Bruising in Domestic Violence

Bruising is a common injury that we see in the criminal cases that we review. Domestic Violence, Child Abuse, Assault, Elder Abuse and DUI’s commonly will have bruising of  the complaining witness and we are often asked to determine if the bruising is related to  the event in question. 

We recently reviewed a case in which a woman stated her husband had assaulted her. She presented to the Emergency Department where the physician documented over 25 bruises on her body. The case review was complicated by many factors but the ones that jumped out at the nurse after reviewing her case were her polypharmacy use and her diagnosis of SLE. 

Polypharmacy is the use of multiple prescription and over the counter medications; often many are treating the same condition with unnecessary overlap. In this case, the patient was on a total of 21 medications. The danger of polypharmacy lies primarily in the side effects of the medications and the interactions of the medications, which are commonly additive in nature. For a few of the medications the patient was on, there are several side effects that may lend to falling or accidental injury, leading to bruises..  

Additive Effects of Medications: 

In addition to the potential adverse reactions associated with each drug, when taken together, certain drugs will have an additive effect that will intensify adverse reactions. From the list of the patient’s medications, the Epocrates Online Multicheck, which identifies drug interactions, identified 42 drug combinations that could result in increased risk of adverse effects because of the additive effect of the drugs. Many of the drug combinations will increase risk of central nervous system depression and/or psychomotor impairment (Epocrates Online, 2012). Symptoms of central nervous system depression include feeling sleepy and uncoordinated, staggering, blurred vision, impaired perception of time and space, slowed reflexes and breathing. Psychomotor impairment results in a slowing down of thought and a reduction in physical movement (Medicinenet, 2008). It is very likely that the patient’s prescribed medications could make her prone to falls and other accidents because of the adverse effects associated with these medications and the additive effects when taken together. 

Platelet Dysfunction and Bruising: 

Patients who bruise easily but have normal blood platelet levels and coagulation studies may have a disorder of platelet function that causes the easy bruising. Platelet dysfunction can be caused by certain common drugs (Baz, 2012). Two of the patient’s prescribed medications, Cymbalta and Voltaren gel, can cause abnormal bleeding and altered platelet function. Further, the combination of these drugs has a synergistic effect which may cause augmented platelet dysfunction (Epocrates Online, 2012). It is our opinion that the combination of Cymbalta and Voltaren gel could cause the patient to experience easier than normal bruising because of platelet dysfunction.

Systemic Lupus Erythematosus (SLE) is an autoimmune disease. This means that the body’s immune system mistakenly attacks healthy tissue which leads to chronic inflammation. Symptoms of SLE vary from person to person, and may come and go. Almost everyone with SLE has joint pain and swelling. Some develop arthritis. Frequently affected joints are the fingers, hands, wrists and knees. Parts of the body frequently affected by SLE include the skin, kidneys, heart and vascular system, nervous system, connective tissues, musculoskeletal system and other organ systems (A.D.A.M. Medical Encyclopedia, 2011). 

Two complications of SLE may cause the appearance of “bruises” on the skin:  Thrombocytopenia and Vasculitis.  

Thrombocytopenia 

Some SLE patients experience low blood platelet counts (thrombocytopenia). Platelets are necessary for blood clotting and low platelet counts can lead to bleeding and bruising in the skin (emedicinehealth, 2012). Blood tests can determine if a person has  low platelet counts and is therefore prone to bruising.  

Vasculitis 

SLE can also cause vasculitis which is an inflammation of the blood vessels involving an autoimmune reaction in the blood vessel walls. If small vessels are affected, they may break and produce areas of bleeding into the subcutaneous tissues which will  appear on the skin as red or purple dots (petechiae) or larger spots (purpura). The larger spots may look like large bruises (Lupus Foundation of America, 2012). The appearance of vasculitis can look different from one case to the next (Cure4Lupus.org,  2012), however, the following photograph is an example of SLE vasculitis:

(Archiv Ketedre za Dermatovenerologijo, 2012)

Oftentimes in domestic violence as well as other assault-related cases, the victim has the appearance of being badly injured due to the sheer volume of bruises. Sometimes alternate causes of these bruises are apparent, but often it takes a little digging through the records to get the true story. The nurses at Godoy Medical Forensics help you get to the bottom of things.

This newsletter was written using excerpts from a case report written by Eileen Choate,  JD MS RN 

Works Cited 

A.D.A.M. Medical Encyclopedia. (2011, February 14). Systemic Lupus Erythematosus. Retrieved March 6, 2012, from PubMed Health:  

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001471/?report=printable 

Archiv Ketedre za Dermatovenerologijo. (2012). Lupus Erythematodes systemicus. Vasculitis. Retrieved  March 6, 2012, from ibmi.mf.uni-lj.si: http://ibmi.mf.uni-lj.si/mmd/derma/eng/sz 00/sldr000162.html 

Baz, R. (2012). Disorders of Platelet Function and Number. Retrieved March 4, 2012, from Cleveland Clinic: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hematology oncology-disorders-platelet-function 

Cure4Lupus.org. (2012). Cutaneous Vasculitis Pictures. Retrieved March 6, 2012, from Cure4Lupus.org: http://cure4lupus.org/store/index/php?main_page=page&id=190&chapter=1 

emedicinehealth. (2012). Lupus (Systemic Lupus Erythematosus). Retrieved March 5, 2012, from emedicinehealth:  

http://www.emedicinehealth.com/script/main/art.asp?articlekey=59247&pf=3&page=1 Epocrates Online. (2012). Epocrates Online. Retrieved March 5, 2012, from https://online.epocrates.com 

Forcon. (2008). Pharmacology of Drugs. Retrieved March 6, 2012, from Forcon:  http://forcon.ca/print/php?page=learning/pharmacology.html 

Lupus Foundation of America. (2012). Vasculitis. Retrieved March 4, 2012, from Lupus Foundation of  America:  

http://www.lupus.org/webmodules/webarticlesnet/templates/new_aboutintroduction.aspx?a= 105&z=9&page=1 

Medicinenet. (2008). What is CNS Depression? Retrieved March 6, 2012, from Medicinenet:  http://www.medicinenet.com/script/main/art.asp?articlekey=87726