the Sexually Assaulted Patient - PowerPoint Presentation

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

Objectives

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

Outline

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?

Medical Management

of the sexually assaulted patient

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Why 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

Sexual 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.

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ED 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

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History 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

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History 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

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Physical 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

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Physical 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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Patterns 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

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Patterns 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

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Drug 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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Pregnancy 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

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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

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STI 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

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Hepatitis 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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HIV 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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Male 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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Quality 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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References

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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