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)
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
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%
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
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
Reference:
- TN2014
Leave a Reply