Chief Complaint: Sexual Assault

Written by: Logan Wedel, MD (NUEM PGY-3) Edited by: Jason Chodakowski, MD (NUEM ‘20) Expert Commentary by: Erin Lareau, MD

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ED track board reads: 24 F *****, CC: SA

• Unfortunately, this is not an uncommon complaint we see in the ED

• Stay engaged, and prepare for a prolonged patient stay

Sexual Assault has reached Epidemic Proportions in the United States and Globally

19.3% of women and 1.7% of men are raped at some point in their lifetime
Of female rape victims, 78.2% have their first experience of rape before the age of 25 Recent data suggests estimated cost is $122,461 per rape victim .

In one study it was found that alcohol/substance abuse was involved in over 50% of cases.

Only a small proportion of victims present to the emergency department

When they do the we play a vital role in treating injuries, providing prophylaxis, and collecting evidence that can be used to apprehend the attacker

It is not our role to judge the validity of the patient's accusations, to identify the attacker, nor file a police report. The latter is at the patient's discretion.

The process will be time consuming but these patients deserve our full attention: minimize distractions, sit down, provide deep empathy, and give them the space to tell their full story.

Perhaps most importantly you must provide patients with what was violently take from them: a sense of control and safety.

Step 1: Obtain History

1. Time and Location

   • Exact details if able to remember

2. Identity of the Attacker (if known) Number of individuals

   • Possible identifying information

3. Specific Encounter Details - Use Patient Quotes Penetration (vaginal, anal, oral)

   • Ejaculation?

   • Condom use?

   • Use of other foreign bodies?

   • Licking, kissing, biting?

4. Post Assault Activities

   • Shower, urination, defecation?

   • Did they change their tampon, diaphragm, or clothing? Any oral intake or vomiting?

5. Patient's Medical History

   • HIV and Hepatitis B status and vaccination

   • Recent consensual sexual encounters

Step 2: Physical Exam

1. General Physical Exam

   • Immediate and acute interventions always take precedent

2. Pelvic and GU exam

   • Can be done with Evidence Collection Kit If patient consents

3. Detailed skin and soft tissue exam

   • Again can be conducted with Evidence Collection

Step 3: Medical Management

1. Always tend to trauma first

   • Primary and Secondary surveys

   • Workup traumatic injuries (XR / CT / FAST)

2. Baseline Labs and Blood draws

   • CBC, CMP, LFT's, UA, Urine Pregnancy, HIV

3. Offer Medical Advice and Inform patient of Risks, and Potential Prophylaxis Options

   1. High Risk (By Prevalence) --> Empiric Treatment

      • Chlamydia: 528.8 per 100,000 -> Azithromycin 1g PO

      • Gonorrhea:171.9 per100,000 -> Ceftriaxone 250mg IM

      • Trichomonas: 3.1% -> Metronidazole 2g PO

      • Bacterial V.: 29.2% -> Metronidazole 2g PO

   2. Lower Risk--> PEP options

      • HIV: 0.1% vaginal / 2.0% Anal ->

        • Emtricitabine/Tenofovir 200/300mg PO: 1 tab QD

        • Raltegravir 400mg PO: 1 tab BID

      • Hep B: <1% ->

        • Hep B vaccine Series: Now, 1-2m, 4-6m

      • Hepatitis C : < 1% -> No known prophylaxis

      • Syphilis: 9.5 cases per 100,000 ->

        • RPR test at 6wks, 3m, 6m

        • PenicillinG2.4millionUIM

   3. Pregnancy Risks

      • Dependent on Ovulatory Cycle:

      • 3 days before ovulation: 15%

      • 1-2 days before ovulation: 30%

      • Day of ovulation: 12%

      • 1-2 Days after Ovulation: 0%

   4. Emergency Contraception

      • Only if Urine Pregnancy Test Negative

      • Levonorgestrel 1.5mg PO

Step 4: Evidence Collection Kit --Best if within 72 hours

1. Obtain patient consent

   • Verbal Consent to Contact "Rape Victim Advocate"

   • Signed Consent for Sexual Assault Evidence Kit

   • Police must be Contacted//However patient does not have to talk with authorities

     • Patient can also decide to refuse evidence collection at any time

2. AppropriateAttire

   • Gloves,Gown,HairRestraint

3. Collect Articles of Clothing

   • Patient undresses on a sheet, which is supplied in the kit

     • Anything worn at the time of assault

     • Underwear: worn at the time, or up to 72hrs after

   • Individual Articles of Clothing in Separate Areas

     • Place Individually in collection bags, sealed with evidence tape

4. Medical/ForensicDocumentation

   • ObtainedDuringOriginalPatientHistory

   • Key Aspects as Documented Above

5. DetailedPhysicalExam

   • Head to Toe Inspection and Palpation

     • Documentation of ANY Injuries--size, location, color, pattern

     • If Significant, Notify Police to Have Evidence Tech Obtain Photographs

   • Genital/AnalExam

     • Normal Speculum Examination, with Detailed Documentation

     • Note Discharge, Bleeding, Stains, Semen, Foreign Material, Trauma

     • Detailed Description of all Anatomy in Male/Female GU Area

     • Swab Genital / Anal area if Contact Occurred (Lubricate with Sterile Water)

