Evaluation amp Management in the Emergency Department By Dr Robin Clouston amp Maureen Hanlon SANE Co ordinator SJRH Dept of Emergency Medicine Grand Rounds February 13 2018 Objectives ID: 935965
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Slide1
the Sexually Assaulted Patient
Evaluation & Management in the Emergency Department
By: Dr. Robin Clouston & Maureen Hanlon, SANE Co-
ordinator
SJRH Dept. of Emergency Medicine Grand Rounds
February 13 2018
Slide2Objectives
Outline management principles for the care of the sexually assaulted adult patient
Review the local processes in place of the care of sexually assaulted individuals
Discuss the multi-disciplinary approach to the care of the sexually assaulted patient and how we can best apply this care locally
2
Slide3Outline
Medical Management of the Sexually Assaulted Patient
Led by Robin Clouston
Saint John SANE ProgramBy Maureen Hanlon, SANE Co-
ordinator
Group discussion
How can we continually improve care for this population?
Slide4Medical Management
of the sexually assaulted patient
4
Slide5Why is this important?
In New Brunswick, SANE nurses provide most acute care for sexual assault victims
Medical care of a sexual assault victim
Within the scope of care for any emergency physicianPhysicians may be called upon by SANE to assist with managementHow would you provide medical care if SANE nurse were unavailable
?
All emergency physicians, nurses and allied health workers can deliver the
sexual assault survivors therapeutic message
1
5
Slide6Sexual Assault Survivors Therapeutic Message
The victim is not at fault. No one ever deserves to be raped. The perpetrator, not the victim, is responsible for the assault.
Millions of others have experienced similar pain. The victim is not alone.
The victim is now a survivor. She (or he) made the right choices to get through the assault alive. She (or he) is to be congratulated for their courage to seek help.
Medical care can help with the transition from victim to survivor. Appropriate medical care will speed recovery, ease pain, and help her (or him) move on with a normal life.
6
Slide7ED Management Principles2
Appropriate triage of sexual assault victim
–
CTAS 2Creation of a safe and secure ED environmentMedical treatment for physical injuriesIdentification of drug facilitated sexual assault
Prevention of STIs & pregnancy
Forensic evidence collection
Consider emotional & psychological impact
Follow up care after ED visit
Continuous quality improvement
7
Slide8History Taking
Use open-ended, non-leading questions
3,4
Document direct quotes from patientWho: known assailant? Number of assailants?
What happened
3
:
Use
of force,
threat
of force, weapons,
coercion, any areas of painPenetration of body part
(vagina, mouth, anus) w
penis, finger
,
object
D
rugs
and/or alcohol to facilitate sexual assault
(ex: amnesia?)
Was the patient bitten? Did the patient bite the perpetrator?When & where: date, time and location of sexual assault Post-assault activities, ex: shower, brush teeth, change clothes
8
Slide9History Taking
Other pertinent history
3
:Use of contraceptives and what type Last menstrual period (LMP)
Last consensual intercourse
Pregnancy status
Past medical history
3
:
Immunization status (
hepatits
B, tetanus)
History of
anogenital
surgery
Medical conditions
Medications, Allergies
9
Slide10Physical Exam and Labs
Complete documentation of vital signs
3
Head to toe exam for injuriesComplete neurological exam including GCSDocumentation of presence of toxidromeSpeculum exam for presence of injuries
Labs:
Urine pregnancy test, +/- urine for
gc
& chlamydia
Swab for vaginal culture / trichomoniasis, swab for GC & Chlamydia
B/W for
Hep
B, C, HIV, Syphilis
Further physical exam, imaging as indicated
10
Slide11Physical Exam and Labs
Additional features of forensic evidence exam may include
1
:Collection of foreign matter (hairs, fibers, soil, vegetation)Hair clippings, fingernail scrapingsSeminal fluid markers
–
quantitative acid phosphatase
Toluidine blue dye
–
before speculum
Additional blood samples for drug testing if suspicion of drug facilitated sexual assault
Colposcopy
Anoscopy
Must ensure chain of custody is maintained
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Slide12Patterns of injury associated with sexual assault
Manage in accordance with ATLS protocols while attempting to preserve forensic evidence collection
3
Depending on study quoted, 28% to 85% of victims have non-genital physical injury3, Of these:
2 to 17% - moderate injury requiring ED management (ex: laceration repair, fracture requiring casting)
1% - serious injury requiring hospitalization
Common physical injuries
3
:
Soft tissue injuries to head, face, neck
–
most common
Concussion
Bites
Strangulation injury
12
Slide13Patterns of
genitorectal
injury
Risk factors for any
genitorectal
injury
6
:
Higher education
Physical resistance
Multiple assailants
Rectal penetration
Shorter post-coital interval
Most common location is posterior fourchette
1,5
Use of toluidine dye increases identification rate of genital injury
1,5
13
Slide14Drug Facilitated Sexual Assault (DFSA)
Definition
2,6
:The act of using drugs or alcohol to incapacitate a victim in order to commit nonconsensual sexual
act
take
advantage of the vulnerability of a person who has voluntarily consumed alcohol
/ drugs
.
