Sara Laskey
SEXUAL ASSAULT
Victims do not always sustain injury.
The perpetrator is often known to the victim.
Intimate partner violence and abuse (IPVA) is a pattern of behavior and can include sexual, psychological abuse, intimidation, stalking, threats, and deprivation.
Occurs in every race, religion, ethnicity, culture, and sexual orientation.
CLINICAL FEATURES
Elements of a sexual assault history are listed in Table 190-1.
Risk factors for IPVA include females between 20 and 24 years of age, low income status, and being separated from partner.
Look for injuries inconsistent with history, injuries in various stages of healing, and delay in reporting of injury.
Complaints of chronic pain syndromes, gynecologic pain, and psychiatric and substance abuse issues may be initial presentations.
Patients may appear frightened if the partner is present during history. Partner may exhibit hostile behaviors.
Patients should be asked about any suicidal or homicidal ideation and get appropriate, immediate evaluation.
TABLE 190-1 Assault History
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Who? |
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Did the assault survivor know the assailant? |
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Was it a single assailant or multiple assailants? |
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What were the assailant’s identity and race? (Document in the medical records.) |
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What happened? |
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Was the patient physically assaulted? |
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With what (eg, gun, bat, or fist) and where? |
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Was there actual or attempted vaginal, anal, or oral penetration? |
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Did ejaculation occur? If so, where? |
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Was a foreign object used? |
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Was a condom used? |
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When? |
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When did the assault occur? |
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(Emergency contraception is most effective when started within 72 h of the assault.) |
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Where? |
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Where did the assault occur? |
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(Corroborating evidence may be found based on the location of the assault.) |
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Suspicion of drug-facilitated rape? |
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Was there a period of amnesia? |
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Is there a history of being out drinking and then suddenly feeling very intoxicated? |
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Is there a history of waking up naked or with genital soreness? |
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Douche, shower, or change of clothing? |
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Did the patient douche, shower, or change clothing after the assault? (Performing any of these activities prior to seeking medical attention may decrease the probability of sperm or acid phosphatase recovery, as well as recovery of other bits of trace evidence.) |
PHYSICAL EXAMINATION
Perform a complete general medical examination.
Look for defensive injury areas—extremities and hidden injuries—oral cavity, breast, thighs, and buttocks.
Record all signs of trauma using a body map.
Note signs of trauma, discharge and/or abrasions found on speculum examination.
Anal examination is required if anal penetration is reported.
Characteristic injuries include fingernail scratches, bite marks, cigarette burns, rope burns, forearm bruising, and nightstick fractures (Table 190-2).
Pregnant patients are at higher risk for abdominal injuries.
Evidence collection is performed only within the first 72 hours after sexual assault.
Informed consent is required for evidence collection.
Most hospitals have a prepackaged rape kit and chain of custody must be maintained.
If >72 hours have elapsed or the patient declines a rape kit, perform a history and physical examination, document injuries, and provide prophylaxis for pregnancy and sexually transmitted infections.
TABLE 190-2 Signs Suggestive of Intimate Partner Violence
DIAGNOSIS AND DIFFERENTIAL
Sexual assault is a legal determination, not a medical diagnosis.
The legal definition requires carnal knowledge, non-consent and compulsion, or fear of harm.
Many experts recommend routine screening for IPVA for all adolescent and adult women who present to the ED. This should be conducted in a safe and private environment.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
SEXUAL ASSAULT
Obtain pregnancy test.
Offer emergency contraception: levonorgesterol only 1.5 milligrams PO in a single dose or two doses 0.75 milligram PO 12 hours apart, or combined estrogen-progestin, two doses of ethinyl estradiol, 100 micrograms PO, plus lovenorgestrel, 0.5 milligram PO, 12 hours apart.
STI TREATMENT/PROPHYLAXIS
Gonorrhea: ceftriaxone, 250 milligrams IM, or ceftixine, 400 milligrams PO—single dose.
Chlamydia: azithromycin, 1 gram PO, ordoxycy-cline, 100 milligrams PO twice a day for 7 days (do not use during pregnancy).
Trichomoniasis and bacterial vaginosis: metronidazole, 2 grams PO, in single dose (do not use during first trimester of pregnancy).
Syphilis: penicillin G benzathine 2.4 million IU IM. Use erythromycin 500 milligrams PO four times each day for 15 days if penicillin allergy (no prophylaxis).
Hepatitis: Administer vaccines at the time of examination if not previously vaccinated. Schedule follow-up doses at 1 to 2 months and 4 to 6 months after initial dose.
HIV: Circumstances should guide prophylaxis. Rates of seroconversion are low. Routine prophylaxis is not recommended. See CDC Web site (www.cdc.gov) for recommendations.
INTIMATE PARTNER VIOLENCE AND ABU SE
Assess for lethal situations, increased frequency or severity of violence, and threat or use of weapons.
Hospital admission is an option if a safe location cannot be established before discharge.
National hotlines are available (Table 190-3).
TABLE 190-3 Hotlines for Patients
For further reading in Tintinalli’s Emergency Medicine: A comprehensive Study Guide, 7th ed., see Chapter 291, “Female and Male Sexual Assault,” by Sheryl L. Heron and Debra E. Houry, and Chapter 292, “Intimate Partner Violence and Abuse,” by Mary Hancock.