
Because emergency physicians are
The Q angle should be measured when the patient is STANDING.
responsible for the initial evaluation

18 Critical Decisions in Emergency Medicine

Pathophysiology/Risk Factors Treatment Disparities patient with suspected ICH, it is
Reported sex-related disparities in the There are critical contrasts in the important to know if the patient is
pathophysiology of AIS have been based way in which men and women with taking exogenous sex steroids, which
on data from animal models; in human AIS are managed. These disparities can affect the risk of stroke.
patients, however, these differences must be addressed, as women with the Other Stroke Types
are thought to involve variances in disease suffer from consistently worse There are important sex and gender
coagulation, fibrinolysis, inflammation, functional outcomes. Some data indicate differences in other stroke types,
and cell death.27 AIS resulting from that female patients are less likely to including subarachnoid hemorrhage
acute embolism is more common among receive timely brain imaging, and women (SAH). The incidence of SAH in
women, and may be related to higher in a large national stroke registry were premenopausal women is similar to that
rates of AF with ischemic stroke coupled less likely to have defect-free care as in men; however, women older than
with lower rates of anticoagulation.28,29 defined by AHA quality measures.29,34 50 years have a greater prevalence of
Risk factors also differ between men Specifically, women in the study were unruptured aneurysms and about twice
and women and should be considered less likely to receive anticoagulation for the risk of SAH. Emergency physicians
when risk stratifying patients with AF and IV tPA within 1 hour of arrival. should consider these epidemiological
stroke symptoms. Female patients are Several other studies echo this finding, factors when assessing any patient
more likely to present with classic stroke and show that women are less likely with a headache potentially consistent
symptoms such as hypertension and to receive IV tPA for acute ischemic with SAH. Although there is no data
AF, while men are more likely to suffer stroke.35 suggesting that a diagnostic evaluation
from CAD and atherosclerotic disease.30 Although we lack data on sex and with imaging and lumbar puncture
Interestingly, there also are differences in gender differences regarding the should differ between women and men,
the strength of the associations between effectiveness of mechanical thromb­ further research is needed.
certain risk factors and AIS. For example, ectomy for large vessel occlusions, some
the risk of a first-ever stroke is higher in evidence indicates that women with AIS CRITICAL DECISION
diabetic women than in diabetic men.31 are less likely to receive intra-arterial What important sex and gender
There also are several risk factors therapy, including intra-arterial tPA.36 differences should be considered
that are more prevalent in or unique to While women with stroke are, on
when prescribing a medication?
women. For example, migraine with average, older than men with stroke,
aura, which has been established as a emergency physicians should be aware of Due to variances in body size
risk factor for stroke, is three times more possible treatment disparities and should and composition, drug metabolism
common and has a stronger association ensure that eligible patients of either sex and clearance, and hormonal
with stroke in female patients.32 receive acute interventions. effects, drug pharmacokinetics and
Oral contraceptives, especially those It is important to note that pharmacodynamics vary between the
containing estrogen, are a sex-specific pregnancy is a known risk factor for sexes.38 Such factors lead to differences
AIS risk factor for women. Women both ischemic and hemorrhagic stroke; in circulating drug concentrations,
taking oral contraceptives who smoke the incidence is highest in the third therapeutic effects, and complications
and have a history of migraine with trimester and peripartum period. 33 that must be considered when choosing
aura have a stroke risk that is nine times Although pregnant patients have not and dosing medications. Some animal
greater than women without these risk been included in randomized controlled studies suggest that even measured drug
concentrations must be interpreted
factors.33 trials on the use of IV tPA, reported
differently in females and males due to
Finally, in addition to asking about outcomes (including the incidence of
distinctions in plasma-binding proteins
pregnancy, emergency physicians should spontaneous intracranial hemorrhage)
that affect drug activity.38
ask about a history of preeclampsia and appear to be similar in both pregnant
Although this principle cannot be
gestational diabetes. These pathologies and non-pregnant women who receive
applied to all classes of medications,
confer a greater stroke risk, even decades the therapy. 37
women often have higher drug
after the associated pregnancy.33 When managing a transgender
concentrations and greater rates of
adverse effects than men.39 Causes likely
TABLE 3. QTc-Prolonging Medications77
include higher weight-based dosing in
Class of Medications Commonly Used Drugs
women or the use of inaccurate weights,
Antibiotics Ciprofloxacin, azithromycin, sulfamethoxazole/
differences in volumes of distribution
trimethoprim
Antiemetics Ondansetron, prochlorperazine or renal clearance, or incongruities in
the action of cytochrome P450-related
Antipsychotics Haloperidol, quetiapine
proteins.39 For example, renal clearance
Other Amiodarone, procainamide
(as measured by the glomerular filtration
*QTc prolongation associated with these medications should be considered in both women and men; rate) is lower in women and may lead
however, women are at higher risk of QTc prolongation and torsades de pointes.
to adverse reactions in renally-cleared

