What is the immediate management for an 8-year-old 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 life-threatening injuries, followed by simultaneous notification of child protective services and police, as mandated by law in all jurisdictions. 1, 2

Prioritized Initial Actions

1. Physical Examination and Medical Stabilization (FIRST)

• Assess for life-threatening injuries immediately, particularly non-genital trauma requiring urgent intervention, as medical needs take absolute priority over forensic procedures. 1, 2
• Treat any active bleeding or injuries requiring immediate attention before proceeding with forensic examination. 2
• Provide emotional support in a calm, private environment while ensuring the child's immediate physical safety. 1, 2
• Do not delay the physical examination waiting for police arrival—medical needs come first. 1

2. Mandatory Reporting (SIMULTANEOUS)

• Notify child protective services and police immediately, as this is legally mandated in all jurisdictions for child sexual abuse cases. 1, 2
• This notification should occur concurrently with medical assessment, not before it. 1, 2
• Medical care should proceed regardless of whether the family consents to forensic evaluation or legal action. 1

3. Forensic Evidence Preservation

• Instruct the child not to change clothes, bathe, eat, drink, or use the bathroom until forensic examination is complete. 1, 2
• Collect forensic evidence according to local protocols, ideally with a Sexual Assault Nurse Examiner (SANE) if available. 1
• DNA evidence remains viable for at least 72 hours post-assault, potentially up to 4-7 days. 2

Comprehensive Physical Examination

• Perform a thorough physical examination documenting both genital and non-genital injuries using the child's own words when possible. 1
• Use video colposcopy or imaging systems to document findings when available. 1
• Recognize that most sexually assaulted children will have unremarkable anogenital examinations—absence of physical findings does not rule out assault. 1
• Collect specimens for STI testing including gonorrhea, chlamydia, and trichomoniasis using nucleic acid amplification tests (NAATs) from urine or vaginal specimens, avoiding traumatic speculum examination. 1

Immediate Medical Treatment

STI Prophylaxis (Administer Immediately)

• Ceftriaxone 125 mg intramuscularly for gonorrhea prophylaxis. 1, 2
• Metronidazole 2 g orally once for trichomoniasis. 1, 2
• Azithromycin 1 g orally once (preferred) OR doxycycline 100 mg twice daily for 1 week for chlamydia. 3, 1

Vaccination

• Initiate hepatitis B vaccination if not previously immunized. 1, 2
• Consider HPV vaccination if not previously completed. 1, 2

HIV Post-Exposure Prophylaxis

• Assess risk factors including multiple perpetrators, HIV-positive perpetrator, high HIV prevalence area, or perpetrator with genital lesions. 1
• Start HIV PEP within 72 hours if indicated. 1

Psychological Support

• Provide age-appropriate reassurance that the assault was not the child's fault. 1, 2
• Screen immediately for suicidal ideation and self-harm behaviors. 2
• Arrange urgent mental health follow-up with professionals experienced in childhood trauma. 1, 2

Follow-Up Care

• Schedule follow-up within 1 week to assess injury healing, medication adherence, and ensure counseling has been arranged. 3, 2
• Repeat STI testing at 2 weeks. 2
• Repeat syphilis and HIV testing at 6 weeks, 3 months, and 6 months if initial results were negative. 3, 2
• Provide written instructions for the family, as children often do not recall everything said during the evaluation. 1

Critical Pitfalls to Avoid

• Never delay medical examination for police arrival—treat medical needs first. 1, 2
• Never assume no assault occurred based on lack of physical findings—most examinations are unremarkable. 1
• Never fail to report to child protective services—this is mandatory in all jurisdictions. 1, 2
• Never omit STI prophylaxis due to young age. 1
• Never allow inadequate documentation—medical records will likely be subpoenaed for legal proceedings. 1

Answer to the Question

All three options (A, B, and C) are correct and necessary, but the sequence matters: B (Physical examination) must occur FIRST to address immediate medical needs, while A and C (notification of police and family safety services) occur simultaneously but do not delay medical care. 1, 2