Emergency Room Approach: Sexual Assault of a Nursing Student

1. Immediate Priorities on Arrival

• Activate the SANE (Sexual Assault Nurse Examiner) protocol immediately — if your facility has a SANE program, contact them first.
• Assign a private room; do not place in a general waiting area.
• Confidentiality is paramount — given she is a hospital employee/student, restrict EMR access to treating staff only; flag the chart accordingly.
• Do not ask her to report to law enforcement immediately — patient autonomy is central.
• Offer an advocate (rape crisis/victim advocate) before or alongside clinical care. Early advocacy improves outcomes and helps with safety planning.
• Ensure the same-gender provider preference is asked and honored if possible.

2. Triage & Safety Assessment

• Assess for life-threatening injuries first (hemorrhage, airway, hemodynamic instability).
• Assess for suicidal ideation or acute psychiatric crisis.
• Note the time elapsed since assault — this dictates urgency of forensic evidence collection and post-exposure prophylaxis windows.

3. History Taking

Key history elements (Rosen's Emergency Medicine):

• Last consensual sexual intercourse (≤96 hours prior → needed for DNA comparison)
• Consensual partner identity (for DNA upload to CODIS database)
• Gynecologic history: LMP, current contraception, pregnancy status

• Has the patient urinated, defecated, bathed/showered, douched, changed clothes, brushed teeth, or washed clothing?

• Type of penetration: vaginal, anal, oral — penis, finger, or object
• Ejaculation: did it occur? where?
• Oral copulation
• Non-genital acts: biting, sucking, licking, kissing — locations
• Was a condom or lubricant used?
• Number of assailants
• Any weapons used or threats made
• Was the patient incapacitated (alcohol, drugs, unconscious)?

"Date rape drugs" (Rohypnol, benzodiazepines, ketamine, GHB) must be suspected when there is a history of a gap in memory — urine/blood must be collected immediately as these clear rapidly.

4. Physical Examination

General examination:

• Document all injuries: abrasions, contusions, lacerations, bite marks — body diagrams/photographs with consent
• Use alternative light source (Wood's lamp/ALS) to detect semen on skin
• Neck: check for petechiae or ecchymoses (strangulation)
• Head: scalp lacerations, TBI signs

Genital/anal examination:

• Use a colposcope for magnification and photo-documentation if available
• Describe all findings using standard terms: laceration, ecchymosis, abrasion, erythema
• Toluidine blue dye may enhance visualization of posterior fourchette lacerations
• Most common injury sites: posterior fourchette, labia minora, hymen, fossa navicularis
• Rectal exam: fissures, lacerations, bleeding
• Important: ~60–70% of rape survivors have NO genital injury — absence of injury does not mean no assault occurred

5. Forensic Evidence Collection — The "Rape Kit" (SAECK)

6. Laboratory Investigations

7. Medical Management

A. Emergency Contraception

B. STI Prophylaxis (CDC guidelines for adult sexual assault survivors)

• Ceftriaxone 500 mg IM × 1 (gonorrhea; 1g if weight >150 kg)
• Doxycycline 100 mg PO BID × 7 days (chlamydia)
• Metronidazole 500 mg PO BID × 7 days (trichomonas/BV)
• Hepatitis B vaccination (if not immune — first dose in ER)

C. HIV Post-Exposure Prophylaxis (HIV-PEP)

• Indicated within 72 hours of assault; do not offer after 72 hours (ineffective)
• Decision based on: nature/type of exposure, assailant HIV status/risk factors, local HIV prevalence
• Preferred regimen: Tenofovir DF/emtricitabine (TDF/FTC) + Raltegravir × 28 days
• Call CDC PEP hotline if unsure: 1-800-933-3413 (24/7)
• Check baseline renal function before starting TDF

D. Hepatitis B

• If unvaccinated or incompletely vaccinated: administer first dose of HBV vaccine in ER + consider hepatitis B immunoglobulin (HBIG 0.06 mL/kg IM) if source is known HBV+

E. Analgesia and wound care

• Treat injuries as clinically indicated
• Tetanus prophylaxis if bite wounds or laceration contamination

8. Psychological & Emotional Support

• Provide trauma-informed care throughout — explain every step before performing it
• Avoid victim-blaming language; use "survivor" not "victim"
• Assess for acute stress reaction — anxiety, dissociation, numbness are normal responses
• Mandatory early involvement of a rape crisis advocate in the ED — this is required in many jurisdictions
• Screen for intimate partner violence if the assailant is someone she knows
• Do not force psychological debriefing in the acute setting — this can worsen outcomes

9. Mandatory Reporting & Legal Obligations

• Report to law enforcement: In most jurisdictions, adult sexual assault requires consent from the patient before reporting (unlike child abuse). Inform her of her options without coercion.
• Child Protective Services reporting is mandatory if the assailant has access to minors.
• Preserve the chain of custody for all forensic evidence — keep kit locked and documented until law enforcement takes custody.
• Occupational health should be notified if the assault occurred on hospital premises (institutional reporting obligations may apply separately from criminal reporting).

10. Special Considerations — Hospital Employee/Student

11. Disposition & Follow-Up Plan

• Provide referral to sexual assault center/rape crisis center for ongoing support
• Provide safety plan if there is ongoing risk from known assailant
• Ensure she has suitable clothing for discharge (if clothing was collected as evidence)
• Arrange safe transportation — do not let her drive or leave alone if acutely distressed
• Complete HBV vaccine series follow-up (doses at 1 month and 6 months)

Summary Framework

ARRIVAL → Privacy & SANE activation
    ↓
TRIAGE → Life-threatening injury? Psychiatric crisis?
    ↓
HISTORY → Trauma-informed; document assault details
    ↓
CONSENT → Separate consents for exam, evidence, photos, police
    ↓
FORENSIC EXAM → Rape kit + colposcopy + photographs
    ↓
LABS → Tox screen, STI baseline, HIV, HBV, HCV, pregnancy
    ↓
TREATMENT → EC + STI prophylaxis + HIV PEP (if <72h) + HBV vaccine
    ↓
ADVOCACY → Rape crisis counselor, safety plan, reporting options
    ↓
DISCHARGE → Written instructions, transport, follow-up appointments