Rape/Sexual Assault – TN2014

General Approach:

• ABCs, treat acute, serious injuries
• Ensure pt is not left alone & provide ongoing emotional support
• Set aside adequate time for exam (~1.5hr)
• Obtain consent for medical exam & Tx, collection of evidence, disclosure to police (notify police as soon as consent obtained)
• Sexual Assault Kit (document injuries, collect evidence) if <72 hr since assualt
• label samples immediately and pass directly to police
• Offer community crisis resources, eg. shelter, hotline
• Don’t report unless victim requests (legally required if <16yo)
• Legally required to report sexual assault if <16yo to Children’s Aid Society (CAS)

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1 Provide comprehensive care to all patients who have been sexually assaulted, regardless of their decision to proceed with evidence collection or not.

2 Apply the same principles of managing sexual assault in the acute setting to other ambulatory settings (i.e. medical assessment, pregnancy prevention, STI screening/treatment/prophylaxis, counselling).

Hx

• Ensure privacy for the pt – others should be asked to leave
• Questions to ask: Who? When? Where did penetration occur? What happened? Any weapons or physical assault?
• Post-assault activities: urination, defecation, change of clothes, shower, douche etc
• Gyne Hx: gravity, parity, LMP, contraception use, last voluntary intercourse (sperm motile 6-12r in vagina, 5d in cervix)
• Medical Hx: acute injury / illness, chronic dz, psychiatric hx, medications, allergies etc

PE

• Evidence collection is always secondary to Tx of serious injuries
• Never re-traumatize a pt with the examination
• General Exam:
  • mental status
  • sexual maturity
  • pt should remove clothes and place in paper bag
  • Document abrasions, bruises, lacerations, torn frenulum/broken teeth (indicates oral penetration)
• Pelic exam & specimen collection
  • Ideally before urination or defecation
  • examine for seminal stains, hymen, signs of trauma
  • collect moistened swabs of dried seminal stains
  • pubic hair combings and cuttings
• Speculum exam
  • lubricate with water only
  • vaginal lacerations, foreign bodies
  • Pap smear
  • oral/cervical/rectal Cx for gonorrhea & chlamydia
  • posterior fornix secretions if present or aspiration of saline irrigation
  • immediate wet smear for motile sperm
  • air-dried slides for immotile sperm, acid phosphatase, ABO group
• Others: fingernail scrapings, saliva sample from victim

Investigations

• VDRL: repeat in 3 mo if negative
• Serum B-HCG
• Blood for ABO group, Rh type, baseline serology: hepatitis A/B/C, HIV

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3 Limit documentation in sexual assault patients to observations and other necessary medical information (i.e., avoid recording hearsay information).

4 In addition to other post-exposure prophylactic measures taken, assess the need for human immunodeficiency virus and hepatitis B prophylaxis in patients who have been sexually assaulted.

Risk of STD after sexual assault

• Gonorrhea: 6-18%; Chlamydia 4-17%
• syphilis 0.5-3%; HIV < 1%

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5 Offer counselling to all patients affected by sexual assault, whether they are victims, family members, friends, or partners; do not discount the impact of sexual assault on all of these people.

6 Revisit the need for counselling in patients affected by sexual assault.

Management:

• Involve local/regional sexual assault team
• Medical
  • Suture lacerations
  • Tetanus prophylaxis
  • Gyne consult for foreign body, complex lacerations
  • Assume positive for gonorrhea & chlamydia
    • Azithromycin 1g po x 1 (alt: doxycycline 100mg po bid x 7 d) + cefixime 800 mg po x 1
  • May start prophylaxis for hepatitis B & HIV
  • pre and post counselling for HIV testing
  • Offer pregnancy prophylaxis
    • Levonorgestrel 0.75mg po STAT, repeat with 12 hr (Plan B)
• Psychological
  • high incidence of psychological sequelae
  • Have victim change & shower after exam completed

Disposition

• Discharge is injuries / social situation permit
• F/U with MD in rape crisis centre within 24hr
• Best if pt doesn’t leave ED alone

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7 Enquire about undisclosed sexual assault when seeing patients who have symptoms such as depression, anxiety, and somatization.

• Ask about sexual assualt and children at home (encourage notification of police) in domestic violence cases
• Somatic symptoms: chronic & vague complaints
• psychosocial symptoms
• Clinician impression: “gut feeling” – overbearing partner that won’t leave pt’s side

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Reference:

• TN2014