26.2 Acute Physical & Sexual Assault Care

Trauma-Informed Care Principles & Initial Stabilization

Sexual assault is a profound physical and psychological violation affecting millions of individuals, with approximately 1 in 5 women and 1 in 14 men experiencing completed or attempted rape in their lifetimes. Patients presenting to primary care clinics, urgent care centers, or emergency departments following acute sexual assault require an integrated, highly compassionate response that simultaneously addresses acute medical stabilization, forensic evidence recovery, infectious disease prophylaxis, pregnancy prevention, and psychological crisis intervention.

The Foundational Tenets of Trauma-Informed Care

Trauma-informed care shifts the clinical paradigm from "What is wrong with you?" to "What happened to you?" In acute assault care, trauma-informed practice is operationalized through specific clinical behaviors:

1. Patient Autonomy and Control: Traumatic assault strips victims of control. Restoring agency is the primary therapeutic goal. The patient has the absolute right to accept, decline, or pause any portion of the interview, physical examination, photography, or evidence collection. Clinicians must explicitly state: "You are completely in charge of this visit. We will only do what you want to do, and you can tell me to stop or pause at any second."
2. Informed Consent at Every Step: Explain the precise clinical rationale and physical sensation of every maneuver before touching the patient (e.g., "Next, I am going to gently examine your outer skin with this soft cotton swab; is that okay?").
3. Patient Comfort & Chaperone / Advocate Presence: Provide a private, quiet room. Offer a specialized Sexual Assault Nurse Examiner (SANE) or a dedicated community-based sexual assault victim advocate. Allow a trusted family member or friend to remain present if desired by the patient.
4. Non-Judgmental, Empathic Communication: Avoid questions that imply victim blame, such as inquiring why the patient was in a certain location, what clothing they wore, or why they delayed seeking medical care. Validate their courage in seeking evaluation.
5. Trauma-Informed Physical Positioning: Avoid leaving the patient in a lithotomy position with feet in stirrups for any longer than strictly necessary for speculum examination. Keep the patient draped comfortably throughout the encounter.

Immediate Medical Triage: Life-Threatening Injuries First

Forensic evidence collection must never supersede emergency stabilization. Clinicians must immediately assess:

• Airway, Breathing, Circulation: Evaluate for signs of hemorrhagic shock, internal hemorrhage, or blunt abdominal trauma.
• Non-Genital Physical Trauma: Screen carefully for signs of strangulation / asphyxiation (petechiae across the conjunctivae, facial swelling, hoarseness, dysphagia, stridor, odynophagia, neck tenderness). Strangulation carries a high risk of delayed carotid artery dissection, stroke, and progressive laryngeal edema, warranting emergent CT angiography of the neck.
• Intoxication & Head Trauma: Assess Glasgow Coma Scale (GCS), screen for closed head injury, intracranial hemorrhage, and drug-facilitated sexual assault (DFSA).

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The Sexual Assault Forensic Examination (SAFE) & Legal Framework

Timing & Forensic Viability Window

The Sexual Assault Forensic Examination (SAFE), colloquially known as a 'rape kit,' is a standardized evidence collection kit designed to recover biological and physical trace evidence for criminal prosecution.

• Temporal Window: Forensic DNA evidence (spermatozoa, seminal fluid, non-sperm male epithelial cells, touch DNA) is reliably recoverable from anogenital cavities for up to 72 to 120 hours (3 to 5 days) following penetration. After 72 hours, sperm viability in the vagina decreases, but modern polymerase chain reaction (PCR) and short tandem repeat (STR) DNA profiling frequently detect non-sperm male DNA up to 120 hours. On external unwashed skin, dried biological fluids can persist up to 7 days.
• Patient Instructions Prior to Exam: Survivors should be gently advised (if calling prior to arrival) to avoid showering, bathing, douching, brushing teeth, changing clothes, urinating, or defecating before the examination. However, the exam should NEVER be refused or omitted simply because the patient has showered or delayed presentation within the 120-hour window.

