15. Sexual Abuse (Sexual Assault emergency med) Flashcards
1
Q
Describe epidemiology: Sexual Assault (1)
A
1 in 5 women and 1 in 71 men will be sexually assaulted in their lifetime; only 7% are reported
2
Q
Describe general approach: Sexual Assault (7)
A
- ABCs, treat acute, serious injuries; physician priority is to treat medical issues and provide clearance
- ensure patient is not left alone and provide ongoing emotional support
- obtain consent for medical exam and treatment, collection of evidence, disclosure to police (notify police as soon as consent obtained)
- Sexual Assault Kit (document injuries, collect evidence) if <72 h since assault
- label samples immediately and pass directly to police
- offer community crisis resources (e.g. shelter, hotline)
- do not report unless victim requests or if <16 yr old (legally required)
3
Q
Describe history: Sexual Assault (5)
A
- ensure privacy for the patient – 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.)
- gynecologic history
- gravidity, parity, last menstrual period
- contraception use
- last voluntary intercourse (sperm motile 6-12 h in vagina, 5 d in cervix)
- medical history: acute injury/illness, chronic diseases, psychiatric history, medications, allergies, etc
4
Q
Describe physical exam: Sexual Assault (4)
A
- never re-traumatize a patient with the examination
- general examination
- mental status
- sexual maturity
- patient should remove clothes and place in paper bag
- document abrasions, bruises, lacerations, torn frenulum/broken teeth (indicates oral penetration)
- pelvic exam and 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 culture for gonorrhea and 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
- fingernail scrapings and saliva sample from victim
5
Q
Describe investigations: Sexual Assault (3)
A
- Venereal Disease Research Lab (VDRL): repeat in 3 mo if negative
- serum β-hCG
- blood for ABO group, Rh type, baseline serology (e.g. hepatitis, HIV)
6
Q
Describe management: Sexual Assault (3)
A
- involve local/regional sexual assault team (sexual assault forensic examiner or sexual assault nurse examiner)
- medical
- suture lacerations, tetanus prophylaxis
- gynecology consult for foreign body, complex lacerations
- assume positive for gonorrhea and chlamydia
- management: azithromycin 1 g PO x 1 dose (alt: doxycycline 100 mg PO bid x 10 d) and ceftriaxone 250 mg IM x 1 dose
- may start prophylaxis for hepatitis B and HIV
- pre and post counselling for HIV testing
- pregnancy prophylaxis offered
- levonorgestrel 1.5 g PO STAT (Plan B®)
- psychological
- high incidence of psychological sequelae
- have victim change and shower after exam completed
7
Q
Describe disposition: Sexual Assault (3)
A
- discharge if injuries/social situation permit
- follow-up with physician in rape crisis centre within 24 h for repeat pregnancy and STI testing.
- best if patient does not leave emergency department alone
8
Q
Describe: Domestic violence (4)
A
- women are usually the victims, but male victimization also occurs
- identify the problem (need high index of suspicion)
- suggestive injuries (bruises, sprains, abrasions, occasionally fractures, burns, or other injuries; often inconsistent with history provided)
- somatic symptoms (chronic and vague complaints)
- psychosocial symptoms
- clinician impression (your ‘gut feeling’, e.g. overbearing partner that won’t leave patient’s side)
- if disclosed, be supportive and assess danger
- patient must consent to follow-up investigation/reporting (unless for children)
9
Q
Describe management: Domestic violence (3)
A
- treat injuries and document findings
- ask about sexual assault and children at home (encourage notification of police)
- safety plan with good follow-up with family physician/social worker