March 2018 n Volume 32 Number 3 19


TABLE 4. Musculoskeletal Injury
Patterns More Common in Women
ACL strains and tears
Patellofemoral subluxation and anterior
knee pain syndromes
Type 1 ankle sprains
Hallux valgus syndrome
Stress fractures (tibia, femoral neck,
metatarsals, and pubic rami)
Osteoporotic fragility fractures
drugs such as digoxin, vancomycin, and
cefepime. 39
Women, who generally have a higher
percentage of body fat than their male
counterparts, should receive higher
doses of lipophilic drugs; these agents
have larger volumes of distribution and
lower plasma concentrations.40 The
opposite often is true for hydrophilic
medications. Unfortunately, women
have been historically underrepresented
in drug trials, and data on sex-specific
efficacy and adverse reactions frequently
go unreported. 38,40
Opioids
While responses vary based on
factors such as the etiology of pain and
the specific drug used, it generally is
believed that female patients experience
both more analgesia and more adverse
effects than men.41,42 The increased
effectiveness of morphine in women
seems to be especially true in studies
of patient-controlled analgesia.42
Women also appear to experience more
complications from opioids, including
respiratory depression. 38 Whether opioid
consumption is higher in women or men
is a complex question that depends on
the context and setting, the provider,
and the side effects experienced.43
There are no current recommendations
to support a different female-specific
protocol for the administration of
opioids, but more research is warranted.
QT-Prolonging Agents
QT interval prolongation as an
unintended side effect of some of the
most commonly used medications in
the emergency department (Table 3).
Torsades de pointes, the feared
complication from QT prolongation,
is about twice as common in women,
20 Critical Decisions in Emergency Medicine
who have longer corrected QT (QTc)
intervals at baseline. 39,44 Men appear
to benefit from the protective effects
of testosterone, while women become
more susceptible to the disease over
the course of their menstrual cycles
due to fluctuations in estrogen and
progesterone levels.45 Medications
that can prolong the QTc interval
include antiemetics, antibiotics, and
antipsychotics, among others. Prior to
administering these drugs, it is critical
to evaluate the patient’s ECG, taking
into account sex-specific guidelines for
the normal range of QTc intervals.46
Neuromuscular-Blocking
Agents
Despite routine weight adjustments
in the dosing of nondepolarizing
induction agents such as rocuronium
and vecuronium, there are sex-related
differences in the clinical effects of
these medications that are rarely
considered in acute care. Because of
the drugs’ hydrophilic properties,
women experience higher plasma
concentrations, a more rapid onset,
and longer duration of effect. 38,40 As
a result, most women can be treated
with doses at the low end of the
recommended range; conversely, men
should receive doses at the higher end.
No significant sex-related differences
have been found or studied with respect
to succinylcholine.
Sedatives/Anesthetics
In addition, there are some notable
contrasts in the pharmacodynamics of
sedatives and anesthetics, likely due to
a sex-related differences in the volume
of distribution. One important example
is propofol, a lipophilic substance and
widely used sedative agent in acute
interventions. Women have lower
plasma concentrations and more rapid
declines in plasma propofol levels.47
As a result, they may require higher
infusion rates and tend to emerge more
quickly when the drug is discontinued.47
In order to achieve the same clinical
effects, female patients may necessitate
higher weight-adjusted doses of
propofol.40
Vasopressors
Men and women metabolize
vasoactive medications differently,
resulting in distinct clinical effects. The
protein that metabolizes these drugs
is 25% more active in men, a process
that necessitates potentially higher
dose requirements when prescribing
vasopressors, including epinephrine,
norepinephrine, and dopamine.40
Other Agents
There are many other medications
whose effects differ by sex. While
an exhaustive review of these agents
is beyond the scope of this article,
the hallmark example is zolpidem
(Ambien). The recommended dose for
women is now half of the original dose
approved by the FDA 20 years ago. This
important adjustment was made after it
was determined that women metabolize
the drug at a slower rate than men, a
delay that can lead to adverse effects
such as increased and prolonged
sedation and impaired driving.
CRITICAL DECISION
What sex-specific factors
influence sports-related injuries?
Joint Injuries
The number of female athletes has
grown tenfold since the passage of Title
IX in 1972, a development that has led
to increasingly apparent sports injury
patterns (Table 4). For example, notable
sex discrepancies have been displayed in
anterior cruciate ligament (ACL) injuries
of the knee. Women are two to eight
times more likely to sustain an ACL tear
than men.49 Due to multiple factors,
including sex-specific biomechanical
differences, leg muscle strength
incongruity, and the influence of sex
hormones such as estrogen, women
(particularly female athletes involved
in basketball, soccer, skiing, and other
sports that involve turning and jumping
or pivoting) are more likely to sustain an
ACL tear from a noncontact injury. 50,51
An ACL injury should be considered
in any patient with knee pain from an
acute contact or noncontact trauma.
Risk factors such as the mechanism of
injury and patient sex should be taken
into account when considering acute
stabilization and follow-up instructions.
In addition, the implementation of
preventative measures such as core
strengthening, appropriate and safe
landing position training (landing with
both hips and knees flexed, on the balls
of the feet), and leg muscle stretching and
balance exercises, should be routinely
considered by trainers and/or sports
medicine physicians for female athletes.
Contrasts in the sex-specific
anatomical alignment of the pelvis and
femur are evidenced by an increased
Q angle in women (Figure 2). This
variance, which can be illustrated
by drawing a line from the anterior
superior iliac spine to the center of the
patella and another from the central
patella to the tibial tubercle, contributes
to an increased risk of ACL injury
and predisposes female patients to
patellofemoral subluxation and anterior
knee pain syndromes. 52 Patellar and
knee dislocations, however, do not
appear to differ by sex. 51
Conversely, dissimilarities in the
neuromuscular control of jumping and
landing, which also affect the loading
stress on the foot and ankle (as well
as the knee), appear to be responsible
for an increased incidence of fifth
metatarsal fractures and Achilles
tendon ruptures in male patients. 53
Upper-extremity evaluation and
injury patterns also reveal sex-specific
differences. While traumatic injuries
generally are more common in men,
women have greater glenohumeral
instability and increased ligamentous
laxity in the elbow. These physiological
distinctions, due in part to hormonal
n Consider the possibility of nonobstructive disease in women with symptoms of
ACS and negative traditional testing, including catheterization and stress tests.
n Women who smoke, have migraine with aura, and are on oral contraceptives are
at 10 times the risk of stroke than women without these risk factors.
n Women may require higher doses of lipophilic medications such as propofol.
n Sex differences in hormones and biomechanics lead to different orthopedic injury
patterns in women and men.
n Both women and men who present with cardiac arrest and VF/VT may benefit
from aggressive and timely interventions, including PCI and TTM.
