Sexual assault

1. THE 2-MINUTE PHYSIOLOGY (Rapid Pathophysiology)

While sexual assault is primarily a traumatic and psychologic emergency rather than a purely cellular one, the pathophysiology relies on the mechanisms of mechanical injury, infectious inoculation, and toxicologic impairment. Mechanical forces generate defensive trauma (bruising, abrasions) and potential mucosal micro-lacerations that facilitate the direct transmission of pathogens (e.g., HIV, Neisseria gonorrhoeae, Chlamydia trachomatis) across disrupted barriers. Strangulation, a highly lethal mechanism frequently associated with assault, causes direct vascular occlusion leading to cerebral hypoxia, potential ischemic brain injury, and structural neck damage. Additionally, drug-facilitated sexual assault involves the involuntary ingestion of toxicologic agents (e.g., sedatives, alcohol) resulting in profound central nervous system depression and anterograde amnesia.

2. THE BEDSIDE ACTION PLAN (Rapid ER Management)

• Immediate Stabilization & Triage: Place the patient in a private area or examination room immediately upon arrival. Assess the ABCs, prioritizing airway and breathing if there is a history of strangulation or severe trauma.
• Resource Mobilization: Activate your institution's Sexual Assault Response Team (SART) or Sexual Assault Nurse Examiner (SANE) immediately to assist with the specialized forensic and medical evaluation.
• Prophylaxis and Pharmacotherapy:
• Pregnancy: Offer pregnancy prophylaxis to all adolescent and adult female patients.
• HIV: Administer HIV post-exposure prophylaxis (PEP) if the assailant is known to be HIV-positive, if multiple assailants were involved, or if the assailant's HIV status is unknown.
• STI: Administer empiric treatment for common sexually transmitted infections. Be aware that recent alcohol ingestion affects ED treatment options (e.g., contraindicating the use of metronidazole).

3. THE DIAGNOSTIC GRID (Differential Diagnosis & Workup)

• "Can't-Miss" Associated Conditions:
• Occult Strangulation Injury: Highly lethal and frequently underreported; look for voice changes, dysphagia, or petechiae.
• Drug-Facilitated Assault (Toxicology): Altered mental status secondary to involuntary or voluntary drug/alcohol ingestion.
• Prioritized Diagnostic Workup:
• Forensic Evidence Collection: Obtain a medical evidentiary kit guided by SART, encompassing swabs, hair transfers, and clothing.
• Laboratory Panel: Obtain a baseline urine $\beta$-hCG test. Perform comprehensive toxicology testing if the patient provides consent and recent ingestion is suspected.
• STI/HIV Testing: Perform baseline testing, with mandatory arrangements for repeat HIV testing at 6 weeks.

4. THE VISUAL BOARD (ECG / POCUS / Imaging)

• The Physical Inspection: Properly remove and store clothing to preserve evidence. Perform a meticulous head-to-toe inspection looking for defensive injuries, which are predominantly located on the limbs (32%) and face (23%). Carefully evaluate the oral cavity, breasts, thighs, buttocks, and neck (for signs of strangulation).
• Strangulation Imaging Criteria: If the patient reports an attempted strangulation associated with loss of consciousness, bowel/bladder incontinence, persistent voice changes, difficulty swallowing, or shortness of breath, you must obtain advanced imaging. This includes a chest X-ray, CTA or MRI of the neck, and consideration of flexible laryngoscopy.

5. THE SCORING MATRIX (Risk Stratification & Guidelines)

• Clinical Disposition Criteria:
• Safe for Discharge: Most sexual assault patients are discharged from the ED. Provide the patient with the collected forensic kit number, and ensure strict follow-up with a local rape crisis center, primary care provider, and mental health services.
• Mandatory Admission/Observation: You must strongly consider prolonged observation or hospital admission for patients with attempted strangulation exhibiting persistent symptoms (loss of consciousness, incontinence, shortness of breath, or voice changes). Additionally, consider admitting patients if safe house resources or respite care are unavailable.

6. THE DANGER ZONE (Pitfalls & Critical Actions)

• Cognitive Trap (The Overzealous Historian): Asking overly detailed questions about the events leading up to the assault. Correction: The ED history must be victim-centered and limited only to elements necessary for medical treatment and evidence collection (e.g., timing, types of penetration, use of weapons/condoms). Overly detailed questioning retraumatizes the patient and creates discrepancies with the official police report, which can weaken the victim's case in court.
• Cognitive Trap (Pediatric Empiric Treatment): Administering empiric gonorrhea or chlamydia treatment to pre-pubertal children presenting with suspicious discharge. Correction: Empiric treatment should not be given to pre-pubertal children until a sexually transmitted illness is definitively confirmed by laboratory testing.
• Cognitive Trap (Forced Pediatric Exams): Forcing a genital examination on a reluctant child. Correction: It is unlikely to identify transient evidence of sexual contact, and the exam should not be forced if the child is uncooperative.
• Critical Action (Mandatory Reporting): Emergency clinicians are legally mandated to report to Child Protective Services (CPS) whenever there is a reasonable concern for sexual abuse in a pediatric patient.

7. MCQ MASTERCLASS (Written Exam Tips)

• Buzzwords: "Defensive injuries on limbs/face," "Victim-centered history," "Strangulation with voice changes = CTA Neck".
• Classic Distractor (Pediatric Subacute Presentation): A 12-month-old girl presents with malodorous vaginal discharge 2 weeks after visiting a relative. A distractor option will suggest "Administer empiric Ceftriaxone and HIV PEP." Explanation: HIV PEP is unlikely to be effective 2 weeks after the assault, and empiric STI treatment is contraindicated in pre-pubertal children without definitive laboratory confirmation. The correct answer focuses on reporting to CPS and ensuring a safe disposition.
• Classic Distractor (Courtroom Testimony): A question will ask about appropriate behavior when called to testify in court regarding an assault evaluation you performed. A distractor will suggest "Refer to the patient as the victim to emphasize the severity of the crime." Explanation: You should never refer to the patient as the "victim" during court testimony. You should answer verbally (do not nod), state "I cannot recall" if you cannot remember details, and ask for clarification if a question is not understood.

8. THE BOARDROOM SCRIPT (OSCE & Oral Board Tips)

• The Initial Approach: "I am immediately placing the patient in a private examination room to ensure safety and confidentiality. I am mobilizing our Sexual Assault Response Team (SART) to assist with the evaluation and forensic evidence collection."
• The Focused History: "To prevent retraumatization and avoid creating legal discrepancies, I am keeping my history strictly focused on medical necessity. I will only ask when the assault occurred, what type of penetration took place, and whether any foreign objects, condoms, drugs, or alcohol were involved."
• The Physical Exam & Workup: "I will carefully remove and store the patient's clothing to preserve evidence. I am performing a head-to-toe examination specifically looking for defensive bruising on the extremities and face. Because the patient reports being choked and has a hoarse voice, I am ordering a stat CTA of the neck to evaluate for occult strangulation injuries, and I will admit the patient for prolonged observation."