What is the immediate management for a 3-8 year old girl presenting to the emergency department with signs of sexual assault, including visible blood in her underwear?

Immediate Management of Pediatric Sexual Assault

The immediate priority is to perform a physical examination to assess and treat any injuries, followed by simultaneous notification of child protective services and law enforcement as mandated by law. 1

Step 1: Ensure Immediate Safety and Stabilization

• Prioritize treatment of any life-threatening or serious physical injuries first, particularly non-genital trauma that may require urgent intervention 2
• Provide emotional support in a calm, private environment while assessing the child's immediate physical safety 1
• Do not allow the child to change clothes, bathe, eat, drink, or use the bathroom until forensic examination is complete, though care should still be provided even if these activities have already occurred 2

Step 2: Physical Examination and Forensic Evidence Collection

Conduct a thorough physical examination immediately to document injuries and collect forensic evidence 1:

• Examine for both genital and non-genital injuries, with particular attention to the source of bleeding 1
• Collect forensic evidence according to local protocols, ideally with a Sexual Assault Nurse Examiner (SANE) if available 1
• Use video colposcopy or imaging systems to document findings for future review 2
• Collect specimens for DNA evidence (viable for at least 72 hours post-assault) 2
• Document all findings meticulously with diagrams and photographs 1
• Note that most sexually assaulted children will have unremarkable anogenital examinations, so absence of physical findings does not rule out assault 2

Step 3: Mandatory Reporting

Notify child protective services and law enforcement immediately, as this is legally mandated in all jurisdictions for suspected child sexual abuse 1:

• Child sexual abuse cases require mandatory reporting regardless of parental wishes 1
• The report should include the child's identity, nature of the disclosure, description of injuries, and any known information about the perpetrator 3
• Medical care proceeds regardless of whether the family consents to forensic evaluation or legal action 2

Step 4: Medical Treatment and Prophylaxis

Provide empiric STI prophylaxis and other preventive treatments 2, 1:

• Administer ceftriaxone 125 mg intramuscularly for gonorrhea prophylaxis 2, 1
• Give metronidazole 2 g orally once 2
• Provide either azithromycin 1 g orally once or doxycycline 100 mg twice daily for 1 week 2
• Collect specimens for STI testing including gonorrhea, chlamydia, and trichomoniasis 1
• Initiate hepatitis B vaccination if not previously immunized 2, 1
• Consider HPV vaccination if not previously completed 1
• Assess need for HIV post-exposure prophylaxis based on risk 1

Step 5: Psychological Support and Safety Assessment

• Provide age-appropriate reassurance that the assault was not the child's fault 1
• Assess for immediate psychological distress requiring urgent intervention 1
• Arrange prompt mental health follow-up with professionals experienced in childhood trauma 1
• Obtain consent from parent/guardian while maintaining trauma-informed approach 1

Step 6: Follow-Up Care

• Schedule follow-up within 1-2 weeks to assess injury healing and medication adherence 2, 1
• Arrange STI retesting at appropriate intervals 2, 1
• Ensure ongoing psychological support through specialized child advocacy centers if available 1

Critical Pitfalls to Avoid

• Never delay physical examination waiting for police arrival - medical needs take priority 2
• Never fail to report to authorities - this is mandatory regardless of family preferences 1
• Never assume lack of physical findings means no assault occurred - most examinations are unremarkable 2
• Never omit STI prophylaxis due to young age - prepubertal children can contract STIs from sexual assault 1
• Documentation must be thorough as medical records will be subpoenaed for legal proceedings 1