influences on collagen elasticity, result
in atraumatic shoulder dislocations and
elbow dislocations from less forceful
injuries. 54,55
Female athletes are at greater risk
of stress fractures, which are caused
by repetitive subthreshold stress
on abnormally weak bones (due to
demineralization and inadequate
healing and remodeling time). 56
Osteoporosis and
Low-Impact Fractures
Osteoporosis and osteopenia are
major health threats for older men and
women, affecting more than half of
Americans 50 years and older. These
bone disorders disproportionately affect
female patients, who live longer than
men, on average. While osteoporosis
was once considered a women’s
disease, men have a 20% lifetime risk
of sustaining an osteoporotic fracture
(most commonly in the spine, hip,
proximal humerus, or distal radius). 57,58
Osteoporotic fractures often present
after a low-impact injury such as
rolling over in bed; bending over; or,
most commonly, a fall from standing
(a traumatic event that happens to
one-third of adults ≥65 years every
year). While women sustain more
nonfatal injuries from these low-impact
falls, the fall-related death rate is
higher for men. 59 Likewise, men who
sustain fragility fractures have a higher
mortality, often because they are older
and suffer from more comorbidities
than their female counterparts.60
Concussions
Concussion, the most common
type of traumatic brain injury, has
been seen with increasing frequency
in the emergency department over the
last decade, according the Centers
for Disease Control and Prevention.
Defined as a complex pathophysiological
mechanism manifesting after a
direct or indirect blow to the head
or face, a concussion can result in a
host of neurological, cognitive, and
psychological symptoms that can be
cumulative and debilitating.61
Women are at higher risk of
concussion than men in comparable
sports (eg, soccer, hockey).62
Biomechanical factors, including lower
neck-muscle mass and neck muscle
strength in women, may result in the
decreased mitigation and absorption of
rotational acceleration forces.63 Other
evidence suggests that women may have
a lower biomechanical threshold for
concussion, sustaining injuries at lower
linear and rotational acceleration forces
than their male counterparts.64
Female high school and college
athletes are more likely to report
concussive symptoms, specifically
headache, dizziness, fatigue, and
difficulty with concentration.65 Likewise,
objective neuropsychological testing of
athletes after concussion found women
to be twice as likely to be cognitively
impaired than men.66 Women also take
longer to recover from concussions
and are more likely to manifest
postconcussive syndrome, a constellation
of persistent neurocognitive, somatic,
emotional, and sleep-related symptoms
related to the initial head injury.67
Concussions, which can affect both
athletes and trauma patients, result
in distinct sex-related differences in
presentation and long-term recovery.
While we are perhaps just beginning
to understand the etiology of these
discrepancies, the potential implications
are important for emergency department
management, patient counseling, and
future research. In addition, preventative
measures such as neck strengthening,
early sidelining following injury, and
early recognition of concussion are key
for all athletes, regardless of sex or
gender.
March 2018 n Volume 32 Number 3 21
 CRITICAL DECISION
How can sex and gender affect
the treatment and outcomes of
patients in cardiac arrest?
Epidemiology
Cardiac arrest, a condition associated
with extremely high rates of mortality
and morbidity, differs by sex and gender
in several notable ways, including
epidemiology, management, and
outcomes. Women are more likely to
present with nonshockable rhythms,
including asystole and pulseless electrical
activity (PEA), and are more likely
to have causes of arrest other than
cardiac ischemia, including pulmonary
embolus.68 On average, women are 3
to 4 years older at the time of the event
than their male counterparts, and are
more likely to suffer cardiac arrest at
home.68 They also are less likely to
have witnesses present at the time of
the arrest, a social factor that can delay
the administration of CPR and other
prehospital interventions.68
Outcomes
There is ongoing debate about the
effect of sex and gender on the rate of
survival to hospital discharge. Some
studies indicate that women fare better
than men, while others assert the
opposite is true.68-70 Survival to hospital
discharge can be influenced by factors
such as age, comorbidities, and the
context of cardiac arrest; adjusting
for these variables may reduce any
disparities in survivabilty.71 Survival also
may be affected by the early withdrawal
of care secondary to a presumed poor
neurological prognosis, one of the most
common causes of death among patients
with out-of-hospital cardiac arrest.
A secondary analysis of a large,
randomized control trial of out-of-
hospital cardiac arrest patients showed
that women are more likely to have an
early withdrawal of care (within 72
hours of arrest).72 The likelihood of a
good neurological outcome appears to be
the same across gender lines, but there
is little data on longer term outcomes
after cardiac arrest.69 While there is some
evidence that elderly women (>65 years
old) who are alive at hospital discharge
are more likely to survive to 1 year than
elderly men, they are more likely to be
readmitted to the hospital.73
Treatment Disparities
Timely and aggressive interventions,
including bystander CPR, defibrillation
for shockable rhythms, targeted
temperature management (TTM),
and timely percutaneous coronary
intervention (PCI) can help improve
the poor outcomes typically observed
following cardiac arrest. Although
these interventions are being used more
frequently than ever before, they are
employed significantly more often in men
than in women.74
A woman is less likely to undergo
PCI or coronary angiography, regardless
of her initial rhythm and relevant
confounders. Furthermore, female
patients with VF/VT are less likely to
receive TTM than male patients.74 Some
speculate that this gender-related polarity
in the management of cardiac arrest
may be related to code status limitations
or the early withdrawal of care in
female patients.72 When managing any
patient with ROSC, it is imperative for
clinicians to consider therapies such as
angiography, PCI, and TTM.
Treatment disparities also have been
found in the prehospital management of
cardiac arrest patients; women receive
less aggressive care, including basic life
support and bystander defibrillation.70,71
Specifically, the time to initial rhythm
capture and CPR by EMS providers is
longer in women, and female patients
are less likely to receive successful
intravenous access and code medications,
including epinephrine.75 Data on
sex disparities in bystander CPR are
conflicting.68,69
Pregnancy
Pregnancy presents very specific
challenges with respect to women in
cardiac arrest. The American Heart
Association recommendations for
treating cardiac arrest in pregnant
patients (with a uterine fundus palpable
at or above the mother’s umbilicus) are
focused on performing an emergency
perimortem cesarean delivery within 4
minutes of cardiac arrest if ROSC is not
achieved.76
The Future
Historically, women have been
underrepresented in randomized control
trials of patients with out-of-hospital
cardiac arrest. In the ROC PRIMED
trial, for example, women comprised
only 36% of the research sample.72 In
order to gain a better understanding
of sex and gender differences in the
pathophysiology, treatment, and
outcomes of cardiac arrest patients,
future studies must include samples
balanced between women and men, and
should report sex-specific outcomes.