Half
of all
cases involve voluntary alcohol / drug ingestion
C
overt
use
of
“date-rape drugs” like
R
ohypnol and GHB is
identi
fed in less than 3 - 5% of cases. Suspect if:Amnesia / Uncertainty about assault Nausea & vomiting
Profound hangover
Loss of muscle control
Drugs Implicated
in DFSA
Ethanol
Marijuana
Ecstasy
Cocaine
Opioid
Benzodiazepines
(ex:
Rohypnol
)
Muscle relaxants
(cyclobenzaprine)
Ketamine
Antihistamines
(diphenhydramine)
Gamma-hydroxybuturate (GHB)
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Slide15Pregnancy Prevention
Risk of pregnancy after sexual assault is approximately 5%
All non-pregnant patients of child bearing potential should be offered emergency contraception (EC)
Typical regimen: Levonorgestrel
1.5mg as a single dose
1,3,4
95% effective within 24h, 87% effective within 72h, offer up to 5d
Health Canada recommends alternative EC for women greater than 165lbs (75kg) or BMI
>
25
11
http
://
healthycanadians.gc.ca
/recall-alert-rappel-
avis
/
hc-sc
/2014/38701a-eng.php
Alternatives: Ulipristal acetate 30mg (Ella)7
Prescription only, non-formulary in SJRH
Effective up to five days, effective for BMI > 30
Insertion of copper IUD
up to 7 days after incident
1,3
15
Slide16STI Prophylaxis
STI
Suggested prophylaxis
8
Gonorrhea
Cefixime
400mg PO single dose
OR
Ceftriaxone 250mg IM single dose if
cefixime
not available
OR
Ciprofloxacin 500mg
po
single dose (if
allergy to
Cefixime
)
Need sensitivity testing / test for cure
Chlamydia
Azithromycin 1g
PO single dose
OR
Doxycycline 100mg PO BID x 7 days
Trichomoniasis
Treat only if positive test for trichomoniasis
Metronidazole 2g PO single dose
Syphilis
Prophylaxis
with Azithromycin no longer effective due to resistance
Consider prophylaxis only if high risk source
16
Slide17Hepatitis B prophylaxis8
Consider for all cases of sexual assault where:
A
cts have included vaginal or anal penetration or oral-anal contact without a condom or condom status unknownAND victim NOT immune to hepatitis B
Prophylaxis per Canadian Immunization Guide:
HBIG up to 14 days after exposure
3-dose
Hep
B vaccine at 0, 1 and 6
mo
following exposure
Note: typical I3 Sexual Assault panel includes:
HBsAg
, HIV Ag/
Ab
screen, syphilis serology
Not included / may add: HCV antibody screen, anti-HBs, anti-
HBc
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Slide18HIV Prophylaxis8,9,10
HIV Post-Exposure Prophylaxis (PEP) recommended when:
Significant exposure has occurred
Oral, anal, and/or vaginal penetration with no condom / unk
. condom
status
AND the assailant is known to be HIV positive
Typically, if assailant’s HIV status is unknown, HIV prophylaxis is NOT recommended
Consider PEP on case-by-case basis if:
a
ssailant is a known injection drug user, multiple assailants, open wound
If starting PEP, consider consult to infectious disease specialist
Discussion of specific risk, pre-treatment counseling, monitor S/E
PEP should be started within 72h of exposure
PEP 5-day starter kits available in RAZ (Combivir® + Kaletra
®
)
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Slide19Male Sexual Assault
3% of men will experience sexual assault in their lifetime
3
Majority of cases less than 19 years of ageAbout 12% report their assault to policeOf those presenting to ED:
