Prehospital Care
If EMS is involved in transporting the patient, their primary focus should be on stabilization of life-threatening injuries and providing emotional support for the victim. Evidence collection and crisis intervention should be handled by the ED team.
Emergency Department Care
The responsibilities of the ED physician are more complex than in routine patients. The examiner must provide psychological support and referral to the appropriate resources, treat physical injuries, collect legal evidence, document pertinent history, perform a thorough head-to-toe physical examination, give prevention of unwanted pregnancy, and provide prevention of and screening for STDs.
Even in areas where SANE team support is readily available, the clinician must be mindful that the ED record also constitutes legal evidence. Treatment and documentation must be accurate and meticulous.
Common organisms of sexual assault STDs include: Chlamydia trachomatis, Neisseria gonorrhoea, Trichomonas spp., Hepatitis B, HIV, HPV, Tetanus
At present, guidelines for postsexual assault prophylaxis are as follows: [13, 14] [15]
-
GC/Chlamydia/Trichomonas
- Ceftriaxone 250 mg IM in a single dose, plus azithromycin 1 g PO in a single dose, plus metronidazole 2 g PO in a single dose or tinidazole 2 g PO in a single dose.
-
HBV
Evaluate the patient's hepatitis B immunization status. If victim is unvaccinated:
And perpretrator is known to be HBV infected: Administer Hep B vaccine series and HBIG preferrably within 24 hours of exposure. Follow up doses of HBV series at 1 and 6 months.
And perpretrator with unknown HBV status: Administer HBV vaccine series
- Hepatitis B vaccine is not indicated if victim has been previously vaccinated and has documented immunity
-
HPV
- Vaccination is recommended for female survivors aged 9–26 years and male survivors aged 9–21 years. For men who have sex with men (MSM) who have not received the HPV vaccine or who have been incompletely vaccinated, vaccine can be administered through age 26 years. [13, 14]
- Administer a 2-dose vaccine (0, 6-12 months) schedule for girls and boys who initiate the vaccination series at ages 9 through 14 years. Three doses remain recommended for persons who initiate the vaccination series at ages 15 through 26 years and for immunocompromised persons (0, 1-2, 6 months). [16]
-
HIV
- HIV postexposure prophylaxis (PEP) are individualized according to risk and must be started as soon as possible, and within 72 hours of exposure for HIV-uninfected persons.
- A 28-day course of PEP is recommended: Tenofovir disoproxil fumarate (TDF) 300 mg PO daily and Emtricitabine 200 mg PO daily plus Raltegravir 400 mg PO twice daily or Dolutegravir 50 mg PO daily. [14]
-
Pregnancy
- Emergency contraception should be offered to female victims if the pregnancy test results are negative and initiated as soon as possible. The most effective options include:
- Ulipristal 30 mg PO once within 120 hours; has highest oral efficacy.
- Copper intrauterine device inserted within 120 hours. This is the most effective form of emergency contraception; however it is not done in the emergency department.
- Levonorgestrel1.5 mg given as a single dose within 72 hours. [17]
- Emergency contraception should be offered to female victims if the pregnancy test results are negative and initiated as soon as possible. The most effective options include:
-
Tetanus
- Update tetanus status when necessary of the initial examination if they have not been previously vaccinated. If more than 5 years since last booster in tetanus-prone wound or more than 10 years in any wound:
- Administer Tdap vaccine 0.5 ml IM
- If less than 3 doses of primary vaccination series or status of victim is unknown and has a tetanus-prone wound
- Adminitster Tdap vaccine 0.5 ml IM and tetanus immune globulin 250 units IM [15]
- Update tetanus status when necessary of the initial examination if they have not been previously vaccinated. If more than 5 years since last booster in tetanus-prone wound or more than 10 years in any wound:
Provide reassurance and emotional support.
Consultations
If available, offer a consultation with a sexual assault counselor in the ED. Further, refer the patient to a sexual assault center for aftercare and community resources. Given the long-term emotional and psychosocial impact of sexual assault on the victim, aftercare is vital. Community-based sexual assault centers are essential to such efforts; they serve not only as headquarters for SANE teams but also as aftercare clinics and resource centers for patients dealing with the aftermath of the assault. If such a center is not available, consultation with social services can provide access to such services that may exist in the region.
Refer to either the sexual assault center or the OB/GYN for follow-up on laboratory tests and to discuss subsequent HIV surveillance and completion of hepatitis B prophylaxis, when necessary. If the assailant is known to be HIV seropositive or is a high-risk contact, HIV prophylaxis should be considered at the time of ED contact if the patient is seen within the appropriate time window to initiate therapy. Immediate discussion with the OB/GYN and/or infectious diseases services is indicated in such cases. Risk of contracting HIV from an infected source via vaginal penetration is 8:10,000 and via anal penetration is 138:10,000. [14]
Guidelines on postexposure prophylaxis of the sexual assault victim are available from the CDC and New York State Department of Health. [14, 18]