Summary
As clinical research continues to
evolve and embrace the parameters of
n Failing to recognize that exercise stress tests are 10% less sensitive in women. sex and gender in design and analysis,
n Undertreating a female patient with AIS. Women are at risk for receiving less so will the appreciation of when and
aggressive treatment, including IV tPA, than men. how these two defining characteristics
n Administering medications that prolong the QTc without first evaluating the matter. Although the topic areas and
patient with an ECG and obtaining a list of home medications. cases presented here represent a small
n Failing to recognize that that the early withdrawal of care in cardiac arrest portion of the existing multidisciplinary
patients is more common in women, and may be a contributor to sex-related research on sex- and gender-specific
differences in mortality. health, they demonstrate the vast array
of acute conditions in which important

22 Critical Decisions in Emergency Medicine

 CASE RESOLUTIONS
■ CASE ONE
The fatigued woman was admitted
for further risk stratification, and
the clinician initiated an exercise
stress test. Unfortunately, the test
provoked her symptoms (primarily
exertional dyspnea) and was deemed
nondiagnostic. A subsequent coronary
arteriogram revealed a significant
occlusion (>95%) in her right coronary
artery. A drug-eluting stent was
successfully placed. Six weeks later, the
patient had successfully implemented a
tobacco cessation program, remained
compliant with her medications, and
reported resolution of her fatigue and
exertional dyspnea.
■ CASE TWO
The neurointerventional team
successfully retrieved a clot and
restored flow to the confused patient’s
left MCA territory. Four days later, her
NIH stroke scale score had improved
differences exist between men and
women. Emergency clinicians have the
opportunity to transform these advances
in knowledge into a more precise,
informed, and safer delivery approach
for treating any patient.
REFERENCES
1. Rosamond W, Flegal K, Furie K, Go, A. American
heart association statistics committee and
stroke statistics subcommittee. Circulation.
2008;117(4):e25-e146.
2. Towfighi A, Zheng L, Ovbiagele B. Sex-specific
trends in midlife coronary heart disease risk and
prevalence. Arch Intern Med. 2009;169(19):1762-1766.
3. Daly C, Clemens F, Lopez Sendon JL, et al. Gender
differences in the management and clinical outcome
of stable angina. Circulation. 2006;113(4):490-498.
4. Canto JG, Rogers WJ, Goldberg RJ, et al. Association
of age and sex with myocardial infarction symptom
presentation and in-hospital mortality. JAMA.
2012;307(8):813-822.
5. D’Onofrio G, Safdar B, Lichtman JH, et al. Sex
differences in reperfusion in young patients with ST-
segment-elevation myocardial infarction: results from
the VIRGO study. Circulation. 2015;131(15):1324-1332.
6. McSweeney JC, Cody M, O’Sullivan P, et al. Women’s
early warning symptoms of acute myocardial
infarction. Circulation. 2003;108(21):2619-2623.
7. Khan NA, Daskalopoulou SS, Karp I, et al. Sex
differences in acute coronary syndrome symptom
presentation in young patients. JAMA Intern Med.
2013;173(20):1863-1871.
8. Almdal T, Scharling H, Jensen JS, Vestergaard
H. The independent effect of type 2 diabetes
mellitus on ischemic heart disease, stroke, and
death: a population-based study of 13,000 men and
women with 20 years of follow-up. Arch Intern Med.
2004;164(13):1422-1426.
to 4 and she was discharged to a skilled
nursing facility for further rehabilitation
and help with the activities of daily
living.
■ CASE THREE
Aware of the literature on sex-related
differences for the administration of
rocuronium, the emergency physician
elected to treat the critically ill woman
with a dose at the low end of the
approved range (0.8 mg/kg). Infusions
of propofol and norepinephrine
also were administered and titrated
frequently to ensure adequate sedation.
Once stabilized, the patient was
transported to the medical intensive
care unit.
■ CASE FOUR
Concerned about the elderly man’s
markedly limited mobility, the clinician
initiated magnetic resonance imaging
of his right hip, which revealed a
9. Huxley R, Barzi F, Woodward M. Excess risk of fatal
coronary heart disease associated with diabetes in
men and women: meta-analysis of 37 prospective
cohort studies. BMJ. 2006;332(7533):73-78.
10. Huxley RR, Woodward M. Cigarette smoking as
a risk factor for coronary heart disease in women
compared with men: a systematic review and
meta-analysis of prospective cohort studies. Lancet.
2011;378(9799):1297-1305.
11. Daugherty SL, Masoudi FA, Zeng C, et al. Sex
differences in cardiovascular outcomes in patients with
incident hypertension. J Hypertens. 2013;31(2):271-277.
12. Mehta LS, Beckie TM, DeVon HA, et al. Acute
myocardial infarction in women : a scientific statement
from the American Heart Association. Circulation.
2016;133(9):916–947.
13. Yusuf S, Hawken S, Ounpuu S, et al. Effect of
