CARE PRESENTATION. Diana Arriola, M.D. House Officer I

Transcription

1 CARE PRESENTATION Diana Arriola, M.D. House Officer I

2 CASE PRESENTATION 12 y/o F presents to ED 2 days following sexual assault by 2 male individuals (16y/o and 19 y/o) both involving penile-vaginal and penile-oral penetration. Pt stated she met perpetrators at an online website and invited them to her home the night of incident but did not consent to any sexual activity. Patient disclosed to both parents 2 days later, who contacted law enforcement and referred to ED for further evaluation

3 WHAT NEXT?

4 WHAT NEXT? LABS?

5 WHAT NEXT? LABS? FORENSIC EVIDENCE COLLECTION?

6 WHAT NEXT? LABS? FORENSIC EVIDENCE COLLECTION? PROPHYLACTIC TREATMENT?

7 MANAGEMENT OF ACUTE SEXUAL ASSAULT IN THE ADOLESCENT PATIENT

8 OBJECTIVES To review the guidelines regarding collection of forensic evidence following acute sexual assault To distinguish which patients require pregnancy and STI testing and prophylaxis following acute sexual assault To review guidelines for appropriate follow up care following an acute sexual assault

9 SEXUAL ASSAULT IN THE PEDIATRIC PATIENT A form of child sexual abuse Adult uses a minor for the purpose of sexual gratification A broad spectrum of sexual activity, including events with and without vaginal and/or anal penetration and events that may include use of physical force or psychological coercion Pediatric Emergency Care 2012;28:

10 EPIDEMIOLOGY 2007 US Department of Justice: Annual rates of sexual assault per 100: 1 for ages years 2.4 for ages Youth Risk Behavior Surveillance Survey 10.5 % female and 4.5 % of male high school students reported being forced to have intercourse National Electronic Injury Surveillance System Preadolescents and adolescents (aged years) are more frequently evaluated after a sexual assault in the ED than are people of other ages Pediatrics in Review 2012, 33, 19.

11 WHY IS THE TOPIC IMPORTANT? Emergency room physicians and primary care providers are often the first clinicians to care for sexual assault victims. Pediatric Emergency Care 2012;28:

12 WHY IS THE TOPIC IMPORTANT? Emergency care of pediatric sexual assault victims is less than ideal Merchant 2008: Compliance in Rhode Island emergency departments with AAP recommendations for adolescent sexual assaults Many patients did not receive AAP recommended tests and prophylaxis. Straight and colleagues 2007: Emergency department care for victims of sexual offence. Only 7% of ED visits for sexual offense result in appropriate antibiotic prophylaxis

13 ROLE OF THE PHYSICIAN Obtain accurate histories Identify/document injuries Collect forensic evidence when appropriate Offer appropriate STI testing and prophylaxis Plan for follow up needs

14 HISTORY Interview child/accompanying adult in separate room Detailed histories often not necessary and can be deferred to those trained in forensic interviewing. Goal is to obtain pertinent details that will affect medical management Use non-leading, non suggesting types of questions Tell me why you are here today No pointed questions Verbatim documentation, if possible, of encounter Pediatric Emergency Care 2012;28:

15 HISTORY Key information to obtain Why is abuse suspected? Disclosure? Timing of abuse? Nature of abuse? Location of sexual abuse? Perpetrator? Law enforcement or CPS? Any factors that affect the evidence? Concerning medical symptoms Pediatrics in Review 2012, 33, 19.

16 PHYSICAL EXAM Perform with chaperone Explain process beforehand Thorough head to toe visual inspection of the child Injuries to nongenital areas should be photographed and documented Visual inspection of genitalia and documentation of any trauma Generally, speculum and bimanual exam are not necessary Pediatrics in Review 2012, 33, 19.

17 WHEN SHOULD FORENSIC EVIDENCE BE COLLECTED? Forensic evidence should generally be collected in any of the following situations There is reasonable concern that sexual abuse has occurred. AND Adolescent and pre-pubescent patients if incident occurred <72 hrs Can be expanded to 120 hours if necessary Pediatrics in Review 2012, 33, 19.

18 COLLECTING THE FORENSIC EVIDENCE Forensic Evidence Kit What to collect?

19 BACK TO OUR PATIENT Forensic Evidence Collection? Yes! Presented prior to 72 hours with concerning history of sexual assault

20 LABORATORY EVALUATION AAP and CDC Recommendation Pubertal victims should undergo STI testing Ages 10 & up Pre-pubertal victims should undergo STI testing if: Exhibit signs/symptoms of STI They have evidence of ejaculation or oral or genital penetration Suspected assailant is known to have an STI High community prevalence of STI Patient/parent request STI testing

21 STI TESTING WHAT TESTS SHOULD I ORDER? GC/CT NAAT urine tests Serologic tests for HIV and Syphilis Consider BV/Trichomonas, female adolescents with symptoms Pediatric Emergency Care 2012;28:

22 GC/CT TESTING IN PRE-PUBERTAL PATIENTS? GC/CT-NAAT urine test for all suspected sexual abuse cases If test were to result positive, must do a second confirmatory test (culture), prior to starting treatment

