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Department of Pediatrics : Academic Divisions : Emergency Medicine : Resident Manual : Victims of Physical or Sexual Abuse : ED Guidelines for Management of the Sexually Abused Child

  1. History
    1. A complete disclosure history by the examining physician not always necessary or recommended. Much of the vital information can often be gained from other personnel (police, social workers) who have already interviewed the child, without subjecting the child to repeated unnecessary interviews.
    2. A general understanding of what occurred is needed to guide the medical evaluation. Specific medical history and questions regarding the event may need to be elicited in order to determine the type of examination needed.
    3. In addition to medical record documentation, it is also necessary to fill out all the history forms that come with the "rape kit" (Sexual Assault/Abuse Evidence Collection Kit) if you are performing a forensic evaluation for law enforcement.
    4. Explain to the patient what will happen, give ample time for questions, and proceed at the patient's (not your own) pace.
    5. Document who is the source of information.
       
  2. Physical Exam
    1. Purpose
      1. Medical evaluation for diagnosis and treatment of traumatic injuries, sexually transmitted diseases, or pregnancy.
      2. Forensic evaluation
        1. Documentation of physical findings
        2. Collection of evidence for law enforcement and the forensic lab
          1. Body fluids of suspected perpetrator (semen, saliva)
          2. Trace evidence (hairs, fibers)
          3. Reference specimens from the victim (saliva, blood type)
        3. Must meet legal requirements for the collection, storage, and transfer of evidence collected.
      3. Reassurance for the victim that their body is not damaged (or that it will heal quickly)
    2. Indications
      1. Full forensic examination (rape kit)
        1. History of acute assault in previous 72 hours.
        2. When nature and timing of the assault indicates that physical evidence may still be present.
          1. Direct contact with perpetrator's genitalia or oral secretions.
        3. If forensic exam is indicated, it should be done immediately. Timing is based upon likelihood of recovering evidence of assault, esp.- sperm and biochemical evidence.
      2. Modified Medical Evaluation
        1. In cases where the last episode is greater than 24-72 hours, the medical evaluation can be delayed unless patient is symptomatic for acute injury or infection (pain, bleeding, discharge).
    3. General techniques
      1. Be organized, setup beforehand, and have a plan.
      2. Never force or rush the examination.
      3. Build rapport early.
      4. Assure the patient that you will explain what you are going to do let them know before you do something new.
    4. Suggested Order
      Note: Forensic Evidence Kit components in bold type
      1. Collect shoes and clothing from time of assault if available. If child has changed clothes, collect underwear only.
        1. Undress over 2 pieces of paper (or a sheet with paper on top).
        2. The top sheet is saved to look for hairs, fibers, or other materials that might identify the assailant or the location of the crime.
        3. Allow to air dry any wet spots or stains on the clothing.
        4. Package each article of clothing separately in paper (not plastic) bags and label appropriately per rape kit instructions.
        Note: All material for forensic evidence must be properly packaged, and labeled per instructions on the kit. Be careful not to include your own biologic markers in the kit (i.e.- wear gloves, and seal envelopes with saline soaked gauze or tape)
      2. General physical exam of head, heart, lungs, abdomen and skin looking for signs of physical abuse and extragenital trauma, ecchymoses, lacerations, or abrasions
      3. Collect Oral Swabs per instructions and air dry prior to packaging (swab both sides of buccal mucosa between teeth and gums and under the tongue).
        1. Smear on slide by rolling the cotton tip, allow both swabs and slide to thoroughly air dry.
        Note: All forensic samples for analysis for semen or seminal fluid markers (i.e.- acid phosphatase), must be thoroughly air dried for 1 hour. This prevents degradation of the DNA and blochemical markers, which can occur within hours in a warm, moist environment. We have a swab dryer in the dirty utility room for this purpose. Using dry swabs will hasten the drying process, but may be unacceptably uncomfortable.
      4. Swab oropharynx for GC and plate on Thayer-Martin agar (chocolate agar supplemented with antibiotics to inhibit most normal flora).
      5. Complete evaluation of skin under direct light and wood's lamp.
        1. Document all physical findings with drawings or photographs, noting size, configuration, locations, and color.
        2. If using photography, include a label in the photo with the patient's initials, MR#, and date.
        3. Collect secretions that fluoresce blue-green to orange under the wood's lamp for analysis for sperm and seminal markers. Swab bite marks or areas of reported oral contact.
          1. If the secretions are dry, collect with moistened swab, and if wet, use a dry swab.
          2. Smear on slide, air dry, and package.
        4. Collect any miscellaneous debris (i.e.- grass, loose hair, fibers) found during gross examination and package per instructions.
      6. Collect fingernail scrapings and package per instructions.
      7. Collect head and pubic hair samples (plucked, not cut)
      8. Collect pubic hair combings looking for foreign pubic hair.
        1. Place paper or envelope under buttocks of patient, comb hair and debris onto the paper, and package paper and comb.
      9. Genital exam
        1. Position
          1. Most infants and toddlers are best done in the frog leg position (feet together).
          2. Stirrups preferred in girls greater than 8 years for better visualization and access.
          3. Knee-Chest position may offer better visualization of hymen
        2. Visually inspect perineum for evidence of trauma (abrasions, tears, blood).
          1. Make a point of sequentially evaluating each structure (labia majora, clitoris, labia minor urethra, fossa navicularis, posterior fourchette, and lastly, the hymen and vaginal orifice)
          2. Examine using both labial separation and then labial traction techniques.
          3. In patients with annular or cresentic hymen (generally girls aged 3 or 4 until onset of puberty) measure horizontal diameter
        3. Colposcope / digital camera photos
          1. Take photographs of hymen, including the labia majora, fossa navicularis, and posterior fourchette prior to manipulation of tissues with swabs or speculum exam.

