Sexual Abuse Clinical Pathway — Emergency Department

Trauma Consult

Adolescents have the highest rates of rape and other sexual assaults of any age group
Physical trauma from sexual assault includes general body injury as well as genital injury
Complete history and PE are necessary to identify, document and treat injury
Consult Trauma as indicated
Older adolescents and those where there is concern for intimate partner violence (IPV) are at higher risk for extragenital and genital injury compared to younger teens/children and older women

Physical Injury After Sexual Assault: Findings of a Large Case Series

Review of 800 women > 15 yrs of age:

General body injury: 52%, associated with kick, hit, strangulation, penetration and stranger assault
Genital-anal trauma: 20%, more frequent in victims, 20 yrs
No injury: 41%

Reference: Physical Injury After Sexual Assault: Findings of a Large Case Series

Comparative Analysis of Adult vs. Adolescent Sexual Assault: Epidemiology and Patterns of Anogenital Injury

Adolescent sexual assault was less likely to be involved with weapons or physical coercions and was associated with fewer non-genital injuries (33% vs. 55%) but had greater frequency of anogenital injuries (83% vs. 64%).

Reference: Comparative Analysis of Adult versus Adolescent Sexual Assault: Epidemiology and Patterns of
Anogenital Injury

Consider Injuries associated with Sexual Assault

Blunt trauma to head, torso, extremities may occur
Penetrating genital injury may be associated with intra-abdominal trauma
Coercion with weapons may occur, there may be associated substance use
Trauma Resuscitation Pathway

History Reported	Symptoms, Signs	Evaluation
Manual or Ligature Strangulation	Strangulation Fact Sheet Airway Dysphagia, dysphonia, dyspnea, stridor, SOB Neuro Amnesia, LOC, urination, fecal incontinence Headache, visual changes, nausea Seizure-like activity, stroke-like symptoms Physical exam findings Ligature mark Neck soft tissue injury, bruising, swelling, neck tenderness Petechial hemorrhage, oral, facial, neck, chest Dysphonia, stridor, respiratory distress Chest wall or neck crepitus Abnormal MS, focal neurologic findings (stroke)	Consider CTA Neck and CT C-Spine based on presence symptoms, signs KOPH ED Obtain imaging as indicated Transfer as needed for Trauma Consult
Forceful Oral, Urethral, Vaginal, or Rectal Penetration	Vaginal, rectal bleeding, pain Abdominal pain, incontinence- urine or stool Physical exam findings Abdominal tenderness Perineal trauma with significant hematoma, bleeding Poor or absent rectal tone, incontinence Concern for foreign body Injury requiring further evaluation to determine repair Lacerations beyond posterior fourchette, vaginal wall Internal or external rectal sphincter	Consider need for exam under anesthesia Abdominal, pelvic imaging
Human Bite Mark(s) in Pre-pubertal Children	Pain Bruising, bleeding	Typical bite mark pattern Inter-canine distance 3.0 to 4.5 cm c/w adult bite Laceration Pathway

History Reported

Symptoms, Signs

Evaluation

Manual or Ligature Strangulation

Strangulation Fact Sheet
Airway
- Dysphagia, dysphonia, dyspnea, stridor, SOB
Neuro
- Amnesia, LOC, urination, fecal incontinence
- Headache, visual changes, nausea
- Seizure-like activity, stroke-like symptoms
Physical exam findings
- Ligature mark
- Neck soft tissue injury, bruising, swelling, neck tenderness
- Petechial hemorrhage, oral, facial, neck, chest
- Dysphonia, stridor, respiratory distress
- Chest wall or neck crepitus
- Abnormal MS, focal neurologic findings (stroke)

Consider CTA Neck and CT C-Spine based on presence symptoms, signs

KOPH ED
- Obtain imaging as indicated
- Transfer as needed for Trauma Consult

Forceful Oral, Urethral, Vaginal, or Rectal Penetration

Vaginal, rectal bleeding, pain
Abdominal pain, incontinence- urine or stool

Physical exam findings
- Abdominal tenderness
- Perineal trauma with significant hematoma, bleeding
- Poor or absent rectal tone, incontinence
- Concern for foreign body
- Injury requiring further evaluation to determine repair
  - Lacerations beyond posterior fourchette, vaginal wall
  - Internal or external rectal sphincter

Consider need for exam under anesthesia
Abdominal, pelvic imaging

Human Bite Mark(s) in Pre-pubertal Children

Pain
Bruising, bleeding

Typical bite mark pattern
Inter-canine distance 3.0 to 4.5 cm c/w adult bite
Laceration Pathway

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.