potentially modifiable risk factors associated with
myocardial infarction in 52 countries (the INTERHEART
study): case control study. Lancet. 2004;364(9438):937-
952.
14. Einstein AJ, Henzlova MJ, Rajagopalan S. Estimating
risk of cancer associated with radiation exposure from
64-slice computed tomography coronary angiography.
JAMA. 2007;298(3):317-323.
15. Spatz ES, Curry LA, Masoudi FA, et al. The variation in
recovery: Role of gender on outcomes of young AMI
patients (VIRGO) classification system: a taxonomy
for young women with acute myocardial infarction.
Circulation. 2015;132(18):1710–1718.
16. Reis SE, Holubkov R, Conrad Smith AJ, et al. Coronary
microvascular dysfunction is highly prevalent in
women with chest pain in the absence of coronary
artery disease. Am Heart J. 2001;141(5):735-741.
17. Pelletier R, Khan NA, Cox J, et al. Sex Versus Gender-
Related Characteristics Which Predicts Outcome after
Acute Coronary Syndrome in the Young? J Am Coll
Cardiol. 2016;67(2):127-135.
18. Lee CS, Chien CV, Bidwell JT, et al. Comorbidity
profiles and inpatient outcomes during hospitalization
for heart failure: an analysis of the U.S. Nationwide
inpatient sample. BMC Cardiovasc Disord. 2014;14:73.
19. Piro M, Della Bona R., Abbate A, et al. Sex-related
differences in myocardial remodeling. J Am Coll
Cardiol. 2010;55(11):1057-1065.
minimally displaced intertrochanteric
femur fracture. He was admitted
for orthopedic management, and
discharged to a rehabilitation facility
following an uncomplicated surgical
repair. He returned home 6 weeks
later, but required in-home assistance
for the activities of daily living.
His primary care provider formally
diagnosed him with osteoporosis
during a follow-up visit.
■ CASE FIVE
The critically ill woman was
admitted to the intensive care unit
following consultations with the
cardiologist and critical care team.
After 72 hours without improvement,
a discussion was held with the patient’s
family regarding her poor neurological
prognosis, and her code status
was changed to comfort measures
only. Care was withdrawn, and she
ultimately was terminally extubated.
20. Benjamin EJ, Levy D, Vaziri SM, et al. Independent
risk factors for atrial fibrillation in a population-
based cohort. The Framingham Heart Study. JAMA.
1994;271(11):840-844.
21. Reeves MJ, Bushnell CD, Howard G, et al. Sex
differences in stroke: epidemiology, clinical
presentation, medical care, and outcomes. Lancet
Neurol. 2008;7(10):915-926.
22. Madsen TE, Sucharew H, Katz B, et al. Gender and
time to arrival among ischemic stroke patients in the
greater Cincinnati/Northern Kentucky stroke study. J
Stroke Cerebrovasc Dis. 2016;25(3):504-510.
23. Mochari-Greenberger H, Xian Y, Hellkamp AS, et
al. Racial/Ethnic and Sex Differences in Emergency
Medical Services Transport Among Hospitalized US
Stroke Patients: Analysis of the National Get With
The Guidelines-Stroke Registry. J Am Heart Assoc.
2015;4(8):e002099.
24. Labiche LA, Chan W, Saldin KR, Morgenstern LB.
Sex and acute stroke presentation. Ann Emerg Med.
2002;40(5):453-460.
25. Lisabeth LD, Brown DL, Hughes R, et al. Acute stroke
symptoms: comparing women and men. Stroke.
2009;40(6):2031-2036.
26. Zinkstok SM, Engelter ST, Gensicke H, et al. Safety
of thrombolysis in stroke mimics: results from a
multicenter cohort study. Stroke. 2013;44(4):1080-
1084.
27. Manwani B, McCullough LD. Sexual dimorphism
in ischemic stroke: lessons from the laboratory.
Womens Health (Lond). 2011;7(3):319-339.
28. Kolominsky-Rabas PL, Weber M, Gefeller O, et al.
Epidemiology of ischemic stroke subtypes according
to TOAST criteria: incidence, recurrence, and
long-term survival in ischemic stroke subtypes: a
population-based study. Stroke. 2001;32(12):2735-
2740.
29. Reeves MJ, Fonarow GC, Zhao X, et al. Quality of
care in women with ischemic stroke in the GWTG
program. Stroke. 2009;40(4):1127-1133.
30. Niewada M, Kobayashi A, Sandercock PAG, et al.
Influence of gender on baseline features and clinical
outcomes among 17,370 patients with confirmed
ischaemic stroke in the international stroke trial.
Neuroepidemiology. 2005;24(3):123-128.
March 2018 n Volume 32 Number 3 23
 31. Peters SAE, Huxley RR, Woodward M. Diabetes as a and women. Med Sci Sports Exerc. 2000;32(10):1685-
risk factor for stroke in women compared with men: 1690.
A systematic review and meta-analysis of 64 cohorts, 56. Fredericson M, Jennings F, Beaulieu C, Matheson
including 775 385 individuals and 12,539 strokes. G. Stress fractures in athletes. Top Magn Reson
Lancet. 2014;383(9933):1973-1980. Imaging. 2006;17(5):309-325.
32. Kurth T, Winter AC, Eliassen AH, et al. Migraine and 57. Melton LJ, Atkinson EJ, O’Connor MK, et al. Bone
risk of cardiovascular disease in women. JAMA. density and fracture risk in men. J Bone Miner Res.
2006;296:283-291. 1998;13(12):1915-1923.
33. Bushnell C, McCullough LD, Awad IA, et al. 58. Kanis JA, Johnell O, Oden A, et al. Long-term risk