Step-by-Step Evidence Collection Protocol

1. Chain of Custody: Meticulous documentation of every individual who collects, handles, packages, and transfers the forensic kit. All evidence containers must be labeled with tamper-evident tape, signed, dated, and stored in a locked, temperature-controlled, secure refrigerator until official transfer to law enforcement.
2. Clothing Collection: Have the patient undress while standing over a clean paper sheet to capture any dislodged trace debris (hairs, fibers). Package each piece of clothing individually in breathable paper bags (never plastic bags, as trapped moisture promotes bacterial growth and enzymatically degrades DNA).
3. External Body Examination & Wood's Lamp: Inspect the entire body under natural light and with an ultraviolet (Wood's) lamp or alternate light source (ALS) to detect fluorescent dried seminal fluid, saliva, or urine. Swab suspicious areas using sterile water-moistened cotton swabs.
4. Anogenital Swabs: Systematic swabbing of the perianal skin, rectal canal, vulva, vaginal vault, and ectocervix using designated kit swabs and smear slides.
5. Fingernail Scrapings: Scrape under the patient's fingernails using sterile wooden scrapers to collect defensive touch DNA from the assailant.
6. Toxicology Screening for Drug-Facilitated Sexual Assault (DFSA):
   • Suspect DFSA when the patient experiences unexplained amnesia, sudden unconsciousness, rapid intoxication disproportionate to alcohol intake, or awakening in unfamiliar surroundings.
   • Common Agents: Flunitrazepam (Rohypnol), Gamma-hydroxybutyrate (GHB), Ketamine, Zolpidem, Alprazolam/Clonazepam, and Ethanol.
   • Sample Collection: Collect urine (100 mL) and blood (two grey-top sodium fluoride tubes) as early as possible. GHB is cleared rapidly and becomes undetectable in urine after 12 hours (and blood after 6-8 hours); flunitrazepam metabolites persist in urine for 72 to 96 hours.

Mandatory Reporting Laws: Adults vs. Vulnerable Populations

A critical board examination distinction exists between mandatory reporting obligations across different patient cohorts:

                     MANDATORY REPORTING DECISION MATRIX

                             Patient Demographics
                                       │
         ┌─────────────────────────────┴─────────────────────────────┐
         ▼                                                           ▼
  VULNERABLE POPULATIONS                                      COMPETENT ADULTS
  • Children (<18 years of age)                               (Aged ≥18, cognitively intact)
  • Vulnerable / Dependent Adults                             (No penetrating weapon trauma)
  • Elders (>60-65 years, state-dependent)                           │
         │                                                           ▼
         ▼                                            MANDATORY REPORTING: NO!
  MANDATORY REPORTING: YES!                           • In the vast majority of states, reporting
  • Reporting to Child Protective Services (CPS)        sexual assault of an adult is NOT mandatory
    or Adult Protective Services (APS) is               without patient consent.
    MANDATED BY LAW in all 50 states.                 • Breaching confidentiality without consent
  • Patient / parent consent is NOT required.           violates patient autonomy and trust.
  • Failure to report constitutes a misdemeanor/crime. • Exception: Gunshot wounds / stab wounds.

• Preserving Adult Survivor Agency: For competent adults, clinicians must inform them of their options:
  1. Report to Law Enforcement: Police are contacted, an investigation begins, and the forensic kit is transferred immediately to the forensic crime laboratory.
  2. Anonymous / 'Jane Doe' Evidence Collection: The forensic kit is collected and sealed under an anonymous tracking number without notifying police or documenting patient identifiers on the kit. The evidence is stored securely (often for 2 to 5 years, depending on state statute), allowing the survivor time to process the trauma and decide later whether to participate in criminal prosecution.

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Medical Prophylaxis Protocols: Pregnancy, STIs, Hepatitis B & HIV

Medical prophylaxis must be offered to every survivor of sexual assault regardless of whether they consent to forensic evidence collection. Prophylaxis addresses four critical threats: pregnancy, bacterial sexually transmitted infections, Hepatitis B virus, and Human Immunodeficiency Virus.

1. Emergency Contraception (Pregnancy Prevention)

All female survivors of reproductive potential with female internal genitalia who experienced penile penetration within the past 120 hours must be evaluated for emergency contraception. Verify non-pregnant status first via urine point-of-care beta-hCG.

• Ulipristal Acetate (Ella, 30 mg PO single dose):
  • Mechanism: Selective progesterone receptor modulator that postpones or inhibits follicular rupture (ovulation), even when luteinizing hormone (LH) has already started to surge.
  • Efficacy Window: Highly effective up to 120 hours (5 days) post-assault.
  • Clinical Advantage: Significantly more effective than levonorgestrel across the entire 120-hour window, and maintains superior efficacy in women with elevated body mass index (BMI >25 to 30 kg/m²).
• Levonorgestrel (Plan B One-Step, 1.5 mg PO single dose):
  • Mechanism: Synthetic progestin that prevents ovulation.
  • Efficacy Window: Most effective when taken within 72 hours (3 days); efficacy declines sharply between 72 and 120 hours.
  • Limitation: Significantly reduced efficacy in women with BMI >25 kg/m² and largely ineffective in women with BMI >30 kg/m².
• Copper Intrauterine Device (Copper IUD / Paragard) or 52 mg Levonorgestrel IUD:
  • Timing: Inserted within 120 hours (5 days) of assault.
  • Efficacy: The most effective method of emergency contraception (>99% efficacy), regardless of patient body weight or BMI, while providing ongoing long-term contraception.

