Harbor:Sexual assault

Background

• See Sexual assault for general evaluation and management details. Details below are Harbor-specific.
• Harbor non-occupational HIV PEP protocol https://www.wikem.org/wiki/Harbor:Non-Occupational_Exposure
• Harbor SART Protocol https://www.wikem.org/wiki/File:SART_ED_Protocol_Recommendations.pdf
  • Closest SART Center is in San Pedro
• Pediatric sexual assault protocol http://pemsource.org/wp-content/uploads/2017/09/Suspected-Child-Abuse-and-Neglect.pdf

Coming Soon

• Sexual assault order set in Orchid for all the medications, labs, consults, communication orders
• Working on policy with pharmacy for giving NPO patients their prophylactic medications to-go to take at SART center after forensic exam

Management

Forensics Logistics

• If a patient wants a forensic exam or evidence to be collected, please treat the patient medically first, and if otherwise medically clear, keep in mind the following recommendations.
• In addition to the instructions found on the Sexual assault page, the San Pedro SART has the following policies to preserve forensic evidence
  • Place patient's clothes and belongings into a paper back (NOT the usual plastic patient belongings bags)
  • If patient has had oral trauma within past 6 hours, place patient on strict NPO (no medications, no ice chips or swabs, no rinsing mouth)
  • Have nursing call hospital sheriffs. The hospital sheriffs will coordinate to find the correct police department that needs to be contacted to file a report. The hospital sheriffs will not take a report.
  • Specimens that PD will take to SART center with the patient
    • Dirty catch urine. Label specimen cup with patient's name, time of collection, and who collected

ED Consults

• Consult to Social Work
  • Also speak to social work about arranging a ride home for the patient. Police will bring patient to the SART center, but some patients have no way to get home from the SART center.
• Consult to Violence Intervention Team
• If patient meets criteria for HIV post-exposure prophylaxis, give first dose in ED. See below for details. (No longer need to call HIV consult)

HIV post-exposure prophylaxis

• Indicated if:
  • An exposure occurs to blood, semen, vaginal secretions, rectal secretions, breast milk—or any body fluid visibly contaminated with blood—with non-intact skin, mucosal surface (e.g. vagina, rectum, eye, or mouth) or via percutaneous contact (e.g. by contaminated or shared needle) AND
  • The source is known to be HIV+ or is of unknown HIV status AND
  • The exposure occurred ≤ 72 hours prior to presentation
  • DHS Expected Practice for Non-occupational Post-Exposure Prophylaxis (nPEP) for HIV Prevention in Adults and Adolescents age ≥13 File:Non-occupational Post-Exposure Prophylaxis (nPEP) for HIV Prevention in Adults and Adolescents Expected Practice.pdf

• If see a patient who meets the criteria above, then a baseline rapid HIV should be sent to make sure the patient is not already infected, in additional CBC, BMP, LFTs, Hep screen (Hep A IgG, Hep B sAg, sAb, cAb, and Hep C Ab), needs to be sent. Tenofovir DF is contraindicated in patients with renal dysfunction (creatinine clearance ≤59 mL/min). For these cases, please consult the HIV, or the National Clinical Consultations Center’s PEPline at (888) 448-4911
• Sexual assault victims that meet criteria should be offered Tenofovir/Emtricitabine (Truvada) 200/300 mg daily plus Raltegravir 400 mg BID and should be referred immediately to a SART center for STI testing and prophylaxis.
  • First dose of non-occupational PEP gave be given in ED. We are working on a process to give patient's 48 hours of medications to go home with to tie them over until they can get the 28d course needed from a PEP center.
• Can consider offering Plan B contraception if patient is not NPO for evidence collection.
  • If not going to SART center:
    • STI testing includes: RPR, Chlamydia (CT) and Gonorrhea (GC) Nucleic Acid Amplification Testing (NAAT) testing (urine, pharyngeal, and rectal, or based on site of exposure)
    • Give STI prophylaxis: Ceftriaxone 250 mg IM in single dose PLUS azithromycin 1 gram PO in a single dose, PLUS metronidazole 2gm PO in single dose
• For the patient that seeks post-sexual-exposure/non-occupational HIV prophylaxis (nPEP), the patient should also be referred to a PEP center http://getprepla.com/PEP/Get-PEP-Now/ to obtain the additional medications and follow up labs, such as the Los Angeles LGBT Center. The LA LGBT Gay and Lesbian Center has a program for post-exposure prophylaxis in a number of specific circumstances; patients can be referred within 72 hours of an exposure. Their hours are Mon-Friday 11am-6pm (telephone number is 323-860-5855, and their website is https://lalgbtcenter.org/post-exposure-prophylaxis).

Pediatric-Specific Modifications

• Consult SCAN team
  • Pubertal patients will go to SART center after medical evaluation complete, but SCAN team can follow up with patient
• Speak to social work about calling DCFS

Disposition

• PD from jurisdiction where assault occurred will take patient to SART center
• See "Consult to Social Work" above to arrange a ride home for the patient
• If patient receives HIV PEP, provide a 2 week supply of medications and patient needs follow up appointment in 2 weeks

See Also

• Sexual assault
• Emergency contraception
• HIV post-exposure prophylaxis
• Child abuse
• Occupational exposure