Guidelines for the prevention of stroke in women: of osteoporotic fracture in Malmö. Osteoporos. Int.
a statement for healthcare professionals from the 2000;11(8):669-674.
American Heart Association/American Stroke
59. Stevens JA, Sogolow ED. Gender differences for non-
Association. Stroke. 2014;45(5):1545-1588.
fatal unintentional fall related injuries among older
34. Kelly AG, Hellkamp AS, Olson D, et al. Predictors of adults. Inj Prev. 2005;11(2):115-119.
rapid brain imaging in acute stroke: analysis of the
60. Roger A, Sutton L, Pierre G. Osteoporosis in men:
Get With the Guidelines-Stroke program. Stroke.
An underrecognized and untreated problem. IBCMJ.
2012;43(5):1279-1284.
2011;53:535-540.
35. Reeves M, Bhatt A, Jajou P, et al. Sex differences in
61. Aubry M, Cantu R, Dvorak J, et al. Summary and
the use of intravenous rt-PA thrombolysis treatment
agreement statement of the 1st International
for acute ischemic stroke: a meta-analysis. Stroke.
Symposium on Concussion in Sport, Vienna 2001.
2009;40(5):1743-1749.
Clin J Sport Med. 2002;12(1):6-11.
36. Towfighi A, Markovic D, Ovbiagele B. Sex
62. Abrahams S, Fie SM, Patricios J, et al. Risk factors for
differences in revascularization interventions
sports concussion: an evidence-based systematic
after acute ischemic stroke. J Stroke Cerebrovasc
review. Br J Sports Med. 2014;48(2):91-97.
Dis. 2013;22(8):e347-e353. doi:10.1016/j.
jstrokecerebrovasdis.2013.03.018. 63. Comstock R. High School Sports-Related Injury:
Recent Trends and Research Findings. 2013.
37. Leffert LR, Clancy CR, Bateman BT, et al. Treatment
patterns and short-term outcomes in ischemic stroke 64. Wilcox B. Head Impact Exposure: The Biomechanics
in pregnancy or postpartum period. Am J Obstet of Sports-Related Concussion. 2013.
Gynecol. 2016;214(6):723.e1-723.e11. 65. Covassin T, Elbin, R. J. The female athlete: the role of
38. Gandhi M, Aweeka F, Greenblatt RM, Blaschke gender in the assessment and management of sport-
TF. Sex differences in pharmacokinetics and related concussion. Clin Sports Med. 2011;30(1):125-
pharmacodynamics. Annu Rev Pharmacol Toxicol. 131.
2004;44:499-523. 66. Broshek DK, Kaushik T, Freeman JR, et al. Sex
39. Anderson GD. Gender differences in differences in outcome following sports-related
pharmacological response. Int Rev Neurobiol. concussion. J Neurosurg. 2005;102(5):856–863.
2008;83:1-10. 67. King N. Permanent post concussion symptoms after
40. Booij LH. Sex, age, and genetics in anesthesia. Curr mild head injury: a systematic review of age and
Opin Anaesthesiol. 2008;21(4):462-466. gender factors. NeuroRehabilitation. 2014;34(4):741-
748.
41. Bartley EJ, Fillingim RB. Sex differences in pain: a
brief review of clinical and experimental findings. Br J 68. Bougouin W, Mustafic H, Marijon E, et al. Gender
Anaesth. 2013;111(1):52-58. and survival after sudden cardiac arrest: a systematic
review and meta-analysis. Resuscitation. 2015;94:55-
42. Niesters M, Dahan A, Kest B, et al. Do sex differences
60.
exist in opioid analgesia? A systematic review and
meta-analysis of human experimental and clinical 69. Karlsson V, Dankiewicz J, Nielsen N, et al. Association
studies. Pain. 2010;151(1):61-68. of gender to outcome after out-of-hospital cardiac
arrest--a report from the International Cardiac Arrest
43. Cepeda MS, Carr DB. Women experience more
Registry. Crit Care. 2015;19:182.
pain and require more morphine than men to
achieve a similar degree of analgesia. Anesth Analg. 70. Ahn KO, Shin SD, Hwang SS. Sex disparity in
2003;97(5):1464-1468. resuscitation efforts and outcomes in out-of-hospital
cardiac arrest. Am J Emerg Med. 2012;30(9):1810-
44. Coker SJ. Drugs for men and women - How important
1816.
is gender as a risk factor for TdP? Pharmacol Ther.
2008;119(2):186-194. 71. Winther-Jensen M, Kjaergaard J, Wanscher M, et al.
No difference in mortality between men and women
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after out-of-hospital cardiac arrest. Resuscitation.
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drug-induced QT prolongation and torsade de
pointes. Am Heart J. 2007;153(6):891-899. 73. Chan PS, Nallamothu BK, Krumholz HM, et al. Long-
term outcomes in elderly survivors of in-hospital
47. Hoymork SC, Raeder J. Why do women wake up
cardiac arrest. N Engl J Med. 2013;368(11):1019-1026.
faster than men from propofol anaesthesia? Br J
Anaesth. 2005;95(5):627-633. 74. Kim LK, Looser P, Swaminathan RV, et al. Sex-based
disparities in incidence, treatment, and outcomes of
48. Greenblatt DJ, Harmatz JS, Singh NN, et al.
cardiac arrest in the United States, 2003-2012. J Am
Gender differences in pharmacokinetics and
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administration. J Clin Pharmacol. 2014;54(3):282-290. 75. Mumma BE, Umarov T. Sex differences in the
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glenohumeral joint laxity and stiffness in healthy men

24 Critical Decisions in Emergency Medicine

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Credits™, and 5 AOA Category 2-B credits for completing this activity in its entirety.

QUESTIONS Submit your answers online at acep.org/newcriticaldecisionstesting; a score of 75%

or better is required. You may receive credit for completing the CME activity any time
within three years of its publication date. Answers to this month’s questions will be
published in next month’s issue.

1 Which of the following questions is inappropriate

when screening a patient for intimate partner
violence (IPV)?
6 What is the best approach when discharging a victim of
IPV who refuses help and intends to return to her abuser?
A. Encourage her to “be strong” and reiterate that she
A. Do you feel safe in your current relationship? is taking an unnecessary risk by staying in the abusive
B. Has your current partner ever forced or coerced relationship
you to have sex? B. Inform the patient that you will be contacting the
C. Have you been hit, kicked, punched, or otherwise authorities for her protection
hurt by someone in the last year? C. Reassure the patient that help is always available in the
D. Have you engaged in promiscuous behavior within emergency department, and encourage her to return at
the past year? any time if she feels unsafe
D. Respect the patient’s privacy, and discharge her without
2
A 23-year-old man presents with multiple contusions
and a wound that appears to be caused by a further comment
wielded object. He claims his injuries are the result
of a fall, and his initial IPV screen is negative.
Despite these findings, you suspect he might be a
7 What is the leading cause of traumatic death among
pregnant women in the US?
A. Falls
victim of abuse. What is an appropriate next step? B. Intimate partner violence
A. Call the patient’s bluff and privately contact the C. Motor vehicle accidents
authorities D. Occupational injuries
B. Conduct a secondary IPV screen, explain why
you’re concerned for his wellbeing, and offer to
help develop a safety plan
8 Which of the following is an appropriate step when
managing a victim of IPV?
A. Advise the patient to leave the abuser
C. Men are unlikely to be victims of abuse; no further
B. Confront the abuser and report the case to law
questioning is required
enforcement
D. Reveal your suspicions and advise the patient to
C. Enlist ancillary resources, including social work and local
leave his abusive relationship immediately
domestic violence organizations, to assist with safety

3
What is the most common injury in victims
of IPV?
planning
D. Never report IPV to the authorities due to HIPAA
A. Bite marks B. Craniofacial trauma regulations
C. Lacerations D. Strangulation

4 Which of the following should be considered when

managing a pregnant victim of abuse?
A. Even minor trauma during the second trimester
can cause uterine rupture or abruption
B. Life-threatening maternal trauma results in fetal
loss in about 85% to 95% of cases
C. Significant fetal trauma is unlikely in women with
only minor injuries
D. Vital signs remain the most reliable predictor of
shock in pregnant patients
9 Which of the following is a characteristic of IPV?
A. 50% to 70% of victims have pets that also have been
mistreated or killed by an abusive partner
B. IPV, child abuse, and elder abuse are unrelated
C. It is always safest for a victim of IPV to leave the
relationship
D. Patients in same-sex relationships are not at risk for IPV
10
What is the best imaging modality for the evaluation of a
strangulation injury?
A. Carotid ultrasonography
B. CT angiography

5
Which of the following should be considered when
reporting a case of intimate partner violence?
C. No imaging is required in strangulation cases
D. Radiography
A. IPV reporting is mandated in every state
B. Reporting requirements vary from jurisdiction to
jurisdiction 11
Which of the following definitions is accurate?
A. Gender = Classification of a person by chromosomal
complement
C. There are no reporting requirements for intimate
B. Gender = Rooted in biology and shaped by environment
partner violence
and experience
D. Victims of IPV need not fear retaliation when the
C. “Gender” and “sex” are interchangeable terms
medical provider is the “on-the-record” reporter
D. Sex = A person’s self-representation as male or female