2. Empiric Sexually Transmitted Infection (STI) Antimicrobial Prophylaxis

Because testing at the time of assault only identifies pre-existing infections (and cannot detect newly inoculated organisms during the incubation window), the Centers for Disease Control and Prevention (CDC) recommends routine empiric antimicrobial prophylaxis rather than waiting for laboratory culture/NAAT results:

                      CDC POST-ASSAULT STI PROPHYLAXIS REGIMEN

  TARGET ORGANISM            GUIDELINE-DIRECTED REGIMEN
  ─────────────────────────────────────────────────────────────────────────────
  Neisseria gonorrhoeae      Ceftriaxone 500 mg IM in a single dose
                             (Administer 1,000 mg IM if patient weight ≥ 150 kg)
  ─────────────────────────────────────────────────────────────────────────────
  Chlamydia trachomatis      Doxycycline 100 mg PO twice daily for 7 days
                             (Preferred over azithromycin due to higher cure rates;
                             If pregnant: Azithromycin 1 g PO in a single dose)
  ─────────────────────────────────────────────────────────────────────────────
  Trichomonas vaginalis      Metronidazole 500 mg PO twice daily for 7 days
                             (Preferred over single 2 g dose; Alternative:
                             Tinidazole 2 g PO in a single dose)

3. Hepatitis B Virus (HBV) Immunoprophylaxis

• Unvaccinated or Incompletely Vaccinated Victims: Administer the first dose of the Hepatitis B vaccine (1.0 mL IM) at the time of initial evaluation, with arranged follow-up doses at 1 and 6 months.
• Indication for Hepatitis B Immune Globulin (HBIG): If the assailant is known to be Hepatitis B surface antigen (HBsAg) positive, or if the assailant is of unknown status and the victim is unvaccinated, administer HBIG 0.06 mL/kg IM simultaneously with the first dose of the Hepatitis B vaccine (injected at a different anatomical site, e.g., opposite deltoid or anterolateral thigh). HBIG must be administered within 14 days of exposure (ideally within 24 hours).
• Previously Vaccinated Victims with Documented Immunity: No prophylaxis required.

4. HIV Non-Occupational Post-Exposure Prophylaxis (nPEP)

Sexual assault involving genital, anal, or oral mucosal contact carries a quantifiable risk of HIV transmission, which surges in the presence of mucosal lacerations, genital bleeding, multiple assailants, or an assailant known to be living with HIV.

• The Critical 72-Hour Window: nPEP must be initiated as soon as possible, ideally within 2 hours, and no later than 72 hours post-exposure. Clinical and animal studies demonstrate that antiretroviral efficacy drops to zero if initiated beyond 72 hours.
• Duration: A complete, uninterrupted 28-day course of a 3-drug antiretroviral regimen is mandatory.
• Preferred 3-Drug Regimen for Adults and Adolescents with Normal Renal Function (CrCl ≥50 mL/min):
  1. Tenofovir Disoproxil Fumarate (TDF) 300 mg / Emtricitabine (FTC) 200 mg (Truvada) 1 tablet PO once daily; PLUS
  2. Dolutegravir (Tivicay) 50 mg PO once daily; OR
  3. Alternative Third Agent: Bictegravir (co-formulated as Biktarvy [BIC 50 mg / FTC 200 mg / TAF 25 mg] 1 tablet daily) or Raltegravir (Isentress) 400 mg PO twice daily.
• Baseline & Follow-up Laboratory Surveillance:
  • Baseline: Rapid 4th-generation HIV antigen/antibody test (if positive, patient has pre-existing HIV and does not receive nPEP; refer to infectious disease), pregnancy test, baseline serum creatinine, and AST/ALT.
  • Follow-up: Repeat HIV testing at 4 to 6 weeks and 3 months post-exposure.

5. Tetanus Prophylaxis

Administer Tetanus toxoid-containing vaccine (Td or Tdap 0.5 mL IM) if the patient has sustained skin abrasions, bites, or lacerations and has not received a tetanus booster within the preceding 5 years (for contaminated wounds) or 10 years (for clean wounds).