What is the immediate management for an 8-year-old female patient presenting to the emergency department with blood in her underwear after a reported sexual assault in a garden?

Immediate Management of an 8-Year-Old Sexual Assault Victim

The correct sequence is: Physical examination FIRST, then notify authorities

In an 8-year-old child presenting to the emergency department with blood in her underwear after sexual assault, the immediate priority is physical examination to assess and treat any life-threatening injuries, followed by simultaneous notification of child protective services and police as mandated by law. 1

Step 1: Immediate Physical Assessment and Stabilization

• Assess for life-threatening injuries first, particularly non-genital trauma that may require urgent intervention, as medical needs take absolute priority over forensic procedures 1
• Provide emotional support in a calm, private environment while ensuring the child's immediate physical safety 1
• Do NOT delay the physical examination waiting for police arrival—medical care proceeds regardless of whether the family consents to forensic evaluation or legal action 1
• Treat any bleeding or injuries requiring immediate attention before proceeding with forensic examination 2, 1

Step 2: Mandatory Reporting (Simultaneous with Medical Care)

• Notify child protective services AND police immediately—this is legally mandated in all jurisdictions for child sexual abuse cases 1
• In an 8-year-old child, this is not optional and does not require parental consent, as the child is below the age of consent 2
• Documentation will be subpoenaed for legal proceedings, so meticulous record-keeping using the child's own words is essential 2, 1

Step 3: Forensic Examination and Evidence Collection

• Ideally perform examination with a Sexual Assault Nurse Examiner (SANE) or physician trained in child abuse forensics to ensure proper chain of evidence 2, 1
• Instruct the child not to change clothes, bathe, eat, drink, or use the bathroom until forensic examination is complete 1
• Collect forensic evidence according to local protocols—DNA evidence is viable for at least 72 hours post-assault, and potentially up to 4-7 days 2
• Store clothing in paper (not plastic) bags 2
• Document all findings with diagrams and photographs when possible 2, 1

Step 4: Specimen Collection for STI Testing

Collect specimens from multiple sites based on reported contact 2:

• Cervix/urethra: gonorrhea culture, chlamydia culture, NAAT for both
• Vagina: NAAT for gonorrhea/chlamydia, microscopy for trichomoniasis/bacterial vaginosis/candidiasis
• Anorectal: gonorrhea and chlamydia cultures (if indicated by history)
• Blood: HIV, hepatitis B, syphilis baseline testing

Step 5: Prophylactic Treatment

Administer empiric STI prophylaxis immediately 2, 1:

• Ceftriaxone 125 mg intramuscularly (or cefixime 400 mg orally if only genital penetration occurred) 2, 1
• Metronidazole 2 g orally once 2
• Azithromycin 1 g orally once (preferred over doxycycline in children) 2
• Initiate hepatitis B vaccination if not previously immunized 2, 1
• Consider HPV vaccination if not previously completed 2, 1
• Assess need for HIV post-exposure prophylaxis based on mucosal exposure, trauma, bleeding, and local HIV prevalence 2, 1

Step 6: Psychological Support and Safety Planning

• Provide age-appropriate reassurance that the assault was not the child's fault 1
• Screen immediately for suicidal ideation and self-harm behaviors—up to 80% of sexual assault victims develop post-traumatic stress disorder 2
• Arrange urgent mental health follow-up with professionals experienced in childhood trauma 2, 1
• Encourage involvement of a trusted adult for support, though this must be balanced with safety concerns if intrafamilial abuse is suspected 2

Step 7: Follow-Up Care

• Schedule follow-up within 1 week to assess injury healing and ensure counseling has been arranged 2, 1
• Repeat STI testing at 2 weeks, and syphilis/HIV testing at 6 weeks, 3 months, and 6 months if initial results were negative 2
• Ensure completion of hepatitis B and HPV vaccination series 2

Critical Pitfalls to Avoid

• Never delay medical examination for police arrival—the child's physical safety is paramount 1
• Do not assume normal examination rules out assault—most sexually abused children (68%) have unremarkable anogenital examinations 2, 1
• Do not omit STI prophylaxis due to young age—prepubertal children require the same prophylaxis as adolescents 1
• Do not fail to report—this is mandatory regardless of parental wishes 1
• Do not allow the child to bathe or change clothes before forensic examination unless medical stabilization requires it 1