Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/RSA

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Rape/Sexual Assault - Key Features

1. Provide comprehensive care to all patients who have been sexually assaulted, regardless of their decision to proceed with evidence collection or not.

General Management Principles:
Assessment and follow up of sexual assault victims should be carried out with great sensitivity and in conjunction with local teams or services experienced in the management of victims of sexual assault.

ABCs
Ensure pt not left alone, ongoing emotional support
Sexual assault kit (when available)
Obtain consent: physical exam, treatment, collection of evidence
Do not report to police unless victim requests or consents to this- if patient unsure whether she/he wants to report to police at time of presentation, offer to collect forensic evidence for storage/future use.
Legally required to report child abuse of any kind (in BC age <19yrs)
Offer community crisis resources (see below)
Documentation of Hx, Px and specimen collection is key

Non-disclosure and pre-contemplative pts:
Respect their decision, inform pt of options/resources, encourage pt to return for medical follow up, express your availability as a resource, ensure confidentiality, re-address at future visits.

2. Apply the same principles of managing sexual assault in the acute setting to other ambulatory settings (i.e. medical assessment, pregnancy prevention, STI screening/treatment/prophylaxis, counseling).

History:
-Date/time/place, perpetrator info (known/unknown/HIV+/IVDU)? How many assailants? When? Where did penetration occur/condom use? What happened? Any weapons or phys assault? -Post-assault activities (urination, defecation, change of clothes, shower, etc)
-PMHx: OB/Gyn hx: GTPAL, LMP, contraception, last voluntary intercourse (sperm mobile 6-12 h in vagina, 5 d in cervix), Meds, Immunizations
-Available support systems to pt

Physical Exam:
-Injuries requiring immediate attention take precedence over rest of exam
-Pt should be asked to disrobe completely, & if forensic specimens to be collected, disrobe while standing to collect all evidence (all clothing should also be collected)
-Examine for bruises, lacerations, vaginal/anal trauma, petechial hemorrhages on palate if Hx forced oral penetration
-All injuries should be accurately documented on body-map diagrams
-Most forensic kits do not include tests for STIs or blood-borne pathogens, should offer baseline testing in addition to forensic kit (including speculum exam with pt consent, urine test/blind vaginal sampling alternative option)
* NB: colposcopy and photography rarely useful, may produce unnecessary distress

Investigations:
Syphilis: RPR/VDRL, TP-PA (confirmatory test)- rpt at 3 and 6 months if neg
Serum B-hCG
ABO, Rh type, baseline serology for HIV/HBV/HCV, rpt HIV 6wks/3mos/6mos
Cervical swabs GC/Chlamydia, vag swab for Trichomonas

Management:

1. Medical: suture lacerations, tetanus prophylaxis, Gyne consult (foreign body, complex lacerations)


2. STIs:
-Offer Tx prophlyaxis for GC/Chlamydia: Azithromycin 1 g PO x 1 dose (or Doxycycline 100 mg po BID x 7 d) and Cefixime 400 mg PO x 1 dose
-Prophylaxis for HIV – call local HIV/ID specialists for advice re: risk assessment and need for PEP. If unknown assailant then no HIV PEP needed because low risk. PEP generally recommended when assailant known HIV+, otherwise case-by-case basis (known IVDU, mult. assailants, significant injury, etc.)
-Hep B prophylaxis: if pt not immune- HBIG 1 dose IM (400 IU) as soon as possible after exposure (up to 14d after exposure) AND Hep B vaccine at 0, 1, 6 mo


3. Pregnancy prophylaxis:
-Plan B (Levonorgestrel only) 1.5mg po x 1 dose or 0.75mg BID x 2 doses (if 1 dose not likely to be tolerated) within 72 h of intercourse
-Gravol can be given 30min prior to second dose for anti-emetic, if vomiting within 1hr first dose, give anti-emetics and rpt initial dose
-contraindicated if pregnancy established


4. Other Issues: If pt consents, appropriate referral as available/necessary (e.g. sexual assault teams, local police/RCMP, psychological support (high incidence of PTSD/anxiety), local victim support organizations, etc.).
-Become familiar with provincial requirements/procedures re: child abuse (age requirements, etc), advise local agencies/ministries as required


3. Limit documentation in sexual assault patients to observations and other necessary medical information (i.e., avoid recording hearsay information).

Record only objective info regarding pt’s own injuries and pt’s mental status, use pt’s own words, note when an explanation is inconsistent with injury assessment, document injuries as accurately as possible on body-map diagrams, describe stages of healing, reassess injuries at 24-48 h as indicated.

4. In addition to other post-exposure prophylactic measures taken, assess the need for human immunodeficiency virus and hepatitis B prophylaxis in patients who have been sexually assaulted.

See management section above

5. Offer counseling to all patients affected by sexual assault, whether they are victims, family members, friends, or partners; do not discount the impact of sexual assault on all of these people.

See resources below

6. Revisit the need for counseling in patients affected by sexual assault.

Be aware that not all pts will be interested in counseling initially after assault, follow up necessary with ongoing support and offer for referral to support resources.

7. Enquire about undisclosed sexual assault when seeing patients who have symptoms such as depression, anxiety, and somatization.

As a FP, recognize that depression, anxiety, PTSD and somatization disorders are common sequelae of assault.

Study Guide

Rape/Sexual Assault

Resources

Canadian guidelines on sexually transmitted infections: Sexual assault in post-pubertal adolescents and adults. Canadian Medical Association online Infobase: CMA Clinical Practice Guidelines Database http://www.cma.ca/index.php
BC Sexual Assault Services Protocols and Procedures www.bcwomens.ca/Services/HealthServices/Sexual+Assault+Services/Resources/sexualassaultprotocolsandproceduresmanual.htm