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Evaluation and Management of the
Sexually Assaulted or Sexually Abused Patient
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Mental status and behavioral changes
— Main cause: brain cells deprived of oxygen
— Brief interruption
▪ Findings (symptoms and signs) are temporary and resolve
— Longer interruption
▪ Findings are permanent and do not resolve (may improve partially, but not completely)
▪ Anoxic brain damage
Other neurologic symptoms and signs
— Vision changes
— Tinnitus
— Facial or eyelid palsies
— Hemiplegia
— Incontinence (bladder or bowel)
— Miscarriage
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Clinical Symptoms Caveats
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Symptoms are subjective (described by patient)
Documentation is essential
— Symptoms may resolve or change
— Recording patient experience provides a degree of objectivity
— Objectivity is strengthened by multiple/consistent descriptions
Some symptoms may be non-specific or have multiple causes (but must be thoroughly explored and recorded)
— Light-headedness and dizziness
— Difficulty breathing
Impairment of memory and/or consciousness
— May compromise accuracy and credibility of the history
— Must be explored in detail and carefully documented
No visible findings
— Very common (up to 50%)
— Pain (subjective discomfort)
— Tenderness (discomfort with palpation)
— Other symptoms are often present
Caution! Lack of visible findings (or minimal injuries) does not exclude a potentially life
threatening condition
Clinical Findings
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Visible findings: Petechiae
— Compression impedes venous blood flow (venous return)
— Venous pressure increases
— Small blood vessels near skin or mucous membrane surfaces rupture
— Multiple tiny red spots appear (1–2 mm)
▪ Non-palpable (or “flat”—can’t feel them on exam)
▪ Non-tender (no discomfort when touched)
▪ Do not blanch (temporarily change color when touched)
Caution! “petechiae” may be used inappropriately to describe direct blunt trauma findings
Visible findings: Sub-conjunctival Hematoma
— Compression impedes venous blood flow
— Venous pressure increases
— Small blood vessels on the surface of the eye (sclera, or white part) rupture
— Appearance is very disturbing to patient and family
— Not dangerous; no treatment required; resolves within 2 weeks
— Does not impair vision
Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient | ACEP
Visible findings: Neck Injuries
— Redness (hyperemia or erythema)
▪ Fades quickly
— Bruising (contusion or ecchymosis)
▪ Often not visible initially
— Scratches and abrasions
▪ Common
▪ May be self-defense injuries
— Ligature marks
▪ Abrasions
▪ Bruises (contusion or ecchymosis)
▪ Redness (erythema)—fades quickly
Suggestion: Use the Forensic Approach during evaluation
— Look for “patterning” of findings
▪ appearance gives information about cause or mechanism of injury
— Understand the “mechanism of injury”
▪ Compare and correlate the history of what happened to the physical findings
▪ Assess consistency
— Use follow-up examination(s) + forensic imaging
▪ Document emerging or evolving injuries
▪ Compare and clarify non-specific findings
◊ Redness (erythema)
◊ Swelling (edema)
Management and Documentation
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Clinical management: MEDICAL EVALUATION REQUIRED
— Stabilization
— Diagnostic evaluation (exam, imaging, consultation)
— Treatment and/or observation
Forensic management
— Consider neck swabs (assailant saliva, epithelial cells for touch DNA)
— Follow-up evaluation (exam, imaging studies)
Documentation
— Forensic exam form (e.g. DV exam form or Sexual Assault exam form)
— Medical (ED report, consultation report, imaging)
A separate “Strangulation Form” is useful for complete documentation and should include:
— Narrative of event
— History of injury causing events (mechanisms of injury)
— Patient symptoms (initial and current)
— Physical exam findings
▪ Check list
▪ Body diagrams
— Diagnostic evaluation
— Clinical assessment
— Management
— Follow-up plan
Strangulation
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