26 Critical Decisions in Emergency Medicine

12
Which of the following sex-specific factors should
be considered when prescribing an opioid?
A. Male patients are 50% more likely to receive
opioids
B. Men are more likely to experience respiratory
depression when using opioids
C. Morphine appears to be less effective in women
D. Women experience more analgesia and greater
adverse effects from opioids
13
Which factor should be considered when managing
a patient with a sports-related injury?
A. An increased Q angle anatomically predisposes
women to anterior cruciate ligament (ACL)
injuries
B. Estrogen provides a protective benefit that
reduces the risk of ACL injuries in women
C. Female patients are at greater risk for fifth
metatarsal fractures and Achilles tendon ruptures
D. Men are at greater risk for stress fractures
14 An 82-year-old man presents with left wrist pain
after a fall from standing onto his outstretched
hand. Which factor should be considered?
A. Elderly men rarely have osteoporosis; as such, a
fragility fracture should be very low on the list of
differential diagnoses
B. His risk of death is lower than that of his female
counterparts
C. His injury places him in the minority (<10%) of
elderly patients who fall each year
D. This patient is at risk for osteoporosis and fragility
fracture; early identification is paramount
15
What sex-related differences should be considered
when managing a concussion?
A. Men have a lower biomechanical threshold for
head injuries than women, so they require less
force to sustain a concussion
B. Men take longer to recover from concussions and
are more likely to suffer from post-concussive
syndrome than women
C. Women are less likely to report concussive
symptoms, including headache and dizziness
D. Women have comparably less neck muscle mass
and strength than men, factors that appear to put
them at greater risk for concussion
16
Which of the following medications is unlikely to
require sex-specific dosing adjustments?
A. Propofol
B. Rocuronium
C. Succinylcholine
D. Zolpidem
ANSWER KEY FOR FEBRUARY 2018, VOLUME 32, NUMBER 2
1 2 3 4 5 6 7 8 9 10
D B B B C C A D C D
17
A 60-year-old woman with a history of hypertension and
smoking presents with fatigue, nausea, and vague chest
pressure. Which factor is relevant when evaluating this
patient for possible ischemic heart disease?
A. A coronary CT angiogram accurately depicts
coronary disease in women with only negligible and
inconsequential radiation exposure
B. A history of smoking increases a female patient’s risk
of coronary artery disease by 25%
C. An exercise treadmill test is more sensitive than a
nuclear perfusion test for evaluating a female patient
D. The patient’s history of hypertension disproportionately
increases her risk of coronary artery disease
18
What sex- and gender-related difference should be
addressed when managing patients with cardiac disease?
A. In general, women treated with antiarrhythmic
medications for atrial fibrillation are at lower risk for
torsade de pointes than men treated with similar drugs
B. Masculine gender roles and personality traits are
associated with higher rates of recurrent ACS and major
adverse cardiac events
C. Men are more likely to develop eccentric left ventricular
remodeling in response to cardiac stress resulting in
dilated cardiomyopathy
D. Men with atrial fibrillation are less likely than women to
have associated hypertension and myocardial infarction
19
Which factor should be considered when managing any
patient who presents with stroke symptoms?
A. Male patients are more likely to present with classic
stroke symptoms such as hypertension and atrial
fibrillation
B. The risk of a first-ever stroke is higher in diabetic men
than in diabetic women
C. Women are less likely to present with stroke mimics,
including atypical migraines and conversion disorder
D. Women older than 50 years have a greater prevalence
of unruptured aneurysms and about twice the risk of
subarachnoid hemorrhage than their male counterparts
20
Which of the following accurately describes a sex- and
gender-related difference in the resuscitation of patients
in cardiac arrest?
A. After adjusting for initial rhythm, women and men
are equally likely to receive percutaneous coronary
interventions
B. Even after adjusting for initial rhythm, women are less
likely to receive percutaneous coronary interventions
C. Men are less likely to receive bystander defibrillation
D. Women are more likely to have shockable rhythms such
as ventricular fibrillation or ventricular tachycardia
11 12 13 14 15 16 17 18 19 20
B C A C B C B C C C
March 2018 n Volume 32 Number 3 27
 Drug Box
ICATIBANT INJECTION
By Frank Lovecchio, DO, MPH, FACEP, Maricopa Medical
Center/Banner Poison and Drug Center, Phoenix, AZ
Icatibant is used to manage acute attacks of hereditary
angioedema (HAE) in adults. The drug also is used off-label
to treat angiotensin-converting enzyme (ACE) inhibitor-
induced angioedema.
Mechanism
Inhibits bradykinin from binding to Beta-2 receptors, thus
reducing the activity of bradykinin.
Indications and Dosing
30 mg/3 mL (3 mL); subcutaneous injection only; inject
into the abdomen over ≥30 seconds using the 25-gauge
needle provided. Inject 2 to 4 inches below the belly
button and away from any scars; do not inject into an area
that is bruised, swollen, or painful. No dosage adjustments
are recommended for patients with hepatic or renal
impairment.
HAE: May repeat every 6 hours if response is inade­quate
or symptoms recur (max. daily dose 90 mg).
ACE inhibitor-induced angioedema: A second injection
may be administered if symptoms worsen after 6 hours.
Pharmacokinetics
• Median time to 50% decrease of symptoms is ~2 hours.
• Inhibits symptoms caused by bradykinin for ~6 hours.
• Half-life elimination is 1-1.8 hours; time to peak is 0.75
hours.
Adverse Reactions
Local: injection site reaction (97%), dizziness (3%),
increased serum transaminase (4%), fever (4%)
Rare (<1%): antibody development (anti-icatibant, no
association with efficacy observed)
Precautions
No known contraindications; however, icatibant may
diminish the antihypertensive effect of angiotensin-
converting enzyme inhibitors. Pregnancy category C.
Tox Box
ISOPROPANOL POISONING
By Clifford P. Masom, MD; and Christian A. Tomaszewski, MD,
MS, MBA, FACEP, University of California, San Diego
Isopropanol (IPA) is a clear, colorless, volatile alcohol with a
fruity odor and bitter taste, usually available as rubbing alcohol
(70% IPA). It is found in hand sanitizers, solvents, inks, and
drug preparations. It has abuse potential due to low cost, but
pediatric poisonings can occur from ingestion or prolonged
dermal or inhalational exposure.
Pharmacokinetics
• Peak serum concentrations 30-60 minutes post ingestion
• Volume of distribution 0.45-0.7 L/kg
• Protein binding is negligible
• Half-life 2-8 hours
Mechanism of Toxicity
IPA is intoxicating at ≥0.5 mL/kg of 70%, and metabolized by
alcohol dehydrogenase to acetone (ketosis without acidosis).
Clinical Presentation
Central nervous system: inebriation, ataxia, nystagmus,
dysarthria, sedation
Cardiovascular: hypotension with reflex tachycardia (rare)
Respiratory: depression
Gastrointestinal: nausea, vomiting, abdominal pain,
hemorrhagic gastritis
Other: hypothermia, hypoglycemia
Diagnostic Evaluation
• Electrolytes, creatinine, and glucose (order basic metabolic
panel in severe cases)
• Elevated acetone levels may falsely elevate creatinine
• Serum IPA can be measured, but may not be available
• Elevated osmolar gap
Management
• Supportive care is the mainstay of treatment. Monitor the
patient’s ability to protect the airway and hemodynamic
status; cases of chronic abuse may benefit from thiamine.
• Decontamination is unlikely to be beneficial due to IPA’s
rapid absorption. There usually is no need for dialysis.