   • Note: Do Not Collect G/C or BV Swabs, Unless Patient is 10 Days out or Having Symptoms

     • Offer Empiric Treatment

Collection Specimens

1. Oral Specimens (4 Total)

   • Swabs: Tongue, Gum Line, Recessed Areas

2. Head Hair Combings

   • From Different Areas of Head

   • Place Comb with the Hair into Paper Sheet

3. Fingernail Specimens

   • Wood Stick to Scrap under Nails

4. Miscellaneous Bite Marks / Stains

   • Swab Area, Label Accordingly

5. Patient Blood on Filter Paper

   • Obtains Drops of Blood for Filter Paper

6. Pubic Hair Combings

   • Comb out Hair onto Supplied Paper

   • Cut Hair if Matted

7. Genital / Anal Swab (4 total)

   • Swab External Genital/Anal Area--Sterile Water to Lubricate

Follow Up Appointments and Safety Assessment

1. Prior to ED Discharge

   • Write for 28 day supply for HIV PEP: Medications as above

2. Primary Care Physician

   • Arrange for close follow up with PMD, ideally within 1 week

   • Send referral if patient is without a primary care physician

3. OB-GYN

   • In order to monitor potential GU trauma

   • HPV / STD surveillance

4. Infectious Disease

   • Within 5 days in HIV PEP is started--Due to potential toxicity

   • Close monitoring of liver function

   • Repeat testing as below

5. On-Going Screening / Laboratory Work --Per ID / Primary Care

   • HIV: at 6 weeks, 3 months, 6 months

   • Hepatitis B: 2nd Vaccination at 3 months / 3rd at 6 months

   • Hepatitis C: at 3-6 months

   • Syphilis: at 6 weeks and 3 months

6. Safety Assessment

   • If at risk for being assaulted again, strongly encourage patient's file a police report although this remains the patient's choice

   • If potentially unsafe going home provide resources for shelters

   • If social work isn't involved yet get them involved

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Expert Commentary 

This is a great summary of current epidemiology and ED clinical practices surrounding the care of sexual assault patients.  To reiterate and expand upon your synthesis: 

•   Sexual assault is an extremely common traumatic injury that is underreported to physicians.

•   Sexual assault victims may have multiple traumatic injuries, acute psychiatric needs, and complex social needs.  A multidisciplinary approach to their care is often helpful, and necessary to reduce further psychological stress associated with the emergency department exam experience after an assault.

•   Recently, the US Department of Justice has published guidelines for training forensic examiners of sexual assault patients, including sexual assault nurse examiners (SANEs) and sexual assault forensic examiner (SAFE). These professionals are specially trained to provide care for sexual assault patients, and to perform the evidence collection.  They are often also trained in forensic photography.  SANEs typically manage the entirety of the patient encounter.  This includes coordination of prophylactic medications and proper follow up.  Illinois currently has a program to train all RNs on the sexual assault exam, and requires a SANE nurse to be available in the ED.

•   There are additionally trained SANE/SAFE providers who also specialize in adolescent/pediatric sexual assault forensics.  These providers should be called upon when available for all children suffering from sexual assault, as there is a higher risk for additional trauma surrounding the exam in these populations.

•   Our job as physicians should therefore focus on:

• Identifying and treating additional medical or traumatic injuries

• Counseling patients on prophylactic medication - as indicated by the exposures which you noted above

• Reviewing expectations and follow up

• Collaborating with our SANE colleagues, volunteer rape victim advocates, pharmacists, police departments, and social workers.

• And as always, we should provide compassion and symptom relief to these patients undergoing an overwhelming traumatic event. 

References:

http://www.illinoisattorneygeneral.gov/victims/sane.html.  Accessed 2/12/2020

https://www.justice.gov/ovw/page/file/1090006/download. Accessed 2/12/2020

Erin Lareau, MD

Assistant Professor of Emergency Medicine

Northwestern Medicine

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How To Cite This Post

[Peer-Reviewed, Web Publication] Wedel L, Chodakowski J. (2020, June 29). Chief complaint: sexual assault [NUEM Blog. Expert Commentary by Lareau E]. Retrieved from http://www.nuemblog.com/blog/chief-complaint-sexual-assault

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Resources

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