What is the immediate management for a pediatric patient presenting to the emergency department with signs of sexual assault, including visible blood in their underwear and emotional distress?

Immediate Management of Pediatric Sexual Assault

Perform the physical examination immediately to assess injuries and collect forensic evidence, while simultaneously ensuring appropriate authorities are notified as mandated by law. 1

Priority Sequence in the Emergency Department

First: Address Life-Threatening Injuries

• Treat any serious physical injuries first, particularly non-genital trauma requiring urgent intervention. 1
• The presence of blood in underwear indicates potential genital or non-genital trauma that requires immediate assessment. 2, 1
• Medical care takes absolute priority and should never be delayed waiting for police arrival. 1

Second: Mandatory Reporting

• Notify child protective services and/or police immediately as required by law—this is mandatory in all jurisdictions for pediatric sexual assault. 1
• Reporting requirements exist regardless of whether the family consents to legal action or forensic evaluation. 2
• The physician must comply with state-specific mandatory reporting laws, which typically require notification when sexual assault of a minor is disclosed or suspected. 2

Third: Physical Examination and Forensic Evidence Collection

• Conduct a thorough physical examination with forensic evidence collection before the child changes clothes, bathes, eats, drinks, or uses the bathroom. 1
• Use video colposcopy or imaging systems to document all findings, as most sexually assaulted children will have unremarkable anogenital examinations. 1
• Collect specimens for DNA evidence (viable for at least 72 hours, possibly up to 4-7 days post-assault). 2
• Document injuries meticulously using the child's own words when recording history. 1
• Ideally, examination should be performed by a Sexual Assault Nurse Examiner (SANE) or Sexual Assault Forensic Examiner (SAFE). 1

Medical Treatment Protocol

STI Prophylaxis and Testing

• Provide empiric STI prophylaxis immediately: ceftriaxone 125 mg intramuscularly for gonorrhea, plus metronidazole 2 g orally once, plus either azithromycin 1 g orally once or doxycycline 100 mg twice daily for 1 week. 1
• Collect specimens for gonorrhea, chlamydia, and trichomoniasis testing from throat, cervix/urethra, vagina, and anorectal sites as indicated. 2, 1
• Obtain blood for HIV, hepatitis B, and syphilis baseline testing. 2

Immunizations

• Initiate hepatitis B vaccination if not previously immunized. 2, 1
• Consider HPV vaccination if not previously completed (can be initiated at age 9 years and older). 2

Pregnancy Prevention

• Perform baseline urine pregnancy test. 2
• Offer emergency contraception to post-menarchal females who experienced vaginal penetration or genital contact with ejaculate. 2

Psychological Support and Safety Assessment

Immediate Emotional Care

• Provide emotional support in a calm, private environment while maintaining a trauma-informed approach. 1
• Directly assess whether the child has safety concerns related to the perpetrator, their friends, or others. 2
• Ask specifically whether the child has been threatened, is afraid of anyone, or whether the perpetrator has a history of violence or access to weapons. 2
• Screen for suicidal ideation and self-harm behavior immediately. 2

Mental Health Referral

• Arrange prompt mental health follow-up with professionals experienced in childhood trauma. 1
• If suicidal or homicidal ideation is present, immediate intervention by an experienced mental health professional is required. 2

Critical Documentation Requirements

• Medical records will likely be subpoenaed for legal proceedings—documentation must be thorough, objective, and avoid value judgments. 2, 1
• Use exact descriptions and avoid interpretive terms like "hymen not intact." 2
• Record the child's statements using their own words. 1
• Maintain proper chain of custody for all forensic evidence. 2, 1

Follow-Up Care

• Schedule follow-up within 1-2 weeks to assess healing, medication adherence, and repeat STI testing as appropriate. 1
• Ensure ongoing psychological support and counseling. 1
• Consider referral to specialized child advocacy centers if available. 1

Common Pitfalls to Avoid

• Never delay medical examination waiting for police arrival—medical needs take priority. 1
• Never assume no assault occurred based on unremarkable physical findings—most examinations show no visible trauma. 1
• Never fail to report to appropriate authorities—this is mandatory regardless of family wishes. 1
• Never omit STI prophylaxis due to the child's young age. 1
• Never neglect the psychological impact and fail to arrange mental health follow-up. 1