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)

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
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Posted in 78 Rape / Sexual Assault, 99 Priority Topics, FM 99 priority topics, Gyne

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