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Evaluation and Management of the
Sexually Assaulted or Sexually Abused Patient
History
As with any patient presenting to the emergency department, initial history and evaluation are intended to rapidly
identify and stabilize any life-threatening or emergent conditions. Following this, the history is similar to that of
female victims and should include any identifying information:
• the date and time of the assault and the exam;
• the use of physical force, weapons, or foreign bodies;
• any drug or alcohol use;
• the specifics of the rape, including anal and oral penetration, sucking, licking, and fondling;
• the last bath, shower, or other hygienic practices after the assault;
• last urination, defection, and clothing change;
• and the victim’s last instance of voluntary sexual intercourse and areas of penetration.7
The date and time of the assault are very important, as they may influence evidence collection.1 The examiner should
be familiar with the requirements of his or her jurisdiction.
The examiner should also obtain and document in meticulous detail the victim’s narrative of the assault and note
the victim’s allergies, tetanus and hepatitis B statuses, and other recent injuries or procedures that may alter the
appearance of genitalia.1 It is also important to ask the victim about any injuries inflicted upon the assailant which
may influence evidence collection (e.g., fingernail scrapings after scratching the assailant). Additionally, as stated
above, many assailants are known to the victim; in such a scenario, information regarding assailant’s health status
such as the assailant’s hepatitis B status, HIV status, and risk factors for HIV may be obtained and documented in
order to support medical decisions and treatment plan.
Physical Examination and Injury Detection
As discussed above, begin with attention to the ABCs of the potential trauma victim before proceeding with evidence
collection and injury documentation. Attention should also be given the emotional state of the victim, and the exam
should be preceded by a complete explanation of the procedures and examinations to follow. As with any patient,
informed consent should be obtained for the forensic rape examination.
The patient should be completely disrobed and placed in a hospital gown in order to fully assess for injuries. The
patient’s clothing should be collected as evidence and placed in an appropriate container, which is typically a
paper bag. The examiner should remember to have only the patient handle his or her clothing in order to minimize
contamination.7 A complete inspection of the fully disrobed patient should then follow with consideration given to the
details of the assault. Search for and meticulously document foreign bodies, fingernail scrapings, dried semen stains,
abrasions, lacerations, contusions, incisions, suction injuries, and bites. Consider the use of photography if permitted
or required by the jurisdiction in which the crime will be prosecuted. Swabs of bite and suction marks and semen
stains are obtained as per usual protocol, and consider obtaining oropharyngeal and anorectal swabs for gonorrhea
and chlamydia if indicated.
Signs of trauma in the oropharyngeal examination may include laceration of the labial or lingual frenulum, mucosal
abrasions, and contusions. Additionally, posterior pharyngeal wall and soft palate petechiae may develop days after
the assault, and it should be noted that spermatozoa have been found in the oropharynx as many as 12 hours after the
assault despite brushing or oral intake.1
The history of the patient will advise the areas that should be closely inspected. This MAY include genitals, inner
thighs, and perineum, but would include any areas where the patient reported being grabbed/contacted or other body
parts where the assailant may have ejaculated. If dried semen is present on the patient’s pubic hair, a clipping of the
patient’s hair may be obtained. Penile swabs should also be obtained the glans, shaft, corona, and base of the penis,
as they may contain dried secretions or saliva.1 Additionally, swabs should be taken of the anterior scrotum around
the base of the penis, as they can be a potentially rich source of DNA evidence in cases of oral copulation of the victim
by the assailant. As an alternative to swabs, a moistened gauze pad can be used to swab the penis and the scrotum.
The examiner should consult with his or her crime lab for procedures on the proper acquisition and handling of such
evidence.
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Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient | ACEP
Next, the anorectal region must be inspected for gross injury, including tears, abrasions, bleeding, erythema,
hematoma, discoloration, fissures, foreign bodies, engorgement, and friability. Swabs should be obtained by
inserting them approximately 2 cm into the rectum and gently moving in a circular motion. Some authors suggest
that anoscopy and colposcopy are not routine but should be strongly considered in cases in which there is attempted
or successful anal penetration or in which the patient had a lapse of consciousness.1 It has been found, however,
that anoscopy and colposcopy identify additional findings in both patients with and without findings on gross
examination,8 with anoscopy identifying additional findings in one third of patients whose gross examinations were
positive and findings in about 10% of patients whose gross examinations were normal.8 Alternate Light Source
examination examination may be of limited value, as it has been found positive in only one-third of patients.8 As such,
consider the patient’s narrative of events and gross findings when considering the utility of anoscopy and colposcopy.
Significant pain and inability to tolerate the exam may warrant admission for surgical consultation and exam under
anesthesia. There are also the extreme cases in which significant injuries are present, including large and expanding
rectal hematomas and perforation, which will necessitate emergent surgical consultation and admission.
Disposition
Disposition is based upon the standard of care for the injuries that are identified during the examination. Per the
2010 CDC guidelines9 of the treatment of sexually transmitted diseases, trichimoniasis, gonorrhea, and chlamydia are
relatively common and should be treated empirically. The recommended regimens are as follows:
•
•
•
Gonorrhea: ceftriaxone 250 mg IM once;
Trichomonas: metronidazole 2 gm PO once; and
Chlamydia: azithromycin 1 gm PO once or doxycycline 100 mg PO BID for one week.
Hepatitis B immunity should be assessed; and, in those who did not receive immunization against the hepatitis B
virus or in those who are incompletely immunized, the HBV vaccine should be administered within 24 hours and
again at 1- and 6-months post-exposure. Hepatitis B immunoglobulin should be administered within 72 hours in
the nonimmune patient after a high risk exposure to a known HBV-positive assailant or when local data on infection
dictate.
In considering non-occupational postexposure prohylaxis (nPEP) for HIV, it is important to regard the characteristics
of the assault that may increase the risk. It is known that risk is increased with multiple assailants and decreased
by about 80% with condom use [10]. Additionally, in the scenario of intimate violence, the abusive partner is more
likely to have multiple other sexual contacts, thereby increasing risk.10 Risk is also thought to be increased in forcible
penetration secondary to increased trauma to underlying tissues.1 The risk of HIV transmission also varies with the
acts performed and is estimated to be highest in unprotected anal intercourse at 0.1–3%, followed by contaminated
IV needle use at 0.67%, then occupational needle-stick at 0.4%, and unprotected vaginal intercourse at 0.1–0.2%.5
Transmission during oral sex involving intact mucosa is rare but thought to be possible.
One must also consider that it is estimated the cost of one month of prophylactic antiretrovirals costs $600–$1200,
compared to $223,000 to treat AIDS.10 Thus the consideration to initiate nPEP should involve careful review
of the details of the assault itself, physical exam findings that may suggest increased risk of transmission, local
epidemiological data on HIV infection, and the time elapsed since the assault. The patient must also be made aware of
the unproven benefit, known toxicities, and the need for compliance and close follow-up.
Often institutions have a standardized medication protocol for nPEP. If this is not the case, consultation with an
infectious diseases specialist, the CDC website, or the National HIV/AIDS Clinicians’ Consultation Center (1-888448-4911 or http://www.nccc.ucsf.edu) is warranted.
If nPEP is initiated, it should be started with 72 hours of the exposure, and the patient should be re-evaluated in 3–7
days and again at 6 weeks, 3 months, and 6 months with an infectious diseases specialist to undergo repeat testing for
HIV. Close follow-up is also necessary if the HBV vaccine series is initiated.
Male Patient Sexual Assault Examination
53