What is the immediate course of action for a pediatric female patient presenting to the emergency department with signs of sexual assault, including visible blood in her underwear and acute distress?

Immediate Management of Pediatric Sexual Assault

The immediate priority is to perform a physical examination to assess and treat any injuries (particularly the source of bleeding), followed by simultaneous notification of child protective services/police and collection of forensic evidence—all three actions (B, A, and C) must occur urgently, but medical stabilization takes absolute precedence. 1, 2, 3

Priority Sequence in the Emergency Department

First: Assess and Treat Physical Injuries

• Immediately examine the child to identify the source of bleeding and assess for life-threatening or serious injuries requiring urgent intervention. 1, 2, 3
• The presence of blood in underwear indicates potential genital or non-genital trauma that requires immediate medical assessment. 3
• Medical needs take absolute priority and should never be delayed waiting for police arrival. 1, 3
• Treat any bleeding or injuries requiring immediate attention before proceeding with the full forensic examination. 2

Second: Mandatory Reporting (Simultaneous with Medical Care)

• Notify child protective services and/or police immediately—this is legally mandated in all jurisdictions for child sexual abuse cases. 1, 2, 3
• Reporting is required regardless of whether the family consents to legal action or forensic evaluation. 1, 3
• Medical care should proceed even if the family refuses to consent to forensic evaluation or legal action. 1

Third: Preserve Evidence and Complete Examination

• Instruct the child not to change clothes, bathe, eat, drink, or use the bathroom until forensic examination is complete. 1, 2, 3
• Conduct a thorough physical examination with forensic evidence collection, ideally with a Sexual Assault Nurse Examiner (SANE) if available. 1
• DNA evidence remains viable for at least 72 hours, possibly up to 4-7 days post-assault. 2, 3
• Use video colposcopy or imaging systems to document all findings meticulously. 1, 3

Medical Treatment Protocol

STI Prophylaxis and Testing

• Provide empiric STI prophylaxis immediately: ceftriaxone 125 mg IM, metronidazole 2 g orally once, and either azithromycin 1 g orally once or doxycycline 100 mg twice daily for 1 week. 4, 1, 3
• Collect specimens for gonorrhea, chlamydia, and trichomoniasis using nucleic acid amplification tests (NAATs) from urine or vaginal specimens—avoid traumatic speculum examination in children. 4, 1
• Collect specimens from multiple sites based on reported contact: throat, cervix/urethra, vagina, and anorectal areas as indicated. 2, 3

Additional Prophylaxis

• Initiate hepatitis B vaccination if not previously immunized. 1, 2
• Consider HPV vaccination if not previously completed. 1, 2
• Assess risk factors for HIV post-exposure prophylaxis (PEP), including multiple perpetrators, HIV-positive perpetrator, high HIV prevalence area, or perpetrator with genital lesions—if indicated, start within 72 hours. 4

Psychological Support and Safety

Immediate Emotional Care

• Provide emotional support in a calm, private environment using a trauma-informed approach. 1, 3, 5
• Give age-appropriate reassurance that the assault was not the child's fault. 1, 2
• Screen immediately for suicidal ideation and self-harm behaviors. 2, 3

Safety Assessment

• Conduct a safety assessment to determine whether the child has ongoing safety concerns related to the perpetrator or others. 3
• Arrange urgent mental health follow-up with professionals experienced in childhood trauma. 1, 2

Critical Documentation Requirements

• Medical records will likely be subpoenaed for legal proceedings—documentation must be thorough, objective, and avoid value judgments. 3
• Document the history using the child's own words when possible. 1
• Use exact descriptions and avoid interpretive terms like "hymen not intact." 3
• Document all findings with appropriate diagrams and photographs when possible. 1

Follow-Up Care

• Schedule follow-up within 1-2 weeks to assess healing of injuries and medication adherence. 1, 2, 3
• Repeat STI testing at 2 weeks. 2
• Repeat syphilis/HIV testing at 6 weeks, 3 months, and 6 months if initial results were negative. 2
• Ensure ongoing psychological support and counseling. 1, 3

Common Pitfalls to Avoid

• Most sexually assaulted children will have unremarkable anogenital examinations—absence of physical findings does not rule out assault. 1, 3
• Do not delay medical examination waiting for police arrival. 1, 3
• Do not fail to provide STI prophylaxis due to young age. 1
• Do not allow inadequate documentation of physical findings. 1
• Provide written instructions for the family, as adolescents often do not recall everything said during the evaluation. 4