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

Treat any life-threatening physical injuries first, then immediately notify child protective services and police (as legally mandated), followed by physical examination with forensic evidence collection—all three actions are required, but medical stabilization takes absolute priority. 1, 2

Prioritized Action Sequence

Step 1: Assess and Treat Immediate Medical Threats

• Address any active bleeding or injuries requiring urgent intervention before proceeding with forensic procedures. 2
• The American Academy of Pediatrics emphasizes that medical needs take absolute priority over forensic procedures, particularly non-genital trauma requiring urgent intervention. 1, 2
• In this case, visible blood in underwear requires immediate assessment for the source and severity of bleeding. 2

Step 2: Simultaneous Mandatory Reporting

• Notify child protective services AND police immediately—this is legally mandated in all jurisdictions for child sexual abuse cases. 1, 2
• This notification should occur while medical stabilization is underway, not after. 2
• Documentation will be subpoenaed for legal proceedings, so thorough record-keeping from the outset is critical. 1

Step 3: Physical Examination and Forensic Evidence Collection

• Perform thorough physical examination to assess both genital and non-genital injuries once the child is medically stable. 1, 2
• 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—DNA evidence remains viable for at least 72 hours post-assault, potentially up to 4-7 days. 2
• Ideally utilize a Sexual Assault Nurse Examiner (SANE) or Sexual Assault Forensic Examiner (SAFE) if available. 1

Critical Examination Details

Documentation Requirements

• Use video colposcopy or imaging systems to document findings meticulously. 1
• Record the child's history using her own words when possible. 1
• Document all injuries with appropriate diagrams and photographs. 1

Common Examination Findings

• Most sexually assaulted children will have unremarkable anogenital examinations—absence of physical findings does NOT rule out assault. 1
• When genital trauma is present in assault victims, 94% have trauma at one or more of four locations: posterior fourchette, labia minora, hymen, or fossa navicularis. 3
• Tears appear most often on the posterior fourchette and fossa, abrasions on the labia, and ecchymosis on the hymen. 3

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. 1, 2

Specimen Collection

• Collect specimens for gonorrhea, chlamydia, and trichomoniasis using nucleic acid amplification tests (NAATs) from urine or vaginal specimens. 1
• Avoid traumatic speculum examination in children. 1
• Collect specimens from multiple sites based on reported contact, including cervix/urethra, vagina, anorectal, and blood. 2

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 (multiple perpetrators, HIV-positive perpetrator, high HIV prevalence area, or perpetrator with genital lesions) and start within 72 hours if indicated. 1

Psychological Support

Immediate Interventions

• Provide emotional support in a calm, private environment while ensuring physical safety. 1, 2
• 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
• Assess for immediate psychological distress requiring urgent intervention. 1

Follow-Up Mental Health Care

• Arrange urgent mental health follow-up with professionals experienced in childhood trauma. 1, 2
• Consider referral to specialized child advocacy centers if available. 1

Follow-Up Schedule

• Schedule follow-up within 1 week to assess injury healing, medication adherence, and ensure counseling has been arranged. 1, 2
• Repeat STI testing at 2 weeks. 1, 2
• Test for syphilis and HIV at 6 weeks, 3 months, and 6 months if initial results were negative. 1, 2

Critical Pitfalls to Avoid

• Never delay physical examination waiting for police arrival—medical needs take priority. 1
• Do not interpret absence of physical findings as evidence that no assault occurred. 1
• Do not fail to provide STI prophylaxis due to the child's young age. 1
• Do not allow inadequate documentation—medical records will be subpoenaed. 1
• Do not neglect the psychological impact requiring immediate screening and follow-up. 1