Sexual Assault: Medical & Forensic Evaluation
Comprehensive emergency evaluation, trauma-informed care, and protocolized medical-forensic management of acute sexual assault: Sexual Assault Nurse Examiner (SANE) protocols, legal chain of custody, evidence collection kits (forensic window up to 96–120 hours), comprehensive STI prophylaxis regimens (Ceftriaxone, Doxycycline, Metronidazole), emergency contraception (Levonorgestrel vs. Ulipristal acetate), 28-day HIV non-occupational post-exposure prophylaxis (nPEP: Tenofovir/Emtricitabine + Dolutegravir or Bictegravir), Hepatitis B vaccination/HBIG, and crisis intervention.
Resuscitation Quick Actions • First 2 Minutes
Trauma-Informed Care
Patient autonomy governs care; the patient has the absolute right to accept or decline any component of medical or forensic care
72-Hour HIV nPEP Window
Initiate 28-day HIV nPEP (Tenofovir/Emtricitabine + Dolutegravir 50 mg daily) as soon as possible, ideally within 24h, max 72h
Triple STI Prophylaxis
Ceftriaxone 500 mg IM + Doxycycline 100 mg PO BID x 7 days + Metronidazole 2g PO single dose (give at discharge)
Emergency Contraception
Ulipristal acetate (Ella) 30 mg PO single dose (effective up to 120h) OR Levonorgestrel (Plan B) 1.5 mg PO (effective up to 72h)
Strict Chain of Custody
Evidence kit must be continuously in the physical possession of the examiner or locked in a secure evidence refrigerator until police transfer
Forensic Window
Forensic evidence collection (DNA swabs, clothing) is recommended up to 96–120 hours (4–5 days) post-assault
Bottom-Line Clinical Pearl
Emergency management of sexual assault prioritizes trauma-informed medical care and patient autonomy above evidence collection: patient consent is mandatory for every step of the examination. The forensic evidence collection window extends up to 96 to 120 hours (4–5 days) post-assault. Maintain strict, unbroken legal CHAIN OF CUSTODY for the rape kit. Medical management requires a three-tiered prophylactic regimen: (1) STI Prophylaxis: Ceftriaxone 500 mg IM (gonorrhea) + Doxycycline 100 mg PO BID x 7 days (chlamydia) + Metronidazole 2g PO single dose (trichomoniasis); (2) Emergency Contraception: Ulipristal acetate (Ella 30 mg PO up to 120h) or Levonorgestrel (Plan B 1.5 mg PO up to 72h) if pregnancy test is negative; (3) HIV nPEP: A 3-drug 28-day regimen (Tenofovir disoproxil/emtricitabine + Dolutegravir 50 mg daily) started IMMEDIATELY within 72 hours of exposure.
The medical-forensic evaluation of acute sexual assault must be conducted in a private, supportive environment, ideally by a certified Sexual Assault Nurse Examiner (SANE) or Sexual Assault Forensic Examiner (SAFE). Immediate life-threatening traumatic injuries take priority over forensic collection. Strict chain of custody is legally mandatory: the evidence kit must never be left unattended and must be signed from the examiner directly to law enforcement with precise time-stamped signatures.
| Prophylaxis Domain | Recommended Pharmacologic Regimen | Clinical Indications & Pearls |
|---|---|---|
| Sexually Transmitted Infections (STIs) | 1. Ceftriaxone 500 mg IM (1,000 mg if weight $\ge 150\text{ kg}$)<br>2. Doxycycline 100 mg PO BID x 7 days (or Azithromycin 1g PO in pregnancy)<br>3. Metronidazole 2 grams PO single dose (or 500 mg BID x 7 days) | Empiric coverage for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis. Administer antiemetics (ondansetron) prior to oral antibiotics. |
| Emergency Contraception (EC) | Ulipristal Acetate (Ella) 30 mg PO single dose (effective up to 120 hours/5 days)<br><br>OR<br><br>Levonorgestrel (Plan B) 1.5 mg PO single dose (effective up to 72 hours) | Indicated for females of reproductive potential if assault occurred within 5 days and initial urine pregnancy test is negative. Ulipristal (selective progesterone receptor modulator) is more effective than levonorgestrel, particularly in patients with $BMI > 25\text{ kg/m}^2$. |
| HIV Non-Occupational Post-Exposure (nPEP) | 28-Day Three-Drug Regimen:<br>1. Tenofovir Disoproxil Fumarate (300 mg) + Emtricitabine (200 mg) (Truvada) 1 tab PO daily<br>2. Dolutegravir 50 mg PO daily (or Bictegravir) | Must be initiated within 72 hours of exposure (ideally within 24 hours). Provide an initial 3- to 7-day starter pack in the ED with urgent outpatient infectious disease follow-up for 28-day completion. |
| Hepatitis B Virus (HBV) | Hepatitis B Vaccine (1 dose) + Hepatitis B Immune Globulin (HBIG 0.06 mL/kg IM) | Administer if the survivor is unvaccinated or non-immune. HBIG and vaccine must be injected at different anatomical sites. |
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