What is the immediate management for an 8-year-old girl presenting to the emergency department with signs of sexual assault, including visible blood in her underwear and emotional distress?

Management of Sexual Assault in an 8-Year-Old Girl

The immediate management for an 8-year-old girl presenting with signs of sexual assault should include physical examination with forensic evidence collection, notification of authorities, and medical treatment for injuries and STI prophylaxis.

Initial Steps

• Ensure the child's immediate physical safety and provide emotional support in a calm, private environment 1
• Obtain consent for examination from the parent/guardian while maintaining a trauma-informed approach 1
• Document the history as provided by the child and/or accompanying adult, using the child's own words when possible 1
• Notify appropriate authorities as required by law (child protective services and/or police) 1

Physical Examination and Evidence Collection

• Perform a thorough physical examination to assess for injuries, both genital and non-genital 1
• Collect forensic evidence according to local protocols, ideally with a Sexual Assault Nurse Examiner (SANE) or Sexual Assault Forensic Examiner (SAFE) if available 1, 2
• Document all findings meticulously with appropriate diagrams and photographs when possible 1
• Collect specimens for STI testing including gonorrhea, chlamydia, and trichomoniasis 1

Medical Treatment

• Treat any physical injuries requiring immediate attention 1
• Provide empiric prophylaxis for STIs according to CDC guidelines 1:
  • Ceftriaxone 125 mg intramuscularly (or cefixime 400 mg orally if only genital penetration occurred) 1, 3
  • Metronidazole 2 g orally once 1, 3
  • Azithromycin 1 g orally once or doxycycline 100 mg orally twice daily for 7 days (age-appropriate dosing) 1
• Consider hepatitis B vaccination if not previously immunized 1
• Consider HPV vaccination if not previously completed 1
• Consider HIV post-exposure prophylaxis based on risk assessment 1

Psychological Support

• Provide age-appropriate emotional support and reassurance that the assault was not the child's fault 1, 4
• Assess for immediate psychological distress requiring urgent intervention 1
• Arrange for prompt mental health follow-up with professionals experienced in childhood trauma 1, 4

Follow-Up Care

• Schedule follow-up within 1-2 weeks to assess healing of injuries and medication adherence 1
• Arrange for STI retesting as appropriate 1
• Ensure ongoing psychological support and counseling 1
• Consider referral to specialized child advocacy centers if available 1

Special Considerations

• Child sexual abuse cases require mandatory reporting in all jurisdictions 1, 5
• The child should be removed from any environment where the perpetrator may have access 6
• Documentation must be thorough as medical records will likely be subpoenaed for legal proceedings 1
• Avoid repeated questioning about the assault details to prevent further trauma 5

Common Pitfalls to Avoid

• Failing to report suspected abuse to appropriate authorities 1, 5
• Inadequate documentation of physical findings 1
• Neglecting the psychological impact of sexual assault 1, 4
• Omitting STI prophylaxis due to young age 1, 7
• Not providing appropriate follow-up care 1