Tend to be older (late 20s), more significant injury (52% anal penetration)
Incarcerated victims tend to be younger
Management implications
Forensic swabs include glans penis, shaft, base, anterior scrotum
Inspect
anorectal
region, obtain rectal swabs
Consider
anoscopy
If unable to tolerate exam due to pain, admit for EUA
STI prophylaxis is the same
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Slide20Quality of Care
The care of sexually assaulted individuals is complex
Medical implications
Forensic implicationsPsychological implications for patientsLogistical implications, ex: triage levelPatient comfort –
effect of clothing, showering, eating on evidence
The care of sexual assault victims is multi-disciplinary
SANE Programs were developed to standardize and improve care for sexual assault
victims
1,3,4
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Slide21References
Hogan, TM &
Uyenishi
, AA. Sexual Assault: Medical And Legal Implications of the Emergency Care of Adult Victims. Emergency Medicine Practice. March 2003. Retrieved from: www.ebmedicine.net on Feb 2 2018.
Sexual Assault: Committee Opinion Number 592. American College of Obstetricians and Gynecologists. April 2016, Reaffirmed 2016. https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Sexual-Assault.
Evaluation of the Sexually Assaulted or Sexually Abused Patient, Second Ed. April 2014. From American College of Emergency Physicians. Retrieved from: www.acep.org on Feb 3 2018.
Heron SL &
Houry
DE.
Tintinlli’s
Emergency Medicine 7
th
Ed. 2011. Chapter 291: Female and Male Sexual Assault.
p
p
1980
–
1983.
Sommers
, MS. Defining Patterns of Genital Injury from Sexual Assault: A Review.
Trauma Violence Abuse. 2007 July ; 8(3): 270–280. doi:10.1177/1524838007303194.
DuMont, J et al. Drug Facilitated sexual assault in Ontario, Canada.
Toxicologic
and DNA findings. Journal of Forensic and Legal Medicine 17 (2010) 333e338.
Kim, A & Bridgeman MB.
Ulliprisol
Acetate: A Selective
Progresterone
Modulator for Emergency Contraception. Pharmacy & Therapeutics. 2011 Jun; 36(6): 325-326, 329-331.
Section 6-6: Canadian Guidelines on Sexually Transmitted Infections
–
Specific Populations
–
Sexual Assault in
postpubertal
adolescents and adults. 2013.
Retrieved from https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/canadian-guidelines/sexually-transmitted-infections/canadian-guidelines-sexually-transmitted-infections-43.
html on Feb 4 2018.
2015 Sexually Transmitted Diseases Treatment Guidelines. Sexual Assault and Abuse and STDs. Centers for Disease Control and Prevention. 2016.
Retrieved from https://www.cdc.gov/std/tg2015/sexual-
assault.htm on Feb 4 2018. BC WOMEN’S SEXUAL ASSAULT SERVICE GUIDELINES FOR DISPENSING HIV POST- EXPOSURE PROPHYLAXIS (PEP) AFTER SEXUAL ASSAULT HIV RISK ASSESSMENT GUIDELINES. Feb 23 2015. Retrieved from http://www.cfenet.ubc.ca/therapeutic-guidelines/sexual-assault on Feb 10 2018. Glasier, A et al. Can we identifu women at risk of pregnancy despite using emergency contracepit? Data from randomized trials of ulipristal acetate and levonorgestrel. Contraception 84 (2011) 363–367.
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