          Note: I usually also proceed with photographing the anal region at this time.
        4. Wood's lamp of perineum
          1. Swab areas that fluoresce and smear slides for forensic analysis.
          2. Methylene Blue may aid in visualizing abrasions
        5. Collect vaginal swabs and smear slides for forensic analysis.
          Note: Speculum examination is not indicated in prepubertal children, and should never be forced in any pediatric patient. If a speculum exam is possible, semen is best collected from the cervical os and fluid collected in the posterior fornix. If not, take swabs from the vaginal vault or the perihymenal area.
        6. Collect vaginal or cervical cultures for GC and chlamydia.
          1. Always send cultures (not "gyn probes") in sexual abuse cases. Rapid enzymatic assay tests for chlamydia have a higher false positive rate, making results inadmissible in court.
        7. If assault is < 4-6 hours, may elect to perform wet mount of vaginal secretions looking for motile sperm.
      10. Anal exam
        1. Inspect using lateral separation of the buttocks looking for acute lacerations, abrasions, bruises, or scars.
        2. Document anal opening size within the first 20 seconds with a tape measure.
        3. Collect rectal swabs for forensic analysis and smear slides.
        4. Rectal swabs for GC and chlamydia culture.
      11. Other laboratory analysis,
        1. Blood sample to go with the forensic evidence kit (purple top for DNA analysis). This blood must be drawn in your presence. Have the nurse sign, date, and time the specimen. Document that you witnessed the blood draw and it was handed directly to you.
        2. If drug or ethanol use is suspected, send serum ethanol and urine drug screen to hospital laboratory.
        3. Syphilis serology, hep B, and HIV testing as indicated
        4. Urine or serum pregnancy test
           
  3. Documentation
    1. Document all findings and fill out all documentation in the Forensic Kit in legible, laymen terms.
    2. Carefully consider and write impression including a brief historical and physical exam statement including degree of medical certainty.

      Example: The patient is a 16 year old who relates a history of forced penile-vaginal intercourse within 6 hours of evaluation. General physical exam reveals multiple abrasions and bruises of the arms, legs and buttocks of recent acquisition. Genital exam reveals a tear and mucosal hematoma of the hymen indicative of forced vaginal penetration. Overall, the physical findings are highly consistent with the history the patient is giving.
    3. Print and sign your name.
       
  4. Treatment
    1. As indicated for physical trauma.
    2. If victim of childbearing age, initial pregnancy test is negative, and assault within previous 72 hours, offer pregnancy prophylaxis
      1. 2 Ovral PO now and 2 in 12 hours.
        OR
      2. Plan B
      3. Give prescription for compazine suppositories to treat nausea and vomiting induced by the above treatment regimen.
    3. Consider treatment for GC and chlamydia.
      1. Ceftriaxone 125 mg IM X 1 & Azithromycin 1 gm PO X 1
    4. Give information for rape counseling.
       
  5. Follow-up
    1. Give detailed after-care instructions including support services for counseling
    2. 2 weeks to follow up pregnancy test, and GC/chlamydia cultures.
    3. 4-6 weeks to follow up syphilis serology.
    4. 6 months - 1 year for HIV testing.
       

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