23 BACK TO OUR PATIENT Tests indicated? GC/CT Syphilis HIV Any other tests that could be performed? BV/Trich

24 FOLLOW UP STI TESTING STI testing should be repeated at 1-2 weeks if prophylaxis not given Serologic tests for syphilis and HIV should be repeated at 6 weeks, 3 months, and 6 months Pediatric Emergency Care 2012;28:

25 PREGNANCY TESTING AND PROPHYLAXIS Pregnancy testing Should be performed to every pubertal girl Pregnancy Prophylaxis Can be offered within 120 hours of assault if vaginally penetrated or had genital contact with ejaculate Levonorgestrel =Plan B 1.5 mg one time dose or 0.75 mg div q12 90% effective Antiemetic Pediatric Emergency Care 2012;28:

26 BACK TO OUR PATIENT? Is Pregnancy Prophylaxis Indicated? Yes! Patient is a 12 y/o F presented <120 hours after sexual assault involving penile-vaginal contact Levonorgestrel 1.5 mg dose x 1

27 STI PROPHYLAXIS All pubertal patients should be offered STI prophylaxis High prevalence of STI Poor follow up Generally not recommended in pre-pubertal patients Incidence of STI is low after abuse/assault Lower risk of ascending infection Regular follow up can generally be ensured Pediatric Emergency Care 2012;28:

28 STI PROPHYLAXIS Pediatric Emergency Care 2012;28:

29 BACK TO OUR PATIENT? Is STI prophylaxis indicated? Yes! 12 y/o female presenting 48 hours after sexual assault involving penile-vaginal contact What should she have gotten? Ceftriaxone 250 mg x 1, Azithromycin 1 g PO x1

30 HIV PROPHYLAXIS Not generally recommended but ultimately left up to the patient/guardian Pediatric Emergency Care 2012;28:

31 HIV PROPHYLAXIS Frequency of seroconversion to HIV in individuals whose only risk factor was sexual abuse is low Gellert and colleagues, 1999: Situational and sociodemographic characteristics of children infected with HIV from pediatric sexual abuse Out of 5000 children evaluated for sexual abuse 0.4 % were HIV positive Girardet and colleagues, 2009: HIV post-exposure prophylaxis in children and adolescents presenting for reported sexual assault Out of 2000 children screened for HIV at time of evaluation of sexual assault, 1 patient contracted HIV

32 HIV PROPHYLAXIS WHEN TO CONSIDER? CDC: Case by case basis, assess risk factors Known HIV high risk behaviors of perpetrator Local epidemiology Exposure characteristics of assault Was there vaginal/anal penetration? Did ejaculation occur on mucous membranes? Were multiple assailants involved? Were mucosal lesions present in assailant or patient?

33 HIV PROPHYLAXIS: WHAT IS IT? 2 NRTI +/- NNRTI or Protease Inhibitor x 28 days Given only if within 72 hours of abusive episode Specialist consultation recommended Counsel patients on risks/benefits Careful follow up Repeat HIV testing at 6 weeks, 3 and 6 months

34 HIV PROPHYLAXIS Current recommendations

35 FOLLOW UP CARE Referral to child advocacy centers if available Follow up STI/Pregnancy testing and/or treatment Referral to appropriate mental health services and local support groups

36 FINAL RECOMMENDATIONS FOR OUR PATIENT Followed up at CARE Center 2 weeks after initial incident Initial ER GC/CT/Syphilis/HIV tests were negative Repeat STI tests performed at the CARE center 2 weeks after assault as recommended Recommended to follow up at 6 weeks, 3 months and 6 months for repeat HIV/Syphilis testing Referred for counseling at Center for Hope Family also recommended to obtain counseling

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38 REFERENCES Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance- -United States, Surveillance summaries. MMWR. 2010;59(no. SS-5):6Y7 Fajman N, Wright R. Use of antiretroviral postexposure prophylaxis in sexually abused children and adolescents treatment in an inner city pediatric emergency department. Child abuse and Neglect 2006; 30: Fortin K, Jenny C. Sexual Abuse. Pediatrics in Review 2012, 33, 19. Gellert GA, Durfee MJ, Berkowitz CD, et al. Situational and sociodemographic characteristics of children infected with human immunodeficiency virus from pediatric sexual abuse. Pediatrics.1993;91:39Y44 Girardet RG, Lemme S, Biason TA, et al. HIV post-exposure prophylaxis in children and adolescents presenting for reported sexual assault. Child Abuse Negl. 2009;33:173Y178. Merchant RC, Kelly ET, Mayer KH, et al. Compliance in Rhode Island emergency departments with American Academy of Pediatrics recommendations for adolescent sexual assaults. Pediatrics 2008; 121:e Mollen CJ, Goyal MK, Frioux SM. Acute Sexual Assault: A review. Pediatric Emergency Care. 2012; 28:6 Rovi S, Shimoni N. Prophylaxis provided to sexual assault victims seen at ED emergency departments. J Am Med Women s Assoc. 2002; 57: Straight JD, Heaton PC. Emergency department care for victims of sexual offence. Am J Health Syst Pharm. 2007; 64: