March 2025 Tip of the Month: Identifying Intimate Partner Violence (IPV) in Prehospital Care

Recognizing the Signs of IPV

Intimate partner violence (IPV) is a significant issue across Canada, and Northwestern Ontario is no exception. Studies indicate that up to 35% of women in the region will experience IPV in their lifetime, with higher rates reported in rural and remote communities. Certain Indigenous populations face even greater vulnerability due to unique socio-economic and systemic factors.

As frontline healthcare providers, paramedics are often the first point of contact for victims of IPV. Your ability to recognize and respond to IPV is critical for patient safety and well-being.

1. Recognizing Common Presentations

IPV victims may present with:

· Unexplained or inconsistent injuries (e.g., bruises, fractures, lacerations).

· Injuries in various stages of healing.

· Vague, non-specific complaints (e.g., headaches, abdominal pain, anxiety).

· Injuries to areas typically covered by clothing, such as the abdomen, chest, or back.

· Behavioral signs, including nervousness, avoidance of eye contact, or reluctance to provide details about injuries.

2. Observing Behavioral Cues

· A controlling or overly attentive partner insists on speaking for the patient.

· The patient appears fearful, anxious, or depressed when discussing their injuries.

· The patient hesitates or resists answering questions when their partner is present.

3. Using Open-Ended and Non-Judgmental Questions

Creating a safe and private environment allows patients to disclose abuse. Consider asking:

· “Can you tell me what happened today?”

· “Do you feel safe at home?”

· “Has anyone hurt you or made you feel afraid?”

4. Utilizing the HITS Screening Tool

The HITS (Hurt, Insulted, Threatened, Screamed) tool is a simple, validated screening method to assess IPV. Patients rate four questions on a scale of 1 to 5 (Never to Frequently):

· Hurt – "How often has your partner physically hurt you?"

· Insulted – "How often has your partner insulted or talked down to you?"

· Threatened – "How often has your partner threatened you with harm?"

· Screamed – "How often has your partner screamed or cursed at you?"

A score of 10 or higher suggests a potential IPV case, warranting further assessment and intervention. The brevity of this tool makes it especially useful in prehospital settings.

5. Identifying High-Risk Factors

Certain factors increase the urgency of IPV intervention:

· Strangulation – A strong predictor of future lethal violence.

· Pregnancy-related injuries.

· Multiple EMS calls for vague complaints in a short timeframe.

6. Documenting Accurately

· Record verbatim statements from the patient.

· Describe visible injuries and behavioural cues objectively.

· Avoid assumptions—stick to observable facts.

7. Referral and Reporting

• Hospital Triage: Communicate any IPV concerns to your receiving facility
• Self-Referral Support Services: IPV survivors can access support services independently. Referring patients to available programs and treatment centres can connect them with vital resources.
• Mandatory Reporting: If there are children in the home aged 16 or under, paramedics have a legal obligation to report suspected IPV to child protective services.
• Resource and Support Links:
  • Ontario Government: IPV Support Services
  • Sexual Assault/Domestic Violence (SADV) Treatment Centres – A list of treatment centres by location.
  • 211 Ontario – Enter your location to find local shelters, crisis lines, and other community services.

Evidence-Based Practice

Research indicates that up to 40% of women treated by EMS have experienced IPV, yet it frequently goes unrecognized. The HITS screening tool has been shown to improve IPV identification and facilitate early intervention in prehospital care.

Your Role in IPV Recognition

By applying these guidelines, paramedics can play a critical role in identifying IPV and ensuring that victims receive the support they need. Early recognition and appropriate action can make a life-saving difference.

ALL the ECGs presented this week have a final diagnosis of Pulmonary Embolism (PE)!

Before we begin the review, take a moment and refresh yourself as to where the various leads are with respect to the anatomical location of the heart. I specifically want you to notice that aVR, V1, and lead III are on the right side of the heart.

ECG findings in Pulmonary Embolism

• Sinus Tachycardia
  • You don’t need tachycardia to have a PE. Tachycardia is seen in only ~30% of patients, but signals increased oxygen demand
• Atrial and ventricular dysrhythmias
  • SVT, atrial fibrillation, atrial flutter, etc.
  • SVTs (AVNRT, AVRT, atrial and junctional tachycardias, etc.) are an independent predictor of subsequent clinical deterioration
• ECG Signs of RV strain
  • Rightward axis (look for large S wave in lead I)
    • S₁Q₃or S₁Q₃T₃(not sensitive or specific)
  • Conduction delays and repolarization abnormalities
    • New RBBB or incomplete RBBB
    • Look for tall R waves in V1
  • New T-wave inversions
    • Right precordial leads (V1-V4)
    • Inferior leads (II, III, aVF)
    • New T wave inversions in the anteroseptal leads +/- inferior leads should be considered a sign of acute pulmonary hypertension or PE until proven otherwise
  • ST-segment elevations or depressions (mimics ischemia)
  • ST-segment elevation in rightward leads (V₁, V₂, aVR, III)

• Co, et al. J Emerg Med 2017 (PMID: 27742402) – identified the most common ECG changes in patients with known PE when comparing their ECGs with previous ECGs
  • 285 PEs diagnosed on CTA (62% segmental, 20% in main pulmonary artery, 8% saddle)
    • No ECG changes ~ 24%
    • T wave inversion ~ 34%
    • T wave flattening ~ 30%
    • Sinus tachycardia ~ 27%
    • Rightward axis ~ 11%
    • ST segment changes ~ 9%
    • S₁Q₃T₃~ 4%

ECG 1

This shows the classic S1Q3T3 finding, which is neither sensitive nor specific per PE and present only probably about 4% of the time. More importantly, we see ST elevation in leads aVR, V1 and lead III.

