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Evaluation and Management of the
Sexually Assaulted or Sexually Abused Patient
HIV
1.
CDC. Antiretroviral postexposure prophylaxis after sexual, injection drug use or other non-occupationalnon-occupational exposure to HIV in the
United States. MMWR. 2005; 54.
2. CDC. Sexually transmitted diseases treatment guidelines, 2010. MMWR. 2010; 59.
3. Chacko L, Ford N, Sbaiti M, Siddiqui R. Adherence to HIV post-exposure prophylaxis in victims of sexual assault: a systematic review and metaanalysis. Sex Transm Infect. 2012; 88(5):335–341.
4. Du Mont J, Myhr TL, Husson H, Macdonald S, Rachlis A, Loutfy MR. HIV postexposure prophylaxis use among Ontario female adolescent sexual
assault victims: a prospective analysis. Sex Transm Dis 2008; 35:973–978.
5. Havens P and Committee on Pediatric AIDS. Postexposure Prophylaxis in Children and Adolescents for non-occupational Exposure to Human
immunodeficiency Virus. Pediatrics 2003; 111,1475–1489.
6. Landovitz R, Currier J. Clinical practice. Postexposure prophylaxis for HIV infection. N Engl J Med. 2009 Oct 29; 361(18):1768–1775.
7. Linden J. Clinical Practice. Care of the Adult Patient after Sexual Assault. N Engl J Med 2011; 365:834–841.
8. Loutfy MR, Macdonald S, Myhr T, Husson H, Du Mont J, Balla S, Antoniou T, Rachlis A. Prospective cohort study of HIV post-exposure prophylaxis
for sexual assault survivors. Antivir Ther 2008;13:87–95.
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prospective observational study in an urban medical center. Sex Transm Dis 2007; 34:65–68.
11. Varghese B, Maher JE, Peterman TA, Branson BM, Steketee RW. Reducing the risk of sexual HIV transmission: quantifying the per-act risk for HIV
on the basis of choice of partner, sex act, and condom use. Sex Transm Dis 2002; 29:38–43.
12. Wang SA, Panlilio AL, Doi PA, White AD, Stek M Jr, Saah A; HIV PEP Registry Group. Experience of health care workers taking postexposure
prophylaxis after occupational HIV exposures: findings of the HIV Postexposure Prophylaxis Registry. Infect Control Hosp Epidemiol 2000;
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Emergency Contraception
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Fine P, Mathé H, Ginde S, Cullins V, Morfesis J, Gainer E. Ulipristal Acetate Taken 48–120 Hours After Intercourse for Emergency Contraception.
Obstet Gynecol 2010, 115(2), 257–263
Glasier AF, Cameron ST, Fine PM, Logan SJ, Casale W, Van Horn J, Sogor L, Blithe DL, Scherrer B, Mathe H, Jaspart A, Ulmann A, Gainer E. Ulipristal
acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet. 2010; 375(9714):
555–562.
Holmes MM, Resnick HS, Kilpatrick DG, Best CL. Rape-related pregnancy: estimates and descriptive characteristics from a national sample of
women. Am J Obstet Gynecol. 1996; 175(2): 320–325.
Linden J. Clinical Practice. Care of the Adult Patient after Sexual Assault. N Engl J Med 2011; 365: 834–841.
Piaggio G, Kapp N, von Hertzen H. Effect on pregnancy rates of the delay in the administration of levonorgestrel for emergency contraception:
a combined analysis of four WHO trials. Contraception. 2011; 84(1):35–39.
Richardson AR, Maltz FN. Ulipristal acetate: review of the efficacy and safety of a newly approved agent for emergency contraception Clin Ther.
2012; 34(1): 24–36.
Rodrigues I, Grou F, Joly J. Effectiveness of emergency contraceptive pills between 72 and 120 hours after unprotected sexual intercourse. Am J
Obstet Gynecol. 2001;184:531–537.
von Hertzen H, Piaggio G, Ding J, Chen J, Song S, Bártfai G, Ng E, Gemzell-Danielsson K, Oyunbileg A, Wu S, Cheng W, Lüdicke F, Pretnar-Darovec
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Chapter 15
Bite Mark Guidelines
Ralph Riviello, MD, MS, FACEP
Bite marks can provide important forensic clues in criminal cases. Bite marks are often seen in rape and sexual assault
cases, assaults, homicides, and abuse crimes (child, elder, and IPV). For the emergency medicine provider, the most
important aspects of bite marks are to recognize their presence and to properly collect potential DNA specimens from
them. A forensic odontologist through the use of impressions, casts and overlays of the bite mark can potentially
identify and confirm the rapist. Those techniques are beyond the scope of this handbook.
A bite mark will typically present as a semi-circular injury, which compromises two separate arcs (one from the
upper teeth and one from the lower teeth) with either a central area absent of injury or with a diffuse bruise. It is not
uncommon to see only one arch of teeth, usually from the lower teeth. The amount of bruising present depends on the
amount of suction force applied during the bite. Several factors influence the severity of a bite-mark injury:
• The force by which the original injury was inflicted;
• The anatomical location bitten;
• The time elapsed between infliction and presentation.
Scrape marks from the teeth may be seen. Factors such as clothing and any movement or struggle while biting, can
affect the appearance and depth of a bite wound.
Bite marks can be both attack injuries (present on the victim) and defensive wounds (present on the attacker). A
study of 148 bite marks showed that females were four times more likely to be bitten than males, and over 50% of the
males in the study were the suspects. Females were more likely to be bitten on the breast, arm and legs; and children
on their genitals, legs, and back. Males were most commonly bitten on the hand, back, or face. Overall location rates
were, breast (28%), arm (18%), genitalia (8%), back (7%), and thigh (6%). (Pretty 2000)
Researchers have developed a bite mark severity scale to describe the forensic significance of the injury and whether
or not it can be compared with the suspect. However, for the emergency clinician, any bite mark has the potential to
yield forensically important evidence (DNA).
The Bite Mark and Severity Scale
Increasing wound
severity
1.
Very mild bruising, no individual tooth marks present, diffuse arches visible
may be caused by something other than teeth—low forensic significance.
2. Obvious bruising with individual, discrete areas associated with teeth. Skin
remains intact—moderate forensic significance.
3. Very obvious bruising with small lacerations associated with teeth on the
most severe aspects of the injury. Likely to be assessed and definite bite
mark—high significance.
4. Numerous areas of laceration, with some bruising, some areas of the
wound may be incised. Unlikely to be confused with any other injury
mechanism—high significance.
High Forensic
Significance
5. Partial avulsion of tissue, some lacerations present indicating teeth as the
probable cause of the injury—moderate forensic significance.
6. Complete avulsion of tissue, possibly some scalloping of the injury margins
suggesting that teeth may have been responsible for the injury. May not be
an obvious bite injury—low forensic significance.
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Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient | ACEP
Bite Mark Guidelines
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