ECG 2

Here again, we see S1Q3T3. There is also STE in aVR and widespread STD. You may recall that we have mentioned this pattern before, and it can be seen with critical ACS, however, it is also seen in other conditions whereby the heart is put under stress such as sepsis, profound GI bleeding, and PE!

ECG 3

This ECG shows deep TWI (T wave inversion) in both anterior (V1- V4), as well as inferior leads. This is PE until ruled out!

ECG 4

Here we see an incomplete RBBB, we also see SRE in aVR, V1, and lead III. There is also T wave inversions in the precordial and inferior leads. All of these findings point towards PE as the diagnosis.

ECG 5

Here we see S1Q3T3 again, and certainly, the S wave is deep in lead 1. But also note the significant STE in aVR V1, V2 and lead III.

ECG 6

This ECG is essentially a normal sinus tachycardia with no other specific findings to suggest PE and this is often what we see.

Welcome to the Final Week of ECG Reviews!

This week, we present six ECG examples from patients who all shared the same final diagnosis. Each patient presented with some form of chest pain and shortness of breath.

While historical and clinical clues may provide valuable context, we’re keeping those details undisclosed for now. Your challenge is to analyze the ECGs carefully and determine common patterns or findings that might hint at the underlying diagnosis.

Key Areas to Focus On:

• T waves: Are there signs of ischemia, hyperacute changes, or repolarization abnormalities?
• Territories: Which areas of the myocardium appear affected? Consider anterior, inferior, lateral, or posterior involvement.
• Intervals: Assess for prolonged PR, widened QRS, or QT abnormalities that could provide diagnostic clues.

Your Task:

1. Review the provided ECGs.
2. Identify common patterns across all cases.
3. Consider potential underlying causes based on ECG findings alone.
4. Formulate your working diagnosis before next week’s reveal.

Next week, we will provide detailed explanations and discussion on these cases.

Good luck, and we look forward to your interpretations!

ECG 1

ECG 2

ECG 3

ECG 4

ECG 5

ECG 6

This week we will review and provide “answers “from last week's cases.  The quotations are important. There is no expectation that you would be out in the field definitively determining what each of these ECGs is about. You will always be using clinical judgment based on context, the nature and severity of the patient's condition, and underlying comorbidities. As we always say with ECGs… one begets another! Always consider doing repeat ECGs to look for the evolution of change. This can provide the most important clue.

ECG 1 - Left Ventriuclar Hypertrophy (LVH)

R wave in lead I + S wave in lead III > 25 mm
R wave in aVL > 11 mm
ST segment depression and T wave inversion in the left-sided leads: AKA the left ventricular ‘strain’ pattern

ECG 2 - Hyperacute T waves (HATW)

There is no accepted definition for HATW. They are generally broad-based, and symmetric. The ratio of the area under the T wave compared to the QRS amplitude i.e., PROPORTIONALITY is key. These can be the earliest indication of a STEMI. Look for a straight initial slope instead of a concave, “smiling” contour.
If the T wave is larger than the entire QRS think about HATW.
Remember, never rely on a single ECG.

In example 2, note the size of the T waves across the precordium (the portion of the body over the heart and lower chest), particularly in V3. There is also reciprocal inferior STD. This is very concerning ECG that turned out to be an LAD occlusion

ECG 3 - Hyperacute T waves (HATW)

Here again, we see very large T waves across the precordium. There is a bit of STD before the takeoff of the T wave in V2 and V3, known as deWinter T waves and indicative of LAD occlusion. Once again there is reciprocal STD in the inferior leads.

ECG 4 - Left Bundle Branch Block (LBBB)

Here we have typical LBBB findings…

• QRS duration ≥ 120ms
• Dominant S wave in V1
• Broad monophasic R wave in lateral leads (I, aVL, V5-6)
• Absence of Q waves in lateral leads

       There are no Sgarbossa criteria to suggest ischemia.

ECG 5 - Hyperkalemia

Now those are “peaked” T waves!! No reciprocal changes. Again, context might be definitive in your evaluation.

ECG 6 - Benign Early Repolarization - BER

BER diagnosis criteria are below, but always by exclusion with serial ECGs and looking for reciprocal changes!

• Widespread concave ST elevation, most prominent in the mid-to-left precordial leads (V2-5)
• Notching or slurring at the J point ( lead II)
• Prominent, slightly asymmetrical T waves that are concordant with the QRS complex
• No reciprocal ST depression to suggest Occlusion MI

ECG 7 - Hyperkalemia

This one is classic!! Wide QRS, loss of P waves, HUGE T waves…. but always put in context.

That is all